Glen Park at Glendale - Mariposa St

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspection. LPA was met by Rachel De Chavez, Assistant Administrator and explained the purpose of today's visit. There are currently 81 elderly residents 60 years and older residing in the facility. Only one (1) resident is receiving hospice care and currently, no bedridden residents. At 2:10pm, the Administrator, Susan Park arrived and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility and LPA was screened upon entry. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility has a Dementia waiver in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 12/05/2023. Surety Bond is valid and in place. The last fire Drill was conducted on 07/23/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single storey building located in a residential neighborhood consisting of 98 rooms, some of which are being used as model rooms, administration offices and storage rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. It is licensed to care for 120 non ambulatory elderly residents with a hospice waiver for ten (10). Current census is (81) elderly residents. The facility has Dementia residents. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk and Covid-19 symptom screening is initiated at entry, where LPA was screened. COVID-19 Infection Control screening protocols and supplies included a thermometer, PPE supplies, screening logs, and sign-in sheet were observed in the main lobby. COVID-19 signage was posted around the building. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has twenty six (26) fully charged fire extinguishers which were last inspected on 02/24/2023. Assistant Administrator stated that the local fire department conducted an annual inspection of the facility in February 2023. The facility has a fire suppression system which did not run properly during that time, which required a 2nd inspection on 8/14/2023. During the last fire marshal's visit, the fire suppression system worked and ran smoothly. Facility is currently awaiting for their fire clearance. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit. The following random resident rooms were inspected and the water readings are as follows: Room #1 (113.9 deg F), Room #7 (112.4 deg F), Room #18 (112.7 deg F), Room #33 (108.5 deg F), Room #47 (107.4 deg F), Room #52 (116.2 deg F), Room #67 (105.6 deg F), Room #69 (105.9 deg F), ***CONTINUED ON LIC 809-C*** Staffing: A total of thirty seven (37) staff including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate expired on 8/11/2023, however, Administrator was able to provide proof that renewal was submitted to CDSS on 5/23/2023. Administrator also completed the required courses. Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. The Incident report binder was also reviewed. Resident Rights-Information: Resident personal rights were posted near the lobby area. The Incident report binder was also reviewed. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation. An activity calendar was observed posted in the hallway. The facility has a Resident Council. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel serviced the residents in the facility. Residents medication are centrally stored in the medication room which is inaccessible to residents. Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents. Residents with Special Health Needs: Twenty eight (28) residents are receiving home health services. One (1) resident receives hospice care. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Exit interview was conducted with Susan Park, Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 18, 2023

Allegation investigated: Wrongful eviction. Facility is accepting payments for resident no longer in care. Facility did not adhere to resident's Admissions Agreement.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subeqent complaint investigtion visit for the above noted allegations. LPA met with Administrator Susan Park. The purpose of the viist was explained. It was reported that Resident #1 (R1) was wrongfully evicted from the facility. To investigate this allegation on 8/28/2023 between 11:15am and 12:20pm, staff interviews were iniaited. Interviews revealed that R1 was admitted to the hospital on 11/4/2022 due to numbness and swelling of the arms and legs. On 11/18/22, R1 was discharged to a Skilled Nursing Facility. On 11/28/2022, R1's responsible party was told that they could not remain at the facility due to requiring a higher level of care. On 11/29/2022, R1 told staff that they would not be returning to the community and that their case worker would help them find a new placement. Responsible party agreed to pick up R1's personal belongings on 12/01/2022. Continue on 9099-C Unsubstantiated Between 1:50pm and 2:23pm, LPA reviewed facility records. Facility records confirmed what staff told LPA. R1 was assessed on 11/09/2022 and 11/17/2022 and it was determined that they were bedridden and that they required a higher level of care. At 2:00pm, LPA called R1's responsible party and they stated that R1 was not evicted but rather told that do to their change in condition they could not return to the community because they required a higher level of care. Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that facility is accepting payments for resident no longer in care. Between 11:15am and 12:20pm, staff interviews were conducted. Interviews revealed that as soon as it was determined that R1 would no longer be returning to the community, that the facility stopped billing them. R1 was on an assisted living waiver and their social worker was notified that they would no longer reside at the facility. At 4:14pm, LPA reviewed facility records. Records revealed that R1 was not billed but that Social Security continued to make payments. Facility paid back the money to SSA on 6/20/2023; Based on interviews and records review there is not sufficient information to support this allegation. Thus this allegation is deemed to be UNSUBSTANTIATED at this time. It was reported that facility did not adhere to resident's Admissions Agreement. Between 1:50pm and 2:23pm, LPA reviewed facility records. Moreover, per admission policy in the admission agreement, the facility does not accept or retain the following adults: 1. Persons who are bedridden... R1 was assessed on 11/09/2022 and 11/17/2022 and it was determined that they were bedridden and that they required a higher level of care. Indeed, the facility did not retain R1 because they were adhering to the admission agreement. Staff interviews also confirmed this information. Staff told LPA that R1 had a change in condition and based on hospital assessments, required a higher level of care. Based on records review and interviews, there is not sufficient information to support 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, Aug 28, 2023 · control 31-AS-20230510115726

Allegation investigated: Staff is not allowing resident to select health care provider staff denied resident’s home health agency access to the facility

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigtion visit for the above noted allegations. LPA met with Administrator Susan Park. The purpose of the viist was explained. It was reported that staff is not allowing resident to select home health care provider. To investigate this allegation on 8/28/2023, between 11:15am and 12:20pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) and R1's responsible party were informed that the facility can refer them to third party services which are available within the facility. The facility provided the names of three different home health agencies and asked R1 and R1's responsible party to compare among the differnet home health agencies and to pick one. Staff #1 (S1) stated that neither R1 or R1's responsible party had selected a home health provider from the ones offered or had done any research on them. Staff # 2 (S2) told LPA that in the past different home health agencies that were not reputable were coming into the facility and providing services to Continue on 9099-C Unsubstantiated residents. Moreover, in order to avoid problems and to keep the community safe, they usually refer residents to the home health agencies that they have worked with the past. S1 told LPA that the facility does not force any resident to use the home health agencies they provide referrals to. At 1:30pm, LPA spoke to R1's responsible party and they confirmed what staff had told LPA. Neither responsible party or R1 had looked into other home health agencies besides the one suggested by the M.D. Between 1:50pm and 2:23pm, LPA reviewed facility records. Records revealed that per admission agreement attachment concerning personal rights it states that residents have a right to receive or reject medical care or health-related services. R1 can choose any home health agency of their liking and the facility can not force them to use the ones provided by third parties within the facility. Based on interviews and records review, there is not suffificient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time It was alleged that staff denied resident’s home health agency access to the facility. To investigate this allegation, LPA initiated staff interviews between 11:15am and 12:20pm. Interviews revealed that staff would not deny health-related services chosen by R1 or any other resident. S2 stated that no one was notified of a home health agency coming to the facility and not being allowed inside. At 1:30pm, LPA called R1's responsible party and they said they did not know if in fact the home health agency had even gone to the facility. They were told that they were going to go, but no one saw them. Based on interviews, there is not sufficient information to support this allegation. Thus this allegation is deemed to be UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 28, 2023 · control 31-AS-20230818153501

Allegation investigated: Facility does not have hot water

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Susan Park and formed her the reason of the visit. From 945am to 1130am LPA interviewed the Administrator and conducted a physical inspection of random resident's and measaured hot water, which ranged from temperatures of 105.0, 114.8, 107.6, 109.4, and 119.5, which was in compliance with Licensing regulations. Although, the Administrator confirmed the hot water was out, a plumbing technician and the gas company came the same day, and attempted to fix the boiler. The boiler needed a part, which was ordered and the boiler was fixed two days later. The Administator, submitted an incident report, and all residents were notified that the hot water was not operable, but would be fixed. The facility made hot water arrangements for residents who wanted to shower. Hot was provided to them in there rooms, from the kitchen, by boiling water on the stove. And the facility made arrangements with there other facility, across the street, for residents to shower. Therefore, based on physical plant inspection, and documentation received, the allegation is Unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 22, 2023 · control 31-AS-20230515111101

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff member inappropriately accessed resident's personal property.

On 5/12/23 at 11:30am, Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an initial 10-day complaint visit. LPA was greeted by the Administrator, and entrance interview was conducted. At 11:30 am, LPA collected; including but not limited to the following documents: LIC 500 and staff schedule, the Census, physician report, appraisal needs and service, etc. A physical plant tour was conducted with the Adminstrator at 12:00pm. LPA conducted interviews from 11:40-12:30pm with staff and residents. Allegation: Staff member inappropriately accessed resident's personal property. It was alleged that a staff member takes resident one’s (R1) phone to makes personal calls or sends text messages on R1’s phone. LPA interviewed residents, and it was indicated that four (4) out of eight (8) residents have a personal cell phone. CONTINUED... Unsubstantiated The four (4) residents indicated that staff has never used their cell phone. Interviews with four (4) out of four (4) staff members indicated that staff members do not use resident cell phones. Based on interviews it was found that R1’s phone was accessed and used by another resident in the facility and not a staff member. Therefore, based on interviews it was found that staff members have never accessed R1’s phone nor any other residents phones. The allegation, “Staff member inappropriately accessed resident's personal property,” is deemed unsubstantiated. Exit interview conducted. Copy of report delivered to Administrator.the state’s words, verbatim · CDSS document, May 12, 2023 · control 31-AS-20230504115722

Allegation investigated: Staff are physically abusing residents in care.

