Atria Santa Clarita

Allegation investigated: Staff failed to properly report incident to authorized representative

This is an amendment of the report issued on 04/27/23 to rectify a typographical error. Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Business Office manager and informed the purpose of the visit. LPA conducted physical plant tour at 9:30 AM, requested copy of facility documents relevant to the investigation and reviewed the same from 10:00 AM to 11:30 AM. LPA also conducted interview with staff from 11:30 AM to 12:30 PM. It was alleged that there was no communication from the facility about Resident #1 (R1) to family member (FM) being rushed to emergency surgery for a broken hip on 10/21/19. LPA's record review today between 10:00 AM to 11:30 AM revealed that staff called the family member of R1 and Primary Care Physician (PCP) on the night of the incident on 10/20/19 at around 11:30 PM. LPA's interview with the former Staff #1 (S1) today at 12:10 PM, who attended to R1 on the day of the incident, revealed that S1 was sure that S1 made the call to the family member of R1 after calling 911. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 27, 2023 · control 31-AS-20200225154209

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Johnny Ortiz, and Resident Services Director Venca Avivi informed them the reason of the visit. LPA conducted a case management pertaining to the a incident report that was submitted for resident # 1 (R1), and staff did not follow physician orders when administering the medication. LPA contacted the ED on 04/06/2023 to gather further information pertaining to the incident. According to the ED and Resident Services Director Venca Avivi, R1 was scheduled to have a dental procedure and was prescribed a medication, that was to administered the day before the procedure. Staff #1 (S1) did not have accurate information on the specific date as to when the medication was supposed to be administered to R1 and was given to R1 on the wrong date. The Resident Services Director reported to LPA, the correct information was not communicated to the medication technicians. LPA determined, facility staff did not follow the correct physician orders that was provided for R1. This is a health and safety risk to residents in care. A citation was issued during today's visit. Exit interview, copy of report and appeal rights provided to Executive Director.the state’s words, verbatim · CDSS document, Apr 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 10, 2023

Incident Medical/Dental Care. (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...facility staff..shall be permitted to assist... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met, evidenced by, staff did not administer the medication according to doctor's orders. This a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: Resident Services Director reported to LPA that a medication in-service started 04/06/2023 and other dates are scheduled for additional training. LPA requested copies of the 1st training that was conducted on 04/06/2023. POC cleared during today's visit.

Allegation investigated: Lack of Care and supervision resulting to dehydration

This is an amendment of the report issued on 10/28/22 to change the findings. Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with staff Venca Avivi and explained the reason for today’s visit. On 05/10/21, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Olivia Spindola. On 05/11/2021 at 11:00 AM, LPAs Tuesday Cabiness and Rosaura Valenzuela initiated the complaint visit. LPAs Cabiness and Valenzuela conducted physical plant tour and obtained copies of the facility records relevant to the investigation. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) During the course of the investigation, Investigator Spindola interviewed the Assistant Administrator, staff and family member on different dates and time from 05/13/21 to 07/17/21. IB Investigator Spindola also reviewed Hospital Records on 05/24/21 and 07/07/21 and Los Angeles Sheriff Department (LASD)’s record on 07/09/21. Regarding the allegation that lack of care and supervision resulting to dehydration, IB Spindola’s hospital record review on 05/24/21 revealed that during these hospitalization of R1 due to fall on 03/15/21 and 04/02/21 R1 was diagnosed by the hospital with Urinary Tract Infection (UTI) and again was diagnosed with UTI on 04/30/21 when hospitalized due to another fall. IB Investigator Spindola’s interview with staff on 05/17/21 revealed that R1 used to drink a lot of water before but since R1 declined, R1 had limited intake. LPA’s interview with three (3) care staff who used to care for R1 on 03/26/22, revealed R1 was regularly provided with liquids for hydration, including water, juice and/or soda during R1’s stay at the facility. Based on the information gathered during the course of the investigation, there is an insufficient information to support the allegation. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Mar 18, 2023 · control 31-AS-20210510084331

Allegation investigated: Staff diagnosed resident without proper consent Resident sustained an injury from a fall while in care