On 02/13/2023 Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation at the above facility to address the above allegation. LPA Agard met with Susan Park, Administrator and 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. The facility is licensed to served 120 non - ambulatory residents and has a hospice waiver for 10 residents. The facility is a single-story building located in a residential area. LPA Agard requested a staff and resident roster which were both received at the time of the visit. LPA Agard conduct interviews and reviewed the requested records. Cont. on 9099C Unsubstantiated Regarding the allegation: Staff are physically abusing residents in care. It’s being alleged that two staff are abusing residents while in care. The investigation revealed the following: LPA interviewed 4 out of 35 staff. 0 out of 4 confirmed the allegation. All staff interviewed unanimously denied the allegation. S1cites, S2 and S3 do not provide direct support services to residents in care and act in an administrative role, solely. During interviews with residents, LPA Agard interviewed 7 out of 71 in total. 0 out of 7 confirmed the allegation. All residents interviewed unanimously denied the allegation. All residents interviewed state they have never been hit or witnessed any residents being physically abused. Many residents interviewed denied knowing S2 and S3. R6 states, “I think I know S2, but I know S3 and they are both good to me.” 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, Feb 13, 2023 · control 28-AS-20230203112018

Allegation investigated: Resident left the facility unattended

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with the Assistant Administrator, Rachel De Chavez, and advised her of the complaint. It was reported that, on or around January 14, 2023, Resident 1 (R1) wandered out of the facility, unsupervised. Staff were not aware of R1's absence until R1 was brought back to the facility by law enforcement. LPA's investigation consisted of interviews, which were held between 9:45am to 10:45am, a physical plant inspection, that was conducted approximately between 10:45am to 11:30am, and record review, made between 11:30am to 12:30pm. According to the assistant administrator and staff, both confirmed that R1 wandered out of the facility unsupervised on January 14, 2023. The facility was receiving some deliveries at the time of the incident. The delivery person, set their delivery boxes in front of the receptionist, causing a blind spot. R1 must've exited with the delivery person, unnoticed by staff. By the time staff was getting ready to file a missing Substantiated person report, R1 was brought back to the facility by law enforcement. Assessment made, R1 had no noted injuries. R1 was referred to their primary physician for a reassessment for possible higher level of care. A review of R1's record reveal that R1 exhibits confusion and disorientation. R1 also exhibits sundowning, wandering behavior and cannot leave the facility unassisted. During the physical plant inspection, LPA Cava observed monitors at the front reception desk to view cameras that are installed in common areas and exits for staff supervision. The front door has a delayed fifteen (15) second egress. Although there was sufficient staffing at the time of LPA's investigation and functioning cameras in place to monitor facility activities, based on the information obtained through interviews, record review and plant inspection, there was enough evidence to corroborate the allegation that the resident left the facility unattended. Therefore, the allegation is Substantiated. Citation issued on the 9099D. The assistant administrator was advised, appeal rights and a copy of this report given.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 28-AS-20230117101259

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Feb 2, 2023

Basic Services: If a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal. This requirement was not met as evidenced by R1 wandering out of facility, unnoticed, and as a result had no supervision. A review of R1's files reveal R1 has a wandering behavior and is unable to leave the facility unassisted. Although the resident returned to facility with no injuries noted, this posed a potential risk to the resident in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: As POC, the facility will submit to the licensing agency a reassessment of R1 and an updated care plan to meet R1's needs. POC is due to the licensing agency no later than February 2, 2023.

Allegation investigated: Staff do not answer resident's call button in a timely manner Staff do not provide resident with housekeeping Staff do not communicate with resident

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Susan Park, and advised her of the complaint. Between 12:45pm to 1:30pm interviews were made with residents and staff. At approximately 1:30pm to 2:45 pm, a physical plant inspection and record review were conducted. Staff do not answer resident's call button in a timely manner: In regards to the allegation, it was reported that on or around 12/29/22, at approximately 8:30am, Resident 1 (R1) requested for some water, but response to her request for water wasn't made until 3pm. Interviews with staff and residents deny that staff do not answer calls in a timely manner. According to staff, that were on duty that day, water was given to R1, throughout that day, when requested by R1. No witnesses were identified to corroborate the allegation. Therefore, based on the information obtained, the allegation of staff not answering to the resident's call button in a timely manner is deemed Unsubstantaited at this time. Unsubstantiated Staff do not provide resident with housekeeping: In regards to the allegation, it was reported that on or around 12/29/2022, R1's meal tray wasn't picked up by staff. Interviews with staff and residents deny that staff do not provide residents with housekeeping. According to both administrator and staff, caregivers usually check up on residents throughout the day and if there is an empty meal tray, staff would collect the tray. Also, according to both administrator and staff, some clients would place their meal tray outside their door for staff to pick up. At no time was R1's tray left in their room. A review of R1's records indicate that R1 is ambulatory, able to follow instructions, and able to feed self. There were no witnesses to corroborate the allegation of staff not providing housekeeping. Therefore, the allegation is deemed Unsubstantiated at this time. Staff do not communicate with resident: In regards to the allegation, it was reported that R1 tried to speak with management and staff about their concerns of a visitor, running up and down the halls, and jiggling R1's door knob, however, management and staff will not communicate with R1 when R1 requests to address this with them. Interviews with staff and residents deny that staff do not communicate with the residents. Furthermore, there was no witnesses to, nor video footage in the hallways of a visitor running up and down the hallways of the facility. The administrator stated she has an open door policy, and is available to the residents throughout her shift to address any of their concerns, and she's never denied meeting with R1. Staff are also available to assist residents at their request and answer any of their questions. LPA reviewed and obtained facility logs and records, indicating that the administrator, and staff have met with R1 to address R1's concerns. Concerns were also addressed with R1's physician. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not communicating with residents. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jan 6, 2023 · control 28-AS-20221229160324

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Susan Park (Administrator) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R1) Physician's Report, Medical Records, three 5150 hold evaluation reports and Unusual Incident reports (UIR) on R1 hospital transportation and R1 Admission Agreement. LPA also interviewed Administrator and Staff #1 (S1) in the Activity Room and attempted to interview R1 via telephonically and was not successful. In regards to the allegation: Illegal Eviction. Based on record review and supportive documentation provided indicate R1 was admitted and placed on a 5150 hold on 12/09/22 and transferred to the hospital. Based on record review of R1 Physician Report states R1 type of medical supervision needed is to be placed in a Skilled Nursing Home. Continue to LIC9099C... Unsubstantiated Interview with Administrator and S1 stated denied no new eviction letter was given to R1 written or verbally. LPA Calderon reviewed R1's file and no eviction letter was observed. Interview with Administrator stated R1 told hospital that R1 refuses to be transported anywhere else that isn't the above facility. R1 remains in the hospital until further notice and until R1 is placed in a facility that is appropriate for the level of care R1 is required to have based on doctors reports. Facility will provide Discharging Planner information on Skilled Nursing Homes for R1 proper placement based on R1's needs. Based on LPA's interviews, record review and observation, 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. Exit interview conducted with Susan Park and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 19, 2022 · control 28-AS-20221212111200

Allegation investigated: Staff are not ensuring residents are not exposed to hazardous smells. Staff are not ensuring the facility ventilation system is not in disrepair. Staff are not ensuring the floors are free of dirt.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with Administrator, Susan Park. The purpose of the visit was explained. The investigation consisted of the following: LPA Chan toured the facility and obtained copies of the staff roster, resident roster, and housekeeping assignment sheet. Interviews were held with the Administrator, 5 Staff, and 7 Residents. The investigation revealed the following: For allegation - Staff are not ensuring residents are not exposed to hazardous smells. It is alleged that the smoke and/or smells from the kitchen is polluting the facility and making residents sick. Administrator Park denied any hazardous smells that are causing any residents to be sick. She stated that this concern was brought to her attention and it has been addressed. Unsubstantiated She stated the Department of Public Health (DPH) inspector came out last week to check all the ventilation and did not find any concerns. The Administrator had accommodated the resident by opening the dining room windows and doors to circulate the air. She also stated that the facility fan is consistently running as recommended by DPH. LPA interviewed 5 Staff and none reported any lingering smells or smoke that might cause residents to be sick. 6 out of the 7 residents interviewed do not feel they are exposed to hazardous smells at the facility. LPA toured the dining room and living room during the visit today and did not encounter any hazardous smells. For allegation - Staff are not ensuring the facility ventilation system is not in disrepair. It is alleged that the kitchen vents are not operating properly to remove the smoke and smell out of the facility. Administrator stated that the ventilation system in the kitchen is working properly. LPA toured the kitchen and observed a large kitchen range hood vent that was in operation while the chef was preparing lunch. Interview was conducted with the chef who stated the kitchen ventilation system is on 24 hours a day and is working properly to remove any smoke or smells when they cook. LPA interviewed the office manager from the Maximum Exhaust Cleaning company who confirmed that services for the range hood is done every 6 months at this facility and the last inspection was on 8/24/222. The job report noted that everything is performing properly. For allegation - Staff are not ensuring the floors are free of dirt. The administrator stated the facility is being cleaned at least once a day. There are about 3-4 housekeepers who mop or vacuum the floors/carpets in the resident rooms once a week and more often if needed. They also clean the common areas and hallways daily. If they see the floors need extra cleaning, they will mop the floor again. During the visit today, LPA observed housekeepers vacuuming the rooms and did not see any pile or trail of dirt in the hallways. The staff interviewed indicated they try their best to keep the facility as clean as possible. 6 out of the 7 residents interviewed stated that the staff clean their rooms daily and mop/vacuum at least once or twice a week. They feel the staff do a good job in keeping their rooms and facility 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. An exit interview was held. A copy of this report along with the appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 13, 2022 · control 28-AS-20221207084028

Allegation investigated: Facility staff refused to accept resident back after hospital stay.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Susan Park (Administrator) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R#1) Physician's Report, 30 Day Notice to Quit and Medical Records. LPA also interviewed Staff #1 in the Activity Room and interviewed Skilled Nursing Social Worker via telephone. In regards to the allegation: Facility staff refused to accept resident back after hospital stay. Interview with Staff #1 indicate R#1 was admitted to the hospital on 11/21/22 and was later transferred to a Skill Nursing facility on 12/02/22. R#1 returned to the facility on 12/05/22 from the Skilled Nursing facility and was not refused acceptance back to the facility. Review of medical records indicate R#1 was admitted to the hospital on 11/21/22. LPA verified with the Skilled Nursing facility Social Worker that R#1 was at the Skilled Nursing facility from 12/02/22 to 12/05/22. LPA observed R#1 is currently at the facility. Continue to LIC9099C..... Unsubstantiated Based on LPA's interviews, record review and observation, 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. Exit interview conducted with Susan Park and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 8, 2022 · control 28-AS-20221201141010

Allegation investigated: Unlawful eviction

This report supersedes the complaint investigation report created on 11/03/2022 due to the initial report containing client confidential information (diagnostic). No other changes have been made to the report. On 11/03/2022, Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegation. LPA met with Susan Park and explained the purpose of today's visit. During this visit, LPA obtained a copy of the resident roster, staff roster, interviewed Staff #1 through Staff #3 (S-1 through S-3) and reviewed file for Resident #1 (R-1) and obtained copies of relevant documentation. R-1 is no longer residing at this facility. LPA attempted to interview R-1 via telephone at R-1's current location and was unable to interview as R-1 did not understand interview questions. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Unlawful eviction. During this investigation, LPA interviewed S-1 through S-3 and reviewed R-1's file. LPA attempted to interview R-1 via telephone at R-1's current location and was unable to interview as R-1 did not understand interview questions. (2) out of (3) interviewed staff indicated R-1 was not evicted and indicated R-1 was sent to the hospital on 10/14/22 at 8PM (per physician order) for a psychiatric evaluation due to behaviors and not an evaluation to have R-1 placed in a "memory care". (2) out of (3) interviewed staff indicated staff were able to redirect R-1 and had R-1 participate in a Day Program during the week to keep R-1 engaged (to refrain from exhibiting behavior) and that it was manageable up until this recent hospitalization. (1) out of (3) interviewed staff was only involved in transferring R-1's belongings and was unaware of the reason why R-1 moved out. Per staff interviews, a family member for R-1 indicated that R-1 will be moving near Lancaster and requested that R-1's belongings be taken to R-1's hospital location. (3) out of (3) interviewed staff indicated they followed the family member's request, however, when R-1's belongings were taken to the new hospital location, the hospital location did not allow the items to be left. Therefore, staff returned back to this facility with R-1's belongings and family members came to the facility to retrieve the items. Staff interviews and documentation reviewed do not corroborate this allegation. Based on LPA's observations and interviews, investigation revealed: 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 allegation is unsubstantiated. Exit interview conducted, appeal rights and a copy of this report was provided to Rachel De Chavez/S-2the state’s words, verbatim · CDSS document, Nov 28, 2022 · control 28-AS-20221028082245

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegation. LPA met with Susan Park and explained the purpose of today's visit. During this visit, LPA obtained a copy of the resident roster, staff roster, interviewed Staff #1 through Staff #3 (S-1 through S-3) and reviewed file for Resident #1 (R-1) and obtained copies of relevant documentation. R-1 is no longer residing at this facility. LPA attempted to interview R-1 via telephone at R-1's current location and was unable to interview as R-1 did not understand interview questions. Per record review, R-1 is diagnosed with Dementia. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Unlawful eviction. During this investigation, LPA interviewed S-1 through S-3 and reviewed R-1's file. LPA attempted to interview R-1 via telephone at R-1's current location and was unable to interview as R-1 did not understand interview questions. Per record review, R-1 is diagnosed with Dementia. (2) out of (3) interviewed staff indicated R-1 was not evicted and indicated R-1 was sent to the hospital on 10/14/22 at 8PM (per physician order) for a psychiatric evaluation due to behaviors and not an evaluation to have R-1 placed in a "memory care". (2) out of (3) interviewed staff indicated staff were able to redirect R-1 and had R-1 participate in a Day Program during the week to keep R-1 engaged (to refrain from exhibiting behavior) and that it was manageable up until this recent hospitalization. (1) out of (3) interviewed staff was only involved in transferring R-1's belongings and was unaware of the reason why R-1 moved out. Per staff interviews, a family member for R-1 indicated that R-1 will be moving near Lancaster and requested that R-1's belongings be taken to R-1's hospital location. (3) out of (3) interviewed staff indicated they followed the family member's request, however, when R-1's belongings were taken to the new hospital location, the hospital location did not allow the items to be left. Therefore, staff returned back to this facility with R-1's belongings and family members came to the facility to retrieve the items. Staff interviews and documentation reviewed do not corroborate this allegation. Based on LPA's observations and interviews, investigation revealed: 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 allegation is unsubstantiated. Exit interview conducted, appeal rights and a copy of this report was provided to Rachel De Chavez/S-2the state’s words, verbatim · CDSS document, Nov 3, 2022 · control 28-AS-20221028082245

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of delivering findings for the complaint regarding the above-mentioned allegations. LPA Maldonado met with Administrator Susan Park and explained the purpose for the visit. On 10/20/22, LPA Maldonado made an initial visit to the facility for the purpose of investigating the above-mentioned allegations. During the visit, LPA reqested a copy of the resident and staff roster, and the Facesheet and Physician's Repor for Residents# 1-7 (R1-R7). LPA also requested copies of the following documents for R1: Psychiatric Evalutions and Incident Reports for the months of March 2022-October 2022, Eviction Notice, Copy of House Rules, and written warning of possible eviction. The following documents were obtained for Staff# 1-3 (S1-S3): Personnel Records and Required Training Certification. Interviews were conducted with R1-R7 and S1-S3. (Report Continued on LIC9099-C...) Substantiated The investigation revealed the following: Regarding allegation: Unlawful Eviction. It is alleged that R1 is being evicted for violent or anti-social behavior, harassing to threaten or harm others, and refusing to store over the counter medication. LPA obtained a copy of the 30-day Notice of Eviction, which states that R1 violated House Rule #13, which includes "Violent or Anti-Social Behavior, harming or threat to harm oneself or others, and refusal to store prescribed and over the counter medications with facility." During interviews conducted with S1-S3, (3) of (3) staff stated that R1 is constantly cursing at the facility staff for any reason. R1 threatens to hit staff, but has never physically hit staff or other residents. During interviews conducted with R1-R7, (6) of (7) residents have witnessed R1 yelling and cursing at staff when she is upset. (6) of (7) residents witnessed R1 arguing with one other resident in the past, but stated they never saw R1 become physically aggressive with any resident or staff. R1 admitted to yelling and cursing at the staff due to them not keeping the facility clean the way she wants it or for caring for the facility birds the way she would like to. R1 also admitted to yelling at one other resident before because R1 did not get along with them. After review of the Facility House Rules, it was determined that the house rules may be violating resident's personal rights and the grounds for eviction for which R1 has been given a 30-Day written notice are unlawful. Therefore, this allegation is substantiated. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D. An exit interview was conducted with administrator Susan Park and copy of the report and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff are threatening resident. It is alleged that the facility administrator told R1 that if R1 did not turn in their over the counter medications to the facility staff for storing, they would evict R1. During interviews conducted with R1-R7, (6) of (7) residents have no knowledge of a resident being threatened by facility staff. During interviews with S1-S3, (3) of (3) staff denied ever threatening a resident in care and have no knowledge of other staff threatening residents in care. Regarding allegation: Staff are making inappropriate comments towards resident. It is alleged that facility staff told R1 that if R1 is good to the facility staff, they will also be good to her- regarding R1's notice to the administrator that R1 will no longer continue their voluntary assistance with cleaning the facility. (6) of (7) residents interviewed stated staff have never made inappropriate comments toward them and have no knowledge of staff making inappropriate comments to other residents in care. (3) of (3) staff interviewed stated denied ever making inappropriate comments to any resident in care. Staff state R1 is the one making inappropriate comments to staff and residents. Regarding allegation: Staff forced resident to eat in the library. It is alleged that R1 was forced, by the facility administrator, to eat in the library for the past 6 months, due to R1 not getting along with 2 other residents. R1 admitted to not getting along with 2 residents; However R1 stated that R1 was given the option to eat there alone. R1 stated to prefer it, up until now. (3) of (3) staff denied forcing residents to eat in the library. Staff interviewed stated R1 was given the option to eat there and preferred it until now. R1 has requested to return to eat in the dining room with the other residents. (6) of (7) residents interviewed stated they are unaware of residents being forced to eat in the library. Regarding allegation: Staff did not safeguard residents personal belongings. It is alleged that staff are going to R1's room and going through R1's makeup and breaking R1's lipsticks. (3) of (7) residents interviewed stated some of their personal belongings went missing. They brought it to the attention of the administrator and staff stated to have conducted an investigation, but their missing things were never found. (3) of (3) staff interviewed stated they have no knowledge of resident's personal belonging being lost or damaged by other staff or residents. (Report Continued on LIC9099-C...) Regarding allegation: Staff are not properly cleaning the facility. It is alleged that staff do a sloppy job with putting towels on the rack, throwing trash away and not putting the trash bag in the can correctly. (6) of (7) residents interviewed stated they have no issues with the cleanliness of the facility. They state staff do a good job at maintaining the facility clean. LPA observed common areas, walkways, hallways, offices, and resident rooms to be clean and free of obstruction and hazards. (3) of (3) staff stated that although R1 insisted on cleaning the facility birds and some areas of the facility, R1 was told often to not clean because that is staff responsibility; However R1 continued to do so. R1 admitted to cleaning because R1 liked certain things to be cleaned in a particular way. 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 Susan Park and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2022 · control 28-AS-20221018112737