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Resident Services Director Venca Avivi and explained the reason for the visit. LPA conducted physical plant tour at 9:40 AM, requested copy of facility documents relevant to the investigation and reviewed the same from 10:00 AM to 1:00 PM. LPA also conducted interview with staff from 1:00 PM to 2:30 PM. Regarding the allegation that staff diagnosed resident without proper consent, it was alleged that the facility did not inform Resident #1 (R1)'s family member regarding a doctor's visit to evaluate R1 which resulted to a new diagnosis. LPA's record review today between 10:00 AM to 1:00 PM revealed that R1 was already diagnosed with Dementia prior to moving in at the facility. Further review also revealed that it was R1's PCP who ordered the evaluation and not the facility staff. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with the Resident Service Director today at around 1:00 PM, also revealed that they were not aware of the PCP's ordered evaluation until the evaluating doctor arrived at the facility. Regarding the allegation that resident sustained an injury from a fall while in care, it was alleged that R1 fell on the night of 10/20/19 and was rushed to the hospital for an emergency surgery for a broken hip. LPA's record review today between 10:00 AM to 1:00 PM revealed that R1 was assessed by a third party out of state nurse prior to move in on 07/19/19 and was assessed to be a minimal fall risk and was assessed by an out of state physician on 07/10/19 to be ambulatory but requires walker. Pre move in appraisal of the facility dated 07/30/19 also revealed that R1 requires only minimal fall assistance but was placed on status check every two (2) hours. This is consistent with Move in Assessment dated 08/21/19 and Thirty (30) day Assessment of R1 dated 09/19/19. LPA's interview with three (3) care staff who attended to R1 during R1 stay at the facility on 11/05/22 between 11:30 AM to 1:45 PM and two (2) care staff today between 1:00 PM to 2:30 PM revealed all five (5) of them do check R1 every two (2) hours as scheduled on their daily assignment to ensure that R1 was doing well. Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 31-AS-20200225154209

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 staff not providing assistance to residents in a timely manner.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with the Executive Director (ED), Johnny Ortiz, and discussed the reason for the visit. --- Facility staff not providing assistance to residents in a timely manner. It was alleged that the residents are waiting a long period of time because the facility is understaffed. To investigate the allegation, on 10/31/2022 at 10:45 AM, LPA requested records, at 12:00 PM, LPA interviewed residents, at 1:45 PM, LPA made observations and, at 2:00 PM, LPA interviewed staff. Record reviews show that in the past seven days the call button was used two hundred sixty four times (264), the average response time was seven minutes (07) and there is at least one caregiver per floor per shift caring for an average ten (10) residents per floor in the Memory Care building and twenty eight (28) in the Assisted Living building. (Cont. on LIC9099-C) Unsubstantiated During interviews with residents, they all stated that they do not feel that the facility is understaffed and that the response times for assistance are not long. Furthermore, LPA pushed resident #3's (R3) call button and observed that staff responded within three (03) minutes. During interviews with staff, they all stated that they do not feel the facility is understaffed, that no matter how busy the staff are, there is always someone available to assist residents and the average response times to the call buttons are between five (05) to ten (10) minutes. Based on interviews, record reviews and observations, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 31, 2022 · control 31-AS-20221027112508

Allegation investigated: Lack of Care and supervision resulting to multiple falls sustaining severe injuries Due to insufficient staffing residents needs were not met

This is an amendment of the report issued on 10/28/22 to partially change the findings. Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the findings for the above allegation. LPA met with staff Venca Avivi and explained the reason for today’s visit. On 05/10/21, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Olivia Spindola. On 05/11/2021 at 11:00 AM, LPAs Tuesday Cabiness and Rosaura Valenzuela initiated the complaint visit. LPAs Cabiness and Valenzuela conducted physical plant tour and obtained copies of the facility records relevant to the investigation. (continued on LIC 9099-C) Substantiated (continued from LIC 9099) During the course of the investigation, Investigator Spindola interviewed the Assistant Administrator, staff and family member on different dates and time from 05/13/21 to 07/17/21. IB Investigator Spindola also reviewed Hospital Records on 05/24/21 and 07/07/21 and Los Angeles Sheriff Department (LASD)’s record on 07/09/21. Regarding the allegation that lack of care and supervision resulting to multiple falls sustaining severe injuries, it was alleged that Resident #1 (R1) had fallen four (4) times between the period of 12/07/20 to 04/02/21 resulting to multiple injuries. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be, due to lack of staff. LPA’s record review on 10/20/22 at around 1:45 PM revealed that the last Functional Needs Assessment and Functional Needs and Services Plan for R1 was done on 03/25/21. The need of assistance on the document was scored by the points. R1 was a fall risk resident and required “stand-by/remind” assistance 3 x per day and escort assistance as needed but scored “0” on the assessment. On the status check also R1 required “stand-by/remind” assistance 3x a day but scored “11” on the assessment. IB Investigator’s interview with Staff #1 (S1) on 07/14/21 at 2:30 PM, revealed that on 04/30/21 S1 saw R1 on the hallway but was unable to help R1 because S1 was assisting another resident. By the time S1 rushed to assist R1, resident was found on the floor. Investigator Spindola’s interview with Staff #2 (S2) on 5/17/21 at 12:30 PM also revealed that R1 fell twice on 04/30/21 between 8:00 AM to 9:00 on the first fall and at 11:15 AM, R1 was hospitalized on the 2nd fall, and no one witnessed R1 falling on both incidents. Regarding the allegation that due to insufficient staffing residents needs were not met, it was alleged that the memory care unit was understaffed. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be due to lack of staff. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff on 04/03/22 between 10:00 AM to 1:00 PM however, revealed that five (5) of six (6) staff interviewed between 03/26/22 and 04/03/22 believed that there is sufficient staff working at Memory Care unit during this time period. Based on the information gathered during the course of the investigation, the allegations are deemed substantiated at this time. Citation issued, appeal rights discussed and given. Exit interview conducted. Copy of this report issued. (continued from LIC 9099-C) Regarding the allegation that due to insufficient staffing residents needs were not met, it was alleged that the memory care unit was understaffed. IB Investigator Spindola’s interview with four (4) staff on 5/27/21, 07/08/21 and 07/14/21 revealed that two (2) out of four (4) staff believed that they were unable to help residents at the memory care unit as they should be due to lack of staff. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff on 04/03/22 between 10:00 AM to 1:00 PM however, revealed that five (5) of six (6) staff interviewed between 03/26/22 and 04/03/22 believed that there is sufficient staff working at Memory Care unit during this time period. Based on the information gathered during the course of the investigation, the allegation is deemed substantiated at this time. Citation issued, appeal rights discussed and given.the state’s words, verbatim · CDSS document, Oct 28, 2022 · control 31-AS-20210510084331

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Oct 31, 2022

Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by: Based on IB investigator's interview and record review, licensee did not ensure to supervise/monitor the resident to ensure R1's health safety and wellbeing. R1 fell and sustain injuries due to lack of proper supervision/monitoring. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2022

Plan of correction: Executive Director agreed to agreed to submit a Statement of Understanding and step by step plan to avoid similar issues from happening again regarding meeting basic care needs of the residents and will submit to CCL on or before the POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 31, 2022

(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on IB investigator interview and record review, licensee failed to ensure that there is sufficient staff to care for R1 based on R1's current appraisal. This poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 28, 2022

Plan of correction: Cleared during visit. LPA record review and recent interview with staff revealed that the staff is sufficient at this time.

Allegation investigated: Facility staff billed resident for services not being provided. Changes in resident’s condition was not discussed with the family and physician.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Johnny Ortiz and discussed the reason for the visit. --- Facility staff billed resident for services not being provided. --- Changes in resident’s condition was not discussed with the family and physician. It was alleged that resident #1 (R1) is being billed for care they are not receiving, and that staff reassessed the R1 but did not inform their doctor. To investigate these allegations, on 09/06/2022 at 12:30 PM, LPA interviewed staff, on 09/06/2022 at 2:30PM, LPA requested pertinent documents and, on 10/06/2022 at 01:30 PM, LPA interviewed the Reporting Party (RP). During interviews with staff, they stated they do not charge for services not provided, that R1 was at a Level One (01) with Level One (01) Medication assistance, that R1's spouse requested for a higher level of care by phone and after a reassessment of needs, the level of care was increased to Level Two (02). (Cont. on LIC9099-C) Substantiated After subsequent discussions between staff and the responsible party, the Level was changed back to a Level One (01). During interviews with the responsible party, they stated they are at the facility often, the resident is able to manage some of their own medications, staff are not checking on the resident as needed, staff increased the level of care from a Level One (01) to a Level Two (02) because the RP was no longer able to visit as often and that both they and the resident’s physician were not notified of the change from a Level One (01) to a Level Two (02) in writing. Although Level Two (02) services may or may not have been provided, record reviews revealed that the resident’s Responsible Party AND physician were not notified in writing about the change of the resident's needs and/or condition that resulted in a change of the level of care. Therefore, based on record reviews, the allegation is substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No health and safety hazards observed during the visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Oct 17, 2022 · control 31-AS-20220829113112

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(b) · Plan of correction due date: Oct 24, 2022

87463 Reappraisals (a)…The reappraisals shall document changes in the resident's physical, medical, mental, and social condition…(b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by; Based on record reviews, the family AND physician were not notified in writing of the change in level of care which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2022

Plan of correction: The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87463 Reappraisals; The written letter must be sent to the LPA by the POC due date. Furthermore, the facility will make any necessary adjustments in fees charged and provide a copy of any adjustments to the LPA by the POC due date.