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(3) · Plan of correction due date: Nov 4, 2022

87224 Eviction Procedures (a) The licensee may evict a resident... Thirty (30) days written notice to the resident is required.(3)Failure of the resident to comply with general policies of the facility... general policies must be in writing... for the purpose of making it possible for residents to live together and must be made part of the admission agreement. This requirement if not met as evidenced by: Based on interviews and records review, the licensee issued an eviction notice based on house rules that include verbal abuse directed towards staff, which is not a reason for eviction, per eviction procedures. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2022

Plan of correction: Licensee will rescind the 30-day writen notice and the Behavior Contract signed by the resident. A written notice of the rescinded notices will be emailed to LPA by the POC due date.

Allegation investigated: Facility is retaliating against a resident

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Darkis Giron and was later joined by the Administrator / Susan Park who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Facility is retaliating against a resident". During today's visit, LPA interviewed the Administrator, the Assistant Administrator and Resident 1 (R1). Also, copies of the following documents were obtained and reviewed in reference to R1; • Identification and Emergency Information • Physician's Report • Admission Agreement • Unusual Incident/Injury Reports • 30 Day Notice to Quit • Friendly Reminder/Final Written Order • House Rules • Medical Reports from LA Downtown Medical Center (LADMC) Please see LIC 9099C for additional information Unsubstantiated The investigation revealed the following; Allegation: Facility is retaliating against a resident. The details of this allegation state that on 10/10/22, R1 told the Administrator that she would no longer clean the library, the living room and dining room and three days after, on 10/14/22, R1 received an eviction notice in retaliation. During the interview with the Administrator and Assistant Administrator, LPA discovered that R1 was issued a Friendly Reminder/Final Written Order on June 15, 2022, for violating Facility House Rules/Facility Policies. The concerns listed on the Friendly Reminder included the following; • Verbal or physical abuse directed toward other residents or staff • Use of profanity and offensive language • Violent or anti social behavior • Harming or threat to harm oneself or others • Refusal to store prescribed and over the counter medications with facility According to the Administrator and the Assistant Administrator, R1 was issued a 30 Day Notice To Quit on 10/14/22, as a result of ongoing concerns for failing to comply with facility house rules and policies (based on the concerns listed above). The Administrator and Assistant Administrator both denied issuing the 30 Day Notice To Quit as a form of retaliation to R1. Statements obtained from interviews conducted were consistent and corroborated that R1 voluntarily cleaned the library, the dining room and living room and often cared for the facility birds. R1 was not required or asked by facility staff to clean inside the facility or take care of the birds. It was strictly voluntary on behalf of R1. During the interview of R1, R1 admitted to being verbally abusive, using profanity and offensive language towards staff and residents. R1 also admitted for failing to have facility staff store prescribed over the counter vitamins. During the file review of R1, LPA discovered that R1 was hospitalized at LADMC in July of 2022 for depression, and being verbally abusive and physically aggressive. Based on the information gathered, there is insufficient evidence to support the allegation of "Facility is retaliating against a resident" to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2022 · control 28-AS-20221017102430

Allegation investigated: Facility failed to meet resident's needs. Resident's personal belongings are missing.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Rachel de Chavez). 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 deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Nicol Wesley on 10/01/21. LPA/RA Ceniceros re-interviewed (between 2:15 p.m. - 2:40 p.m.) Asst. Administrator (A2: Rachel de Chavez) and Witness #1 (W1: Dr. James Lee, M.D.). Resident #1 was not re-interviewed; as the resident moved on 08/16/22 and the contact numbers were out of service. LPA/RA Ceniceros reviewed (between 2:45 p.m. – 3:20 p.m.) the requested documents: Emergency I.D. & Information Face Sheet, Physician’s Report (dated 06/22/22) - including additional documents: PRN Authorization Letter (dated 09/07/21), Medication Administration Record (September 2021), Safeguards for Property/Valuables for Resident #1 (R1); and Staff & Residents Roster. Unsubstantiated Regarding Allegation #1: this investigation revealed that Resident #1 was requesting the pain medication (Acetaminophen 325 mg.) every two (2) hours. LPA/RA Ceniceros reviewed the physician's order from Witness #1 (W1: Dr. James Lee, M.D.) that was issued in a "PRN Authorization Letter" (dated 09/07/21) for PRN medication (Acetaminophen 325 mg) to be administered: two (2) tablets (650 mg) by mouth every four (4) hours as needed for pain. A review of the resident's Medication Administration Record (MAR) for the month of September 2021 documented that the resident had been administered the PRN medication (Acetaminophen 325 mg) every four (4) hours as needed for pain (from 09/02/21 thru 09/30/21). 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 SUPERVISION: Facility failed to meet resident's needs is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed that Resident #1 was admitted to the facility on 05/25/21. LPA/RA Ceniceros reviewed the resident's "Personal Property Inventory" (signed and dated 05/25/21) by Resident #1 that did not document the resident brought a brown suitcase and/or Filipino costume with other personal belongings upon facility move in. 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: Resident's personal belongings are missing is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator (Rachel de Chavez).the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 28-AS-20210924163328

Allegation investigated: Staff do not assist the resident with making phone calls as needed. Resident not accorded dignity in personal relationships with staff.

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Assistant Administrator Rachel De Chavez who assisted with the visit. Regarding the allegation that staff do not assist resident #1 with making phone calls as needed, the investigation consisted of : Interviews with Assistant Administrator, Staff #1 and Resident #1- Resident #6 and review of Resident #1's file. Assistant Administrator and Staff #1 stated that resident(s) who receive phone calls at the facility are assisted when needed. Staff interviewed stated that if a call comes in for a resident, staff will page the resident, and will transfer the phone call to another phone for the resident. Resident(s) interviewed were unable to corroborate the allegation. Five out of Six resident(s) interviewed stated that staff do provide assistance to resident(s) with phone calls when needed. Regarding the allegation that Resident #1 is not accorded dignity in personal relationships with staff, the investigation consisted of : Interviews with Assistant Administrator, Staff #1, and Resident #1 - Resident #6. Unsubstantiated Assistant Administrator and Staff #1 denied the allegation and stated that residents are treated with dignity and respect. Resident(s) interviewed were unable to corroborate the allegation. Five out of Six residents stated that staff treat them with dignity and respect. 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 Assistant Administrator, Rachel De Chavez.the state’s words, verbatim · CDSS document, Aug 18, 2022 · control 28-AS-20220812093156

Allegation investigated: Resident(s) not being provided their prescriptions as prescribed. Resident(s) medications not being refilled in a timely manner. Facility is in disrepair. Unqualified staff providing residents medications.