Allegation investigated: Staff did not ensure that resident's hygiene needs were met. Staff did not provide appropriate incontinent care. Staff issued an improper eviction notice to resident.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Johnny Ortiz, Executive Director (ED), and discussed the reason for the visit. --- Staff did not ensure that resident's hygiene needs were met. It was alleged that resident #1 (R1) was found to be malodorous during a visit by the Reporting Party (RP). To investigate this allegation, on 09/06/2022 at 12:30 PM, LPA interviewed staff and residents, on 10/06/2022 at 01:30 PM, LPA interviewed the Reporting Party (RP). In addition to the interviews, on 10/10/2022 at 12:30 PM, LPA conducted a physical inspection of randomly selected rooms. (Cont. on LIC 9099-C) Unsubstantiated Interviews with staff revealed that all hygiene needs are being met, that each resident has a shower schedule, are also showered more often if needed, and that caregivers are on standby for those who need assistance. Staff also stated that at times R1 refuses to shower and that they can only encourage R1 to shower but cannot force. During interviews with residents, they all stated (including R1) that their hygiene needs are being met and that they are being showered timely. During interviews with the RP, they stated that R1 was not being showered often enough, smelled at times, but they are also aware that R1 refuses to shower. During observations of residents, LPA found that they all appeared clean, well groomed and did not experience any malodor during the visit. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not provide appropriate incontinent care. It was alleged that resident #1 (R1) is not getting assistance with diapering. To investigate this allegation, on 09/06/2022 at 12:30 PM, LPA interviewed staff and residents and, on 10/06/2022 at 01:30 PM, LPA interviewed the Reporting Party (RP). In addition to the interviews, on 10/10/2022 at 12:30 PM, LPA conducted a physical inspection of randomly selected rooms. Interviews with staff revealed that all incontinent care needs are being met, they change R1’s diaper up to three times a day, but are changing R1 more often, if needed. Staff also stated R1 always requests for two diapers at a time so that in the event they soil one, they may rip it off, discard it, and pull up the clean one. During interviews with the RP, they stated that the facility is not checking on R1 frequently enough and they are not changing the diaper as often as they should. During interviews with residents, they all stated (including R1) that their toileting needs are being met timely. Furthermore, LPA observed residents and found that they all appeared clean and did not see or smell any bodily fluids or waste during the visit. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Cont. on LIC 9099-C) --- Staff issued an improper eviction notice to resident. It was alleged that resident #1 (R1) was issued an eviction notice. To investigate this allegation, on 09/06/2022 at 12:30 PM, LPA interviewed staff and residents, on 09/06/2022 at 2:30PM, LPA requested pertinent documents and, on 10/06/2022 at 01:30 PM, LPA interviewed the Reporting Party (RP) and requested documents. Interviews with staff revealed that R1 was not issued an eviction notice. During interviews with the RP, they stated that, because they did not agree with certain charges, the facility issued an eviction notice. LPA asked RP to produce this eviction notice but they did not provide one. During interviews with residents, they all stated (including R1) that they have either never been issued an eviction notice or did not know whether they ever have been. Record reviews also confirmed that R1 was not issued an eviction notice. However, according to what was found in the R1’s file and what was provided by the RP, the responsible party failed to pay for a portion of the bill (for higher level of care) and it stated that failure to pay may lead to a termination of services “including potential eviction procedures” and on a different letter for an attempt to collect a debt it stated, if payment is not received “we have no choice but to terminate the Residency Agreement and commence eviction.” Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Oct 10, 2022 · control 31-AS-20220829113112

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to the facility. LPA arrived at 11:00 AM. Upon entry, LPA met with the Executive Director, Johnny Ortiz, and screened for COVID 19. LPA conducted a physical plant tour at 11:30 AM. An SOC341 was received 08/02/2022 alleging that staff #1 (S1) grabbed and pulled resident #1 (R1) by the arm and wrist to re-direct the R1. Later that day, R1 complained about soreness at the site of where R1 was allegedly grabbed. On 08/08/2022, from 12:30 PM - 3:00 PM, LPA interviewed three staff and one resident. No action was taken during the visit. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 8, 2022

Allegation investigated: Resident is not being assisted with services. Facility did not communicate with authorized representative about change of services being provided. Facility is in disrepair.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with the Executive Director (ED), Johnny Ortiz, and discussed the reason for the visit. --- Resident is not being assisted with services. It was alleged that resident #1 (R1) was not getting the services that the family pays for, such as diaper changing, wrapping his left leg and changing his bedding. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and on 04/20/2022 at 3:30pm, LPA interviewed residents and conducted a physical inspection of randomly selected rooms including R1’s room. The observations and interviews revealed that the beddings were clean and, according to staff, they are changed once a week or as needed. (CONT. on LIC9099-C) Unsubstantiated It was also reported that the R1’s diaper is changed at least three time per day and more if needed. On 04/20/2022 at around 4:00pm, LPA interviewed Med Tech Miriam Zepeda Aguilar. Interviews revealed that R1’s gauze is changed by home health twice a week and that the facility wraps gauze around the open wound as needed. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility did not communicate with authorized representative about change of services being provided. It was alleged that the Responsible Party did not have any knowledge of the change in level of care. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and requested records. On 04/20/2022 at around 5:00PM LPA interviewed the complainant. Interviews and record review revealed that an assessment was completed, the facility did notify the resident prior to the change in the level of care and the Admission Agreement, which was signed by all parties, clearly states, “…when the assessment of your needs indicates that the level of care we are providing you is not appropriate for your needs, we may change your level of care and the fees that we charge you. Any such change in fees due us resulting from a change in the level of care will be effective immediately and we will notify you or the Responsible Party of the change”. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility is in disrepair. It was alleged that R1’s room had a leak from the room above and as current R1's ceiling is peeling and has not been repaired. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and on 04/20/2022 at 3:30pm, LPA conducted a physical inspection of randomly selected rooms including R1’s room. Interviews revealed that one day the tenant in the room above R1’s room left the sink running and that the water was leaking below, but that it was soaked up immediately and there were no damages. During the physical inspection, LPA did not observe any disrepair in any of the rooms, including R1’s room. (Cont. LIC 9099-C) LPA asked the Reporting Party about the disrepair and they were unable to identify any problems or where the alleged previous problems were. The room was neat and clean, there was no sign of water damage, cracking, paint chipping or molding. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jun 29, 2022 · control 31-AS-20220315143212