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation(s). LPA Flores met with Siranush Aleksanyan - Receptionist and explained the reason for the visit. The investigation consisted of the following: On 4/4/22 LPA Flores requested a copy of staff/resident roster. LPA and assistant administrator tour rooms #20,12,32,29,48,96,90, hallways, and dining room. LPA Flores interviewed residents #1,#2,#3,#4,#5,#6,#7, assistant administrator(S1), and staff #2(S2),#3(S3),#4(S4),#5(S5). LPA Flores reviewed medication for residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7) and requested copies of medication sheets (MARS) for January, February, March 2022 for R1,R2,R3,R4,R5,R6,R7, training for staff, call logs for physician/pharmacy contacts, contract for roof repairs. On 7/14/22 LPA Flores requested copy of staff/resident roster, Med-Tech notes for March, and delivered findings for the above allegations. (CONTINUED LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Resident(s) not being provided their prescription as prescribed. It is alleged an unqualified staff was dispensing medication resulting in resident given the wrong medication. Interviews with residents revealed 6 out of 7 residents interview stated that a Med-tech provides the medication to residents and 1 out of 7 residents did not know if staff was trained to provide medication to residents. 4 out of 7 residents stated to have never miss a dose of medication or been given the wrong medication. 2 out of 7 residents stated to have missed a dose of their medication recently, and 1 out of 7 residents stated to "seldom" miss a dose in the past. Interviews with staff revealed 5 out of 5 staff interview stated to not have heard residents state missing medication or of medication errors. On 4/4/22 LPA reviewed medication for R1,R2,R3,R4,R5,R6,R7 which consisted of reviewing the medication sheet which lists all prescribed and PRN medication and comparing it to the bubble packs or medication bottles, checking initials marked on dates for medication provided by Med-Tech and ensuring the medications listed are available. No errors were observed. 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 allegation: Resident(s) medications not being refilled in a timely manner. It is alleged staff did not have nor had requested residents medications prior to running out. Interviews with residents revealed 4 out of 7 residents have always have their prescription available and filled, 2 out of 7 residents stated to either their prescription not filled timely or had been missing at the time of providing dose, and 1 out of 7 residents stated their social worker ensures prescription is filled. Interviews with staff revealed 3 out of 5 staff stated to not have heard of prescription not available at facility, 2 out of 5 staff stated resident had complaint of not having prescription available or prescription was not filled timely, however the prescription was not filled due to change of pharmacy by resident. 1 out of 5 staff interview stated that the pharmacy did not filled a prescription for resident due to communication between the physician and the pharmacy, and facility reach out to assist with getting the prescription filled out. Documents review revealed medication sheet noted a medication had finished on 2/25/22 and 3/27/22 for R7 and there were (0) zero refills available, a fax communication transcript was reviewed dated 2/14/22 regarding requesting refill to a different pharmacy and Med-tech notes regarding same medication for March 25th and 26th showed staff noted a follow up with physician for refill of medication. 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, (CONTINUED ON LIC 9099C) therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility is in disrepair. It is alleged that rooms #19, #21, the hallways and the dining room have water leaks. On 4/4/22 LPA conducted a facility tour and observed no leaks or ceiling water stains throughout the facility. In room #29 LPA observed a repair patch around the fan on the ceiling. On 7/14/22 LPA Flores observed room #21 and did not observed leaks. Interviews with residents revealed 4 out of 7 residents revealed that no leaks were observed at the facility and 3 out of 7 residents interview stated to have observed leaks throughout the facility when it rains. Interviews with staff revealed 4 out of 5 staff stated to have observed leaks throughout the facility and 1 out of 5 staff interview stated to have not observed leaks throughout the facility. Documents reviewed revealed facility has a Contract Agreement - Proposal dated: 1/7/22 with Pro Roofing Co. with an estimated starting date of: 3/18/22 and estimated completion date of: 4/8/22 for facility area to be re-roof of: entire roof. Per administrator the contractors met the completion date. Maintenance Request Order forms between January and March 2022 note toilet overflow water repairs only. Two (2) Internal Incident Reports dated: 12/25/21 - Location room #21 revealed the following, first report shows housekeeper reported to management regarding leak in room #21, Reason for Review date and reviewed by: on 12/21/21 and initialed noted "recommended resident to move room to get room fixed". Second report note on Reason for review - date and reviewed by: on 12/27/21 no initials notes resident was "recommended to move room temporarily" resident answered "No". 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 allegation: Unqualified staff providing residents medications. It is alleged that there have been several times unqualified staff have provided residents the wrong medications. Interviews with residents revealed 6 out of 7 residents interview stated Med-Tech passes out the medication and 1 out of 7 residents stated to not know if the staff is trained to pass out medication. Interviews with staff revealed 5 out of 5 staff stated the Med-Tech passes out the medication to the residents. Documents reviewed revealed 2 out of the 5 staff interviewed have a Certificate of Completion on Medication Training completing shadow training, didactic, and written exam S2 completed training on 2/24/22 and S3 completed training on 5/5/21. On 4/4/22 LPA reviewed medication for R1,R2,R3,R4,R5,R6,R7 which consisted of reviewing the medication sheet which lists all prescribed and PRN medication and comparing it to the bubble packs or medication bottles, checking initials (CONTINUED LIC 9099C) marked on dates for medication provided by Med-Tech and ensuring the medications listed are available. 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 Marina Pink Administrator and Rachel De Chavez Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2022 · control 28-AS-20220328134143

Allegation investigated: Staff did not keep resident's records confidential

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Rachel De Chavez and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Assistant Administrator Rachel De Chavez, Receptionist Darkis Giron and Resident 1-7 (R1-7). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information (LIC601),Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 2/8/22, Functional Capability Assessment (LIC9172) dated 2/14/22, Individual Service Plan (ISP) dated 2/9/22, Physician's Orders for Life Sustaining Treatment (POLST) dated 11/24/20 and Internal Resident Incident Reports for dates 2/17/22 - 6/1/22. LPA also attempted a call to The Gardens of El Monte. (See LIC9099C for continuation) Unfounded Investigation revealed the following: Regarding allegation of, Staff did not keep resident's records confidential, it is alleged that R1's family member (FM1) is not listed on any emergency forms at the facility and is not R1's authorized representative. R1 does not want any communication with FM1 and it is alleged that facility staff disclosed information to FM1 about R1's medical records and violated HIPAA. Interview with Assistant Administrator Rachel De Chavez revealed that facility has never violated any facility resident's confidential information. Ms. De Chavez stated that there are some residents that have responsible parties, Power of Attorney's and authorized representatives which information is on record and only then is information disclosed regarding a resident. She stated that if a resident is independent their private, confidential information is always kept confidential. She stated that R1 recently accused the facility of not keeping their records confidential. Ms. De Chavez stated that the facility does not have any of R1's family members information on record and only has R1's information as the resident is self responsible. Interview with Staff Giron revealed that on 6/1/22, R1 called the front desk yelling and stating that the facility needed to keep their information private. Staff Darkis stated that she then reviewed R1's file and did not see any other contact information besides R1's contact information and also saw that R'1 is self responsible. Interviews with 6 out of 7 residents revealed that they are satisfied with all services received at the facility and have not had any issues or concerns regarding the facility not keeping their records confidential. 6 out of 7 residents stated that they do not have any concerns regarding the facility, the services received or their interactions with facility staff. Interview with R1 revealed that they reviewed their Physician's Orders for Life Sustaining Treatment (POLST) dated 11/24/20 and saw that FM1's information was noted down. LPA reviewed R1's facility file which revealed that R1 was admitted to the facility on 2/14/22. LPA collected a copy of R1's POLST and review of the document did reveal that FM1's name and contact information was listed but this document was completed on 11/24/20 by a staff at a short-term rehabilitation facility that R1 resided at before being admitted to Glen Park at Glendale - Mariposa St. Based on LPA interviews with facility staff, facility residents and LPA review of documentation which revealed that the document that listed R1's FM1 was not completed by staff at Glen Park at Glendale - Mariposa St. LPA Gonzalez determined that there was insufficient evidence to support the above stated allegation. This agency has investigated the complaint alleging, Staff did not keep resident's records confidential. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview held. A copy of the report was provided to Assistant Administrator Rachel De Chavez.the state’s words, verbatim · CDSS document, Jun 9, 2022 · control 28-AS-20220603145532

Allegation investigated: Resident is being discriminated against while in care

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Assistant Administrator Rachel De Chavez and explained the reason for the visit. The purpose of the visit is to investigate the above allegation. Interviews were conducted from 9:30 AM to 11:30 AM with Assistant Administrator Rachel De Chavez and Resident's R1-R8. File was reviewed for Resident R8 and SIR's, Physician's Report, and Emergency ID page were submitted. In regards to the allegation Resident is being discriminated against while in care, based on interviews conducted and information gathered all 8 residents interviewed had not observed any discrimination. Resident R 8 confirmed that staff are respectful on a daily basis and staff are ok. Stated that unhappy that family member isn't able to stay overnight. 7 of 8 resident's interviewed stated staff are nice, respectful and do a good job. Staff interviewed stated that they do person centered care and there is no discrimination. Stated that Special Incident Report's (SIR's) were submitted in which family member of Resident R 8 had stayed Unsubstantiated overnight at the facility and was not adhering to facility protocol. Resident R 8 was with family member at 4 AM on patio. Family member is not allowed to stay overnight which has caused Resident R 1 to be aggressive and law enforcement has been called. 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.the state’s words, verbatim · CDSS document, Jun 2, 2022 · control 28-AS-20220525084343

Allegation investigated: Resident belongings not safeguarded. Resident’s medications are being mismanaged

Licensing Program Analyst (LPA) Tao conducted an Initial 10-Day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with Assistant Administrator, Rachel De Chavez. Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #4 (S4); interviews of residents from Resident#1 (R1) through Resident #6 (R6); reviewed resident#1’s (R1) record reviews, and a facility tour. LPA obtained copies of the Staff and Resident Rosters; and residen files for Resident #1 (R1) with relevant information. The investigation revealed the following: For the allegation of “resident belongings not safeguarded”, it was alleged that resident#1 had several items stolen from resident's room. (-continued in LIC 9099 C) Unsubstantiated Five (5) out of six (6) residents could not corroborate the allegation. Resident interviews from R2 through R6 revealed that staff safeguarded residents’ belongings and residents did not have items missing from their rooms. Interview with R1 stated resident had belongings missing since moved in. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed that facility would safeguard residents’ belongings. Staff said that residents’ belongings were mostly misplaced if they were reported missing. File review revealed R1 did not have the procession of the missing items upon admission to the facility. LPA visited resident#1 in resident’s room and observed the said missing items were in resident’s closet. In regard to allegation: “Resident’s medications are being mismanaged”, it was alleged that staff did not administer one of R1’s medication as prescribed three times a day in a timely basis. Five (5) out of six (6) residents could not corroborate the allegation. Resident interviews from R2 through R6 revealed that staff administer residents’ medication as prescribed. Interview with R1 stated resident did not get medication as prescribed. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed staff did not mismanage resident’s medication. LPA reviewed R1’s medication record, it revealed that R1’s medication is PRN which is administered as needed, not on a routine basis of three times a day. The investigation did not reveal staff mismanaged resident’s medications. Although the allegations 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 are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Assistant Administrator. A hard copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2022 · control 28-AS-20220524162211

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Rachel De Chavez, Assistant Administrator and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 10 hospice residents. There is currently 1 resident on hospice. The facility is a single story building located in a residential area. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the reception area. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. LPA toured randomly selected residents rooms. All bedrooms were furnished with required furniture. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water was between 110.1 to 112.3 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. LPA observed sufficient seven day non-perishable and two day perishable food supplies. All the appliances are clean and operating properly. The common areas include the living room, activity room dining room, outside patio were observed clean and properly furnished. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. The facility has a sprinkler system with wired alarm. Fire extinguishers are present through the facility and are fully charged. LPA observed the facility had the required carbon monoxide detectors. Continue 809C LPA reviewed 7 residents and 5 staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was conducted with Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2022

Allegation investigated: Administrator does not ensure a safe and healthful environment for residents Financial abuse Administrator is retaliating against a resident Staff do not assist residents with incontinence needs Resident do not get enough to eat Staff do not provide snacks to residents Staff do not afford resident confidentiality Staff do not safeguard residents property

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Administrator, Marina Pink and Assistant Administrator, Rachel De Chavez who assisted with today's visit. Regarding the allegation that Administrator does not ensure a safe and healthful environment to residents, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. Administrator and staff interviewed denied the allegation. They stated that the facility does ensure a safe and healthful environment for residents. Residents interviewed were unable to corroborate the allegation. 5 out of 6 residents stated that the environment at the facility is safe and healthful. Regarding the allegation of financial abuse, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. Adminstrator and staff interviewed denied the allegation. They stated that resident #1 has a balance that is overdue, and they have provided resident #1 with documentation of the amount that is overdue. Residents interviewed were unable to corroborate the allegation. 6 out of 6 residents stated that they have not experienced financial abuse at the faciilty. Unsubstantiated Regarding the allegation that the Administrator is retaliating against a resident, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. Administrator and staff interviewed denied the allegation. They stated that Administrator is not retaliating against any resident at the facility. Residents interviewed were unable to corroborate the allegation. 5 out of 6 residents stated that they were not aware that Administrator is retaliating against any resident(s) at the facility. Regarding the allegation that staff do not assist residents with incontinence needs, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. Administrator and staff interviewed denied the allegation. They stated that residents who require assistance with their incontinence needs are assisted. Residents interviewed were unable to corroborate the allegation. 6 out of 6 residents interviewed, stated that they received assistance, or were aware that assistance was being provided to residents who require assistance. Regarding the allegation(s) that residents do not get enough to eat and staff do not provide snacks to residents, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. LPA also obtained copy of facility menu, and toured facility kitchen including food supply. Administrator and staff interviewed denied the allegation. They stated that residents are provided with a sufficient amount of food to eat at mealtimes, and they are provided with snacks. Residents interviewed were unable to corroborate the allegation. 6 out of 6 residents interviewed stated that residents are getting enough to eat and the staff do provide snacks to the residents. Regarding the allegation that staff do not afford resident confidentiality, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. Administrator and staff interviewed denied the allegation. They stated that residents are afforded with confidentiality. Residents interviewed were unable to corroborate the allegation. 5 out of 6 residents stated that they are afforded with confidentiality. Regarding the allegation that staff do not safeguard residents property, the investigation consisted of interviews with Administrator, Assistant Administrator, Staff #1 and Resident #1- Resident #6. Administrator and staff interviewed denied the allegation. They stated that residents property is safeguarded. Residents interviewed were unable to corroborate the allegation. 6 out of 6 residents stated that their property is safeguarded. 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 Assistant Administrator, Rachel De Chavez.the state’s words, verbatim · CDSS document, Apr 6, 2022 · control 28-AS-20220329161435

Allegation investigated: Staff do not meet the residents dietary needs. Staff do not provide adequate care and supervision.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA met with Assistant Administrator, Rachel De Chavez, and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the staff roster, resident roster, food menu, staff schedule and duties, list of diabetic residents, and a resident tracking sheet. A tour of the dining room and kitchen was conducted with Staff. LPA also interviewed 6 Staff and 7 Residents today. The investigation revealed the following: Regarding allegation - Staff do not meet the residents dietary needs. The facility has started a seasonal menu which began on March 6, 2022 and menu will change every quarter. Per the Administrator, the food menu is created by a licensed dietitian from the New Menus Solution Company, who looks at the dietary needs of residents on low sodium, low carbs, and/or those with diabetes. Unsubstantiated The food menu is also inspected by a state dietitian from the Dietitian of Orange County. LPA reviewed the food menu and appear to be nutritional with items from each food group. For lunch and dinner, the chef cooks 2 different plates in which residents may choose from. There are other options available if residents do not like what is on the menu. The daily menu is available and posted in the dining room and weekly menu can be obtained in the front desk. LPA toured the dining room and kitchen during the lunch hour and observed adequate servings with additional options in the kitchen. Three (3) out of Seven (7) residents interviewed stated the food do not seem to fulfill the dietary needs of residents. They feel there are too much carbs and/or not enough selections. Staff interviewed have not heard of residents complaining about the meals except for one. Regarding allegation - Staff do not provide adequate care and supervision. Based on interviews with Staff, they feel there is adequate care and supervision provided to residents. The caregivers stated they have walkie-talkie in which the front desk will page them when a resident pulls the call light in their rooms. They will assist residents as soon as they could and will inform residents when they are assisting another person to wait a few minutes. They also stated that they check on residents every 2 hours and are documented on the residents' tracking sheet. LPA obtained and reviewed the one of the residents tracking sheet on each shift as a sample of their documentation. The facility also has video surveillance in the common areas and hallways for additional supervision. Four (4) out of Seven (7) residents feel there are adequate staffing and staff provide good care and meet their needs. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the Assistant Administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 28-AS-20220324093208

Allegation investigated: Staff member inappropriately touched resident

Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegation. LPA met with Assistant Administrator Rachel De Chavez and explained the reason for the visit. The investigation consisted of: During the initial visit conducted on 11/16/20, LPA conducted a telephone interview with Office Manager Leticia Flores and also conducted a televisit via Facetime with Office Manager for the purpose of conducting a health and safety check. LPA Gonzalez and Office Manager Flores toured the facility. Health and safety check included a tour of the entire facility including lobby and dining room and a sample of resident rooms. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA additionally requested and received copies of Staff and Resident Rosters. On 12/16/21, LPA Gonzalez interviewed Assistant Administrator Rachel De Chavez, Office Manager Leticia Flores and Licensee/ Administrator Marina Pink. (See LIC9099C for continuation) Unfounded LPA attempted to get in contact with North LA County Regional Center Service Coordinator. LPA also conducted a phone call with Assistant Director of CBEM, which is a Crisis Prevention and Intervention Service vendored by North LA County Regional Center. LPA additionally requested and received current resident and staff rosters and also copies of Resident Rosters for the months of September - November 2020. Investigation revealed the following: Regarding allegation of, Staff member inappropriately touched resident, it is alleged that R1 was inappropriately touched by a male staff member in their private area. R1 was also having stomach related problems at the time. Interview with Assistant Administrator Rachel De Chavez revealed that R1 is not a resident of the facility. Interview with Office Manager Flores revealed that R1 has never been a resident of the facility. Interview with Licensee Marina Pink revealed that R1 has never been a resident of the facility. Licensee stated that R1 was a resident of Glen Park at Valley Village but moved out over a year ago. Licensee stated that she does not know where R1 moved to. She stated that R1 did not ever bring up any allegations of being inappropriately touched by a male staff while they lived at the facility. She stated that she was in communication with North LA County Regional Center Service Coordinator regarding R1 but not for the allegation of being inappropriately touched but for concerns regarding the dispensing of R1's Personal and Incidental monies during unscheduled time frames. LPA attempted to contact North LA County Regional Center Service Coordinator but did not receive a call back. LPA spoke to Assistant Director of CBEM, who confirmed that R1 was a resident of Glen Park at Valley Village. LPA review of resident rosters for the months of September - November 2020 revealed that R1 was not a resident of the facility. Based on LPA interviews with Licensee, Office Manager and Administrator and LPA review of documentation which revealed that R1 is not a resident and has not been a resident of the facility, LPA Gonzalez determined that there was insufficient evidence to support the above stated allegation. This agency has investigated the complaint alleging, Staff member inappropriately touched resident. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or are without reasonable basis. We have therefore dismissed the complaint. Exit interview held. A copy of the report was provided to Licensee Marina Pink.the state’s words, verbatim · CDSS document, Dec 16, 2021 · control 28-AS-20201113111739

Allegation investigated: Staff does not treat residents with dignity and respect. Staff threatens residents