Allegation investigated: Residents door is in disrepair

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit. LPA met with Venca Avivi and discussed the reason for the visit. ---Residents door is in disrepair It was reported that the resident's door is in disrepair. To investigate this allegation, on 03/11/2022, between 12:30pm - 2:30pm and on 05/02/2022 between 2:15 PM - 3:20 PM, LPA conducted interviews and requested pertinent documents. The interviews revealed that the resident would often aggressively handle the door, motioning the door handle up and down beyond its intended design limitations and it eventually broke. Although documents revealed that a work order was place for repairs on 03/08/2021 at 12:43pm and the door was repaired the following day, the facility failed to completely remove the mechanism from the disrepaired door which resulted in a visitor and resident being locked in the room. (Cont. on LIC 9099-C) Substantiated Based on interviews, observations and record review, the allegation is SUBSTANTIATED at this time. No other health and safety hazards were noted during the visit. An exit interview was conducted. A copy of this report, the original LIC 9099-D and Appeal Rights were discussed and provided. The signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 24, 2022 · control 31-AS-20200309111042

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 27, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is met as evidenced by; Based on interviews, record review and observations, the licensee did not comply with the section cited above as the door was left in disrepair while the room was occupied by a resident which poses a potential Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, May 24, 2022

Plan of correction: Licensee/adminsitrator shall review California Code of Regulations Title 22 section 87303 and submit a written plan to ensure that the facility is in good repair at all times.

Allegation investigated: Staff not providing resident’s medications as prescribed.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegation. LPA met with Venca Avivi and discussed the reason for the visit. --- Staff not providing resident’s medications as prescribed. It was alleged that the Resident #1 (R1) was given his potassium pills twice a day instead of once a day as written on the bottle. To investigate this allegation, on 03/16/2022 at 11:50am, Licensing Program Analysts (LPA) requested pertinent documents and, on 04/20/2022 at 3:45pm, LPA interviewed staff and complainant. A review of R1’s Physician’s Orders revealed that R1 was prescribed potassium 10mg once daily, yet the Medication Administration Records (MAR) dated 08/20/2020 shows that the facility administered the medication twice daily. (Cont. on LIC9099-C) Substantiated Based on the information gathered during the course of this investigation, the allegation is SUBSTANTIATED at this time. No other health and safety hazards were noted during the visit. An exit interview was conducted. A copy of this report, the original LIC 9099-D and Appeal Rights were discussed and provided. The signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, May 24, 2022 · control 31-AS-20220315143212

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 25, 2022

87465(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the section cited above as the facility did not ensure that medications were given as prescribed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2022

Plan of correction: Administrator will schedule medication training for all staff with an approved vendor. Training will need to be scheduled within 24 hours and completed by 6/07/2022. Administrator will provide a copy of the scheduled training to the LPA after scheduling.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not seek timely medical care for resident. Facility has C diff contamination.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with Executive Director (ED), Johnny Ortiz, and explained the reason for the visit. --- Staff did not seek timely medical care for resident. It was alleged that the facility did not seek timely medical attention for Resident #1 (R1). To investigate this allegation on 04/06/2022 LPA interviewed staff and requested pertinent documents from 11:00 AM - 2:20 PM. Interviews and record reviews revealed that the facility staff completed a Notice of Change in Condition on 05/03/2020, 05/06/2020 and 05/11/2020 and faxed them to the physician at HealthCare Partners Medical Group and Affiliated Physicians. (Cont. on LIC9099-C) Unsubstantiated Interviews revealed that staff notified R1’s physician about the loss of appetite, decreased fluid intake and loose stool and that the physician’s response was, “no update in medications or care needed at this time”. Subsequently, Staff #1 (S1) was notified of R1’s rapid decline and immediately called 911. Based on the interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility has C diff contamination. It was alleged that R1 got the infection from staff or other residents and since residents share bathrooms, it is highly likely that the facility has more cases of C diff. To investigate this allegation on 04/06/2022 LPA conducted a physical plant tour at 10:00 AM, interviewed staff and requested pertinent documents from 11:00 AM - 2:20 PM. Interviews, record review and observations revealed that there were no other cases of C diff during R1’s time at the facility. LPA observed R1’s room and R2’s room, whom which R1 shared a restroom with. Record reviews revealed that R2 did not have C diff before or after R1 was admitted. Record reviews and interviews further revealed that neither staff nor residents contracted C diff during R1’s time at the facility. Based on the interviews, record reviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 31-AS-20200521113557