Licensing Program Analyst (LPA) Tao conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator, Marina Pink and Assistance Administrator, Rachel De Chavez who assisted with today's visit. The investigation consisted of interviews with administrator, assistant administrator, staff #3 to staff #7, interviews with residents #1 to resident #7, and review of resident #1 files. Regarding the allegation that Staff does not treat residents with dignity and respect, it was alleged that Staff#7 (R7) talk to Resident# 1 (R1) in a disrespectful manner. Per staff interviews, seven (7) of seven (7) staff denied the allegation. Staff interviews revealed staff treat residents with respect and dignity. Per resident interviews, seven (7) of seven (7) residents could not corroborate the allegation. LPA observed that staff treat residents with respect and dignity during the visit. (-continued in LIC 9099 C-) Unsubstantiated Review of staff training, staff received in-service training on resident’s right. 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 that Staff threatens residents, it was alleged that S7 threatened R1. Per staff interviews, seven (7) of seven (7) staff denied the allegation. It revealed staff did not threat residents. Per resident interviews, seven (7) of seven (7) residents could not corroborate the allegation. They stated that they have not observed any resident(s) being threatened by staff. LPA did not observe staff threaten residents during the visit. Review of staff training, staff received in-service training on resident’s right. 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 cited under California Code of Regulations Title 22. An exit interview conducted, and a copy of the report was provided to Assistance Administrator.the state’s words, verbatim · CDSS document, Dec 8, 2021 · control 28-AS-20211129121019

Allegation investigated: Resident was not accorded dignity in their personal relationships with staff.

Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Administrator Marina Pink. The investigation consisted of the following: A physical plant tour of the facility, record review, staff (S1- S6), and residents (R1- R8) were interviewed. Resident (R1's) file was reviewed and documents [Admission Agreement, Face Sheet, Appraisal/Needs and Services Plan, Physician Report, Individual Service Plan (ISP), Resident Appraisal, Functional Capability Assessment, incident reports,bathing schedule, staff roster, and resident roster ] were obtained. No health and safety issues were observed during the visit. See LIC 9099C for report continuation. Unsubstantiated Allegation: "Resident was not accorded dignity in their personal relationships with staff." Based on interviews conducted and record review the findings indicate that facility staff have not caused emotional distress or harassed resident (R1) about hygiene, sponge baths, and cultural background. It is alleged that facility staff communicated communicated to a third party health professional that the resident is not sponge bathing itself. The facility provides shower assistance to residents twice a week, and/or more if needed due to incontinence issues. On the days that residents do not receive a shower they are sponge bathe by staff. Resident (R1) refuses shower assistance and sponge baths. Therefore is not on the facility bathing schedule. Per record review, resident (R1) can bathe itself without assistance. It was noted that the resident is at times disoriented and confused due to health diagnosis. Resident (R1) confirmed refusal of bathing assistance, and stated it bathes and/or washes hair regularly on its own. Resident (R1) stated there are possible cultural differences in hygiene practices. Six (6) out of six (6) staff denied allegation and stated that resident (R1) has good hygiene and is able to perform own bathing. Two (2) out eight (8) residents stated that staff have harassed them and were not treated with dignity during bathing assistance. A resident stated that caregiver staff rush bathing sessions and ask the resident to quickly get out of the shower with soap still in some body parts. Six (6) out of eight (8) residents stated they are treated well by staff and do not feel harassed or mistreated. There is insufficient supportive evidence to concur with the reported allegation. Based on interviews conducted, records reviewed, and LPA observations there is insufficient information to support the allegation. Although the allegation 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. Exit interview conducted with Administrator Marina Pink. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2021 · control 28-AS-20211116162531

Allegation investigated: Staff are abusing residents Staff are stealing from residents

This report supersedes report generated on 8/20/2021 to clarify previous report.********* Licensing Program Analyst's (LPA's) Linda Almaraz and Luis Mora conducted a subsequent complaint visit to investigate the allegations listed above. LPA's met with Assistant Administrator Leticia Flores and explained the reason for today's visit. The investigation consisted of the following: On 12/24/2020, LPA Almaraz interviewed Staff #1-2. On 8/20/2021, LPA's interviewed Flores, Staff #3-5, Residents #1-7 and requested a copy of staff and resident roster. The investigation revealed the following: Based on interviews conducted with staff they have not seen any other staff be abusive to residents or towards residents. Staff also stated they have not heard or been told by residents that they are being mistreated or abused. In regards to the allegation "Staff are stealing from residents," all interviews conducted stated they have not hear of any staff stealing from residents. ( Continued on an LIC 9099C) Unsubstantiated Staff stated there is a resident who is currently at a Skilled Nursing Facility (SNF) who is always stating things are missing and that someone is stealing from the resident. Per interview with staff, they always assist the resident and help the resident look for missing items and they find them. Interviews with residents stated they have not had anything stolen from them. One (1) out of seven (7) residents stated they go in the residents room and the resident could tell they have gone through the residents items but they have not stolen anything from the resident. Based on LPA's interviews conducted, observations and records reviewed, 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 above allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided.the state’s words, verbatim · CDSS document, Nov 6, 2021 · control 28-AS-20201217072050

Allegation investigated: Resident is being harassed by another resident.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Administrator, Marina Pink and Assistant Administrator, Rachel De Chavez who assisted with today's visit. Regarding the allegation that resident is being harrassed by another resident. The investigation consisted of interviews with administrator, assistant administrator, interviews with residents #1 - resident #5, and review of resident #1 and resident #2 files. The investigation revealed that there was an incident on 9/17/21, involving resident #1 and resident #2. Resident #1 stated that resident #2 came to his room, holding an aersol can and threatening to spray it at him. Resident #2 stated that she was holding an aerosol can, but she did not threaten resident #1. Staff interviewed stated that resident #1 and resident #2 have an ongoing issue due to resident #1's playing his music too loudly for resident #2's liking. Resident #3 witnessed the incident, and stated that he did not observe resident #2 threatening resident #1. Unsubstantiated Staff stated that both residents have been counseled regarding the incident, and staff have taken measures to resolve the issues between resident #1 and resident #2. Staff stated that they submitted a special incident report (SIR) to Community Care Licensing as required. LPA Rea obtained a copy of the SIR on today's visit. Other residents interviewed were unable to corroborate the allegation. They stated that they have not observed any resident(s) being harassed by another resident at the facility. Based on LPA's observations and 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 allegations is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of the report was provided to Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 22, 2021 · control 28-AS-20211020141223

Allegation investigated: Staff are not assisting residents with voting

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Rachel De Chavez and explained the reason for the visit. The investigation consisted of: LPA collected copies of Staff and Resident Rosters, conducted interviews with Assistant Administrator Rachel De Chavez at 10:15am -10:30am, Office Manager Leticia Flores at 10:45am, Receptionist Siranush Aleksanyan at 11:00am, Activity Director Shirley Lee at 11:15am and Residents 1-7 (R1-7) from 11:30-12:30pm. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff are not assisting residents with voting, it is alleged that facility staff are not assisting R1 with getting their ballot in for the Gubernatorial Recall Election. Staff have allegedly told R1 that they would help but have kept putting resident off and resident is afraid of not getting their vote in on time. Interviews with facility staff revealed that they did assist residents with their ballots for the Gubernatorial Recall Election if they requested assistance. Facility staff stated that residents who chose to vote by mail got their ballots ready and dropped them off at the reception desk to be mailed out. Staff also stated that the facility also provided transportation to any resident that wished to vote in person at their assigned voting poll location. Interview with R1 revealed that they voted in person and that the facility provided them with transportation to their voting poll location. R1 stated that staff did provide assistance and were helpful regarding making sure they voted. R1 stated that they have no current concerns regarding the facility. 3 out of 7 residents that were interviewed stated that facility staff did assist them with voting by either making sure their ballots were mailed out on time or providing transportation to poll location. 4 out of 7 residents that were interviewed stated that they did not request assistance from staff regarding voting as they chose not to vote. Based on interviews conducted with facility staff and residents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Assistant Administrator Rachel De Chavez.the state’s words, verbatim · CDSS document, Sep 20, 2021 · control 28-AS-20210913134558

Allegation investigated: Lack of supervision resulting in resident eloping from facility.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Rachel De Chavez and explained the reason for the visit. The investigation consisted of: On 10/19/20, LPA conducted an interview with Office Manager Leticia Flores and obtained copies of Staff and Resident Rosters. On 9/20/21, LPA collected copies of Staff and Resident Rosters, conducted interviews with Assistant Administrator Rachel De Chavez at 10:15am -10:30am, Office Manager Leticia Flores at 10:45am, Receptionist Siranush Aleksanyan at 11:00am, Activity Director Shirley Lee at 11:15am and Residents 1-7 (R1-7) from 11:30-12:30pm. LPA also reviwed R8's facility file and (See LIC9099C for continuation) Substantiated collected copies of the following documents: Glen Park at Glendale - Mariposa Internal Incident Report dated 6/1/21, Physician's Report for Residential Care Facilities for the Elderly (LIC602A) dated 3/11/20 and 6/10/21, Appraisal/ Needs and Services Plan (LIC625) dated 7/14/20 and 3/6/21, Preplacement Appraisal Information dated 3/1/19, Resident Appraisal dated 3/2/19 and Functional Capability Assessment dated 3/1/19. LPA additionally attempted to interview R8's responsible party. The investigation revealed the following: Regarding allegation, Lack of supervision resulting in resident eloping from facility, it is alleged Glendale Police Department officer was dispatched to a business on 10/22/20 at approximately 2:45pm due to a report of a lost elderly person (R8). Glendale PD officer stated that store employee reported to officer that R8 walked into the business and told the employee that they were lost. Upon contact with R8, the resident was not able to provide the officer with their birthday, where they where or where they lived and R8 did not have any contact information for family. Glendale PD officer called the facility at approximately 3:33pm to inquire if R8 was missing and was advised by a facility employee that R8 was missing. Officer stated that it appeared that facility staff were not aware that R8 was missing. Interview with Office Manager Leticia Flores revealed that R8 was missing from the facility on 10/22/20 when Glendale PD officer called to inquire if R8 was a resident of the facility. Ms. Flores stated that R8 exhibited exit seeking behaviors especially in the afternoon. Ms. Flores stated that facility staff would regularly redirect R8 and R8 would not succeed in their attempt to elope but on 10/22/20 as the facility was receiving their delivery of groceries the delivery truck parked in an area that blocked the camera view and facility office staff did not see R8 exit the facility. Office Manager stated that R8 was transferred to Glen Park at Glendale - Boynton St due to resident requiring more supervision due to increased exit seeking behavior and also needing a higher level of care. Office Manager Flores stated that since that incident the deliveries are made in an area that does not block camera footage and a staff stands at the gate until delivery is complete to ensure that residents do not exit the facility. Based on interview conducted with facility staff and and LPA review documents, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED. Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. (Refer to LIC 9099D). Exit interview was conducted with Assistant Administrator Rachel De Chavez. A copy of the report and appeal rights were provided to Assistant Administrator.the state’s words, verbatim · CDSS document, Sep 20, 2021 · control 28-AS-20201012151908

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 21, 2021

Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by: Based on interview with facility staff who confirmed that R8 did elope from the facility on 10/22/20 and was found at a local store and brought back to facility by Glendale PD. R8 was not provided with adequate care and supervision on 10/22/20, which poses an immediate risk of residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2021

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.

Allegation investigated: Facility staff handled resident in a rough manner resulting in injury.

Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA was met by Assistant Administrator, Leticia Flores and explained the purpose of today's visit. Later during the visit, Administrator Marina Pink arrived. The investigation consisted of the following: On 7/17/20, LPA conducted telephone interviews with Flores, and Staff #1-3. On 8/31/21, LPA interviewed Staff #4-6 and attempted to interview Staff #7 and Residents' #1 (1:1) Caregiver but was unable because Staff #7 was not at the facility and the 1:1 caregiver was no longer working at the facility. LPA contacted staffing agency for the residents 1:1 caregiver but was not able to reach anyone. LPA also interviewed Residents #1-7. Resident #1's and Staff #1 and 2 file was also requested. The investigation revealed the following: On 7/11/20, an incident occurred at the facility were Resident #1 was getting the residents daily eyedrops from Staff #7 and the staff missed the eye drop when she was putting it on. (Continued on an LIC-9099C) Unsubstantiated It was alleged a staff member handled the resident in a rough manner resulting in a injury. Interviews conducted revealed the resident was combative the day Staff #7 tried to put on the eye drops and the staff tried to calm the resident down. Interviews with staff stated the staff member did not handle the resident in a rough manner and do not remember seeing any bruising or redness on the residents arms. Per staff interviews, the resident never stated Staff #7 handled the resident in a rough manner or was hit. On 7/17/20, the police arrived at the facility and spoke to the resident but no report was filed after speaking to the resident and Flores. Records reviewed showed the resident was never taken to the hospital or had any injury. Interviews revealed that the resident has a history of getting combative with new staff administering medication and will make false allegations because the resident gets upset. LPA also interviewed residents and all interviews stated they have never seen or have been handled rough by Staff #7 or any other staff. Although the allegations 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 the Assistant Administrator and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 31, 2021 · control 28-AS-20200716165452

Allegation investigated: Facility staff stole resident's valuable items

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegation listed above. LPA Spencer met with assistant administrator Rachel de Chavez and explained the purpose of today's visit. The investigation consisted of the following: During the initial visit on 6/21/21, LPA Spencer took a tour of the physical plant and interviewed staff #1-3 (S1-S3) and residents #1-7 (R1-R7). During subsequent visit on 8/31/21, LPA interviewed staff #4-5 (S4-S5). LPA received copies of the staff roster, resident roster, theft and loss policy, and for R7: physician’s report, individual service plan (ISP), personal property inventory list and incident reports from May-July 2021. See LIC9099C for continuation of this narrative. Unsubstantiated The investigation revealed the following: It was alleged that a staff member stole a resident’s valuable items including a ring, cashmere sweater, purse, glasses, makeup, and clothing. All staff interviewed denied the allegation but stated that they were aware of R7’s accusation of stolen items. Staff stated that each time a missing item is reported, it is documented on an internal incident report and searched for by staff. If not found, security footage is reviewed to see who went into the resident’s room. A review of the facility’s theft and loss policy shows that the facility maintains a personal property inventory list for each resident. R7’s personal property inventory lists the ring, cashmere sweater, purse, glasses, and clothing. Staff stated that they later found some of the items in the resident’s room. 7 out of 7 residents interviewed stated that they have not personally witnessed staff stealing items. 5 out of 7 residents stated that they have had items that went missing at the facility, with 4 of the 5 stating clothing items. S5, staff member in charge of laundry services, stated that all resident clothes are labeled and washed separately to prevent loss. S5 stated that residents have not recently complained about missing clothing, but if they do, staff will help residents look for it. Staff stated that many of the residents have memory problems and misplace items that are later found. A review of R7’s incident reports reveal that items were found in the resident’s room and/or checked by camera footage to ensure that no one entered the room. Based on interviews 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 is Unsubstantiated. An exit interview was conducted and a copy of the report was provided to the assistant administrator.the state’s words, verbatim · CDSS document, Aug 31, 2021 · control 28-AS-20210614095847

Allegation investigated: Staff are abusing residents Staff are stealing from residents

Licensing Program Analyst's (LPA's) Linda Almaraz and Luis Mora conducted a subsequent complaint visit to investigate the allegations listed above. LPA's met with Assistant Administrator Leticia Flores and explained the reason for today's visit. The investigation consisted of the following: On 12/24/2020, LPA Almaraz interviewed Staff #1-2. On 8/20/2021, LPA's interviewed Flores, Staff #3-5 and requested a copy of staff and resident roster. The investigation revealed the following: Based on interviews conducted with staff they have not seen any other staff be abusive to residents or towards residents. Staff also stated they have not heard or been told by residents that they are being mistreated or abused. In regards to the allegation "Staff are stealing from residents," all interviews conducted stated they have not hear of any staff stealing from residents. ( Continued on an LIC 9099C) Unsubstantiated Staff stated there is a resident who is currently at a Skilled Nursing Facility (SNF) who is always stating things are missing and that someone is stealing from the resident. Per interview with staff, they always assist the resident and help the resident look for missing items and they find them. Interviews with residents stated they have not had anything stolen from them. One (1) out of seven (7) residents stated they go in the residents room and the resident could tell they have gone through the residents items but they have not stolen anything from the resident. Based on LPA's interviews conducted, observations and records reviewed, 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 above allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided.the state’s words, verbatim · CDSS document, Aug 20, 2021 · control 28-AS-20201217072050

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility is in disrepair.

***This report serves as an amendment and supersedes the original complaint investigation report created on 06/01/2021. The purpose of this amended Licensing report is to change the finding to unsubstantiated. *** Licensing Program Analyst (LPA) Tao conducted an initial complaint investigation of the above allegation on 06/01/21 and subsequent visit on 06/02/22. LPA discussed the purpose of the visit to Rachel. On 06/01/21, investigation consisted of staff interviews from staff#1 to staff#4; resident interviews from resident #1 to resident #8; review of maintenance log; and obtained Resident roster and Staff roster. For the allegation of “facility is in disrepair”, investigation revealed that facility's underground water pipe had burst and water was off for a half day on 05/25/21 and 05/26/21 to complete the repair. Plumbing issue was completed on 05/26/21. Seven out of seven residents confirmed the facility’s water was off only half day and had water supply for half day. Four out of four staff interviewed confirmed water was off due to facility’s plumbing issues at the underground pipe. Incident report was filed to address the issue. Since facility had no control on the plumbing issue of the underground water pipe, administrator had done diligent work to handle the plumbing issues on a timely basis. Although the allegations 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 are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Assistant Administrator. A hard copy of this report was provided. Unsubstantiated Per staff interviews, it reported that the facility had plumbing issues related to underground pipe. An outside plumber was not contacted, and all plumbing issues were handled by maintenance staff. Administrator stated the plumbing issue was repaired. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 05. See LIC 9099 D for citation details. An exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 1, 2021 · control 28-AS-20210526161530

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 1, 2021

87303(a).Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by evidence of: Based on observation during record review and interviews conducted, facility has had plumbing issues and water was off on May 25 and May 26 2021. Plumbing issue and water issues were observed to be in need of repairs.the state’s words, verbatim · CDSS document, Jun 1, 2021

Plan of correction: Administrator had maintainence staff to repair the plumbing issue and water was back on normal on May 26,2021. Issue was fixed. POC is cleared at visit.