Allegation investigated: Staff do not assist with showering.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with Johnny Ortiz, Executive Director (ED), and discussed the reason for the visit. --- Staff do not assist with showering. It was alleged that R1 did not shower for weeks. To investigate this allegation, on 03/16/2022 at 10:15am, LPA interviewed staff and on 04/20/2022 at 3:45pm, LPA conducted a physical inspection of randomly selected rooms and interviewed staff between 3:30pm-4:30pm. The observations and interviews revealed that all hygiene needs are being met, that each resident has a shower schedule, but are also showered more often if needed, and that caregivers are on standby for those who need assistance. (CONT. on LIC9099-C) Unsubstantiated Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 31-AS-20220315143212

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: Resident's walker was in disrepair Staff did not safeguard residents personal belongings

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Resident Care Director Venca Avivi and informed the purpose of the visit. LPA conducted physical plant tour at 9:50 AM, requested facility records relevant to the investigation at 10:30 AM and conducted interview with staff between 11:00 AM to 1:00 PM. Regarding the allegation that resident's walker was in disrepair, it was alleged that Resident #1 (R1)'s walker leg falls off when being picked up. LPA's interview with four (4) staff on 03/26/22 between 10:00 AM to 2:00 PM and two (2) staff today between 10:00 AM to 1:00 PM revealed that no one was aware that R1's walker was broken until it was reported by R1's family member on 04/02/21. LPA's record review on 03/26/22 at around 11:30 AM also revealed that R1 had a new walker delivered the next day, 04.03/21 as ordered by the family member. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff did not safeguard resident's personal belongings, it was alleged that R1's eye glasses were lost. LPA's interview with Staff #1 (S1) on 03/26/22 between 10:00 AM to 2:00 PM revealed that the primary care staff of R1 reported that the R1's eye glasses broke when R1 had an unwitnessed fall on 03/15/21. LPA's interview with the Memory Care Director today at around 11:30 AM today, however, revealed that she did not receive any report about R1's broken eye glasses otherwise she should have reported it to the family member to have it replaced as it was a prescription eye glass. Based on the information gathered during this and prior visits, there is insufficient information to support the allegation and therefore deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 13, 2022 · control 31-AS-20210510084331

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: Resident was overheated. Resident was dehydrated. Facility did not have hot water for a week.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with Executive Director (ED), Johnny Ortiz, and explained the reason for the visit. --- Resident was overheated. It was alleged that Resident #1 (R1) was in her room with the door shut, and the heater was on full blast. To investigate this allegation, on 03/11/2022 at 9:40 AM, Licensing Program Analysts (LPAs), Abeye Duguma and Gary Tan, conducted a physical plant tour and interviewed staff between 10:15 AM – 11:40 AM. Interviews and observations revealed that the facility staff do not adjust the room’s temperature higher than seventy-eight degrees (78º). (CONT. on LIC 9099-C) Unsubstantiated During the physical plant inspection, LPAs observed the thermostats at a comfortable range of 72 - 75º. During the interviews it was reported that R1 bundles up layers of clothing frequently and often feels cold. Based on the interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Resident was dehydrated. It was alleged that Resident #1 (R1) was . To investigate this allegation, on 03/11/2022 at 9:40 AM, Licensing Program Analysts (LPAs), Abeye Duguma and Gary Tan, conducted a physical plant tour and interviewed staff between 10:15 AM – 11:40 AM. Interviews and observations revealed that the resident drinks lots of water and always has a tumbler full of water in the room. LPAs also observed a note on the night stand that read, “drink your water”, a tumbler full of water next to the bed and resident, who was participating in group activities at the time, sitting with a cup full of water. Based on the interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Facility did not have hot water for a week. It was alleged that the facility did not have hot water for a week. To investigate this allegation, on 03/11/2022 at 9:40 AM, Licensing Program Analysts (LPAs), Abeye Duguma and Gary Tan, conducted a physical plant tour, requested pertinent documents and interviewed staff between 10:15 AM – 11:40 AM. Interviews revealed that the water heater’s ignitor pilot was reported broken on 02/28/2022, that a Work Order was submitted the same day and fixed within a weeks’ time. During the time that the water heater was not in working condition, the residents were transferred to the adjacent building for showering and other hygiene needs. In addition, LPAs selected rooms at random and it was observed that all faucets had hot water during the time of the visit. Based on interviews and observations, the facility was able to maintain the health, hygiene needs and safety of their resident through alternate means. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 6, 2022 · control 31-AS-20220310153449

Allegation investigated: Facility is malodorous Residents room was dirty

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Resident Care Director Venca Avivi and informed the purpose of the visit. LPA conducted physical plant tour at 10:00 AM, requested facility records relevant to the investigation at 11:00 AM and conducted interview with staff and residents between 11:00 AM to 2:00 PM. Regarding the allegation that the facility is malorodorous, it was alleged that the hallway of the Life Guidance (Memory Care) Unit of the facility reeked of urine. LPA toured all three (3) floors of the Memory Care unit and did not observe any stink and/or bad smell along the hallways and common rooms of the building. (continued on LIC 9099-C Unsubstantiated (continued from LIC 9099) Regarding the allegation that the residents' room was dirty, it was alleged that the room was filthy and had sticky floors and dusty. During today's visit at around 11:00 AM, LPA inspected five (5) random rooms on the first floor, six (6) random rooms on the second floor and nine (9) random rooms on the third floor of the Memory Care building and did not observe any filth, dust or sticky floors on all of the rooms inspected. LPA Valenzuela's physical plant tour conducted on 05/11/21 at 11:15 AM, where in she inspected a total of twenty one (21) random rooms on all floor, also revealed that the facility was clean and in good condition. Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 26, 2022 · control 31-AS-20210510084331

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: Staff locked residents in their rooms. Residents door is in disrepair.

Licensing Program Analysts (LPAs) Abeye Duguma and Gary Tan conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with Johnny Ortiz, Executive Director (ED) and discussed the reason for the visit. ---Staff locked residents in their rooms. It was reported that the resident is being locked in the room. To investigate these allegations, on 03/11/2022 at 2:00pm LPAs conducted a physical plant tour. During the tour, LPAs selected random rooms to inspect and discovered that the rooms may only be locked from the inside. LPAs' interview facility staff between 12:30pm-2:30pm revealed that no one locked any resident inside their rooms at any time. Based on the information gathered during this and prior investigations, the allegation is unsubstantiated at this time. (CONT on LIC9099-C) Unsubstantiated --- Residents door is in disrepair It was reported that the resident's door is in disrepair. To investigate these allegations, on 03/11/2022, between 12:30pm - 2:30pm LPAs conducted interviews and requested pertinent documents. The interviews with facility staff revealed that the resident would often aggressively handle the door, motioning the door handle up and down beyond its intended design limitations and it eventually broke. The pertinent documents reviewed by the LPAs and interviews with facility staff also revealed that a work order was place for repairs on 03/08/2021 at 12:43pm and the door was repaired the following day. Based on the information gather, during this and prior investigations, the allegation is unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 11, 2022 · control 31-AS-20200309111042

Allegation investigated: Staff did not safeguard resident's personal belongings

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Executive Director (ED) Johnny Ortiz. --Staff did not safeguard resident's personal belongings It was reported that Resident #1’s (R1) dentures were misplaced/lost and the facility staff felt that they should not be held responsible. During the investigation conducted on 01/24/2022 at 10:30am, LPA interviewed the reporting party. On 02/08/2022 at 11:00am, LPA requested facility records and interviewed the Executive Director (ED). LPA conducted a record review and discovered that the personal belonging in question was not listed on the Client/Resident Personal Property and Valuables Inventory Form which was signed and dated by R1’s responsible party. Based on interviews and record review, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 22, 2022 · control 31-AS-20220121083121

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: Resident is left in room all day Facility did not provide resident with a 60day notice of rent increase for COVID expenses Resident's closet door is in disrepair

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Executive Director (ED) Johnny Ortiz. --Resident is left in room all day. It was reported that Resident #1's (R1) resident is left in the room all day. To investigate this allegation, on 01/24/2022 at 10:30am LPA spoke to facility staff and residents. During the investigation conducted on 01/24/2022 at 11:00am, LPA randomly selected residents to inspect and a few of the residents were eating in isolation due to a recent COVID-19 outbreak by choice. LPA observed the residents' freewill to move about but were encouraged to social distance and avoid physical contact. Staff stated that they try to encourage R1 to participate in activities and walking but cannot force R1 to do so. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC 9099-C) Unsubstantiated --Facility did not provide resident with a 60day notice of rent increase for COVID expenses. It was reported that R1 and responsible party was given a notice three weeks ago for rent increase of $500 for COVID expenses starting February 1, 2022. To investigate this allegation, on 02/02/2022 at 12:00pm LPA spoke to facility staff and requested pertinent documents. Interview and record review revealed that the facility notified R1 and responsible party more than sixty (60) days prior to the increase. The notice was sent October 28, 2021 with an increase in rent /fees effective January 01,2022. Based on interviews record review, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Resident's closet door is in disrepair It was reported that resident’s closet door is broken and only one side opens. To investigate this allegation, on 01/24/2022 at 10:30am LPA spoke to other parties and it was reported that the wooden closet in R1’s room was off its track. The report was supplemented with images that were captured during the other party’s visit to the facility. During the investigation conducted on 01/24/2022 at 11:00am, LPA randomly selected residents’ rooms to inspect and all closet doors were in working order. On 02/02/2022 at 12:15pm, LPA interviewed staff and it was reported resident failed to report the disrepair and that upon discovery, the maintenance crew was informed, and the closet door was placed back on its track with minimal delay. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Feb 8, 2022 · control 31-AS-20220121083121

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: Staff did not meet resident's hygiene needs Staff did not provide adequate laundry service for resident Resident's room is dirty Staff are not properly dressing resident Staff did not provide resident with adequate amounts of water

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Executive Director (ED) Johnny Ortiz. --Staff did not meet resident's hygiene needs. It was reported that Resident #1's (R1) toenails were overgrown, and no one called responsible party to inform. To investigate these allegations, on 01/24/2022 at 10:30am LPA spoke to facility staff and responsible party. Interviews revealed that the facility is not allowed to cut R1's toenails, that the responsible party was made aware of R1's needs and given multiple options, but responsible party failed to act timely resulting in R1's overgrown toenails. During the investigation conducted on 01/24/2022 at 11:00am, LPA randomly selected residents to inspect and all residents appeared to be well groomed. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC9099-C) Unsubstantiated --Staff did not provide adequate laundry service for resident It was reported that resident’s laundry hadn’t been done in two weeks because the same clothes were in it. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff and residents. Interviews revealed that laundry is done a minimum once per week. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. LPA discovered that each resident has a separate laundry basket and none were full and the residents had plenty of clean linen and clothes. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Resident's room is dirty. It was reported that resident’s room is not being dusted and cleaned and that there were dirty diapers mixed with clean clothes. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff including housekeepers. Interviews indicated that the room is being picked up daily as needed, deeply cleaned and dusted once a week. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. The floors appeared to be clean and free from hazard. All inspected rooms were neat and clean with minimal dust. All closets and drawers were checked for cleanliness, nothing soiled was found and everything appeared to be well maintained. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Staff are not properly dressing resident It was reported that R1 was in a robe that did not belong to R1. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff and residents. The residents were all asked if they felt that they were missing any belongings and they all replied, “no”. Interviews revealed that laundry is done a minimum once per week. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. LPA discovered that each resident has a separate laundry basket of which none were full, the residents had plenty of clean linen and clothes. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT. on LIC9099-C) --Staff did not provide resident with adequate amounts of water. It was reported that resident is not been given water. To investigate these allegations, on 01/24/2022 at 11:10am LPA spoke to facility staff and residents. The residents were all asked if they felt that they were getting enough food and water and those that were able to all replied, “yes”. Interviews revealed that staff encourage food and water intake. During the investigation conducted on 01/24/2022 at 11:30am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. LPA discovered that residents had water in their rooms. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Feb 2, 2022 · control 31-AS-20220121083121

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident

This is an amendment of the report generated on 08/19/21 to change the findings. Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Executive Director Johnny Ortiz and explained the reason for the visit. LPA conducted physical plant tour at 10:11 AM. LPA requested facility documents relevant to the investigation at 10:30 AM and interviewed the Executive Director between 11:00 AM to 11:30 AM. LPA's interview with Staff #1 (S1) on 03/26/21 at 3:44 PM, revealed that on 03/10/21 at around 4:30 PM, S1 witnessed Staff #2 (S2) heavily slapping Resident #1 (R1) at the back to stop R1 because R1 was throwing a fit and throwing food while eating at the dining area of the memory care unit. LPA's interview with the Executive Director on 03/26/21 at 3:00 PM revealed that S2 was immediately suspended on the same day of the incident, eventually terminated on 03/16/2021 and did not work again at the facility to date.(continued on LIC 9099-C) Substantiated (continued from LIC 9099) LPA record review today at 12:00 PM, revealed that S2 was trained by the facility to handle Dementia residents including but not limited to Managing Challenging Behaviors on 10/07/2019 and 10/11/2019, certified to have read and understood the Employee Handbook on 09/26/19, which includes the section Terminable Misconduct, that states: "Any acts of abuse, neglect and/or mistreatment toward Atria residents, your supervisor, fellow employees, visitors or volunteers", which was the reason for S2's termination on record. Based on the information gathered during this and prior visit, while the facility provided training to S2 to avoid any misconduct and immediately relieved S2 of duties to avoid recurrence of S2's misconduct, the fact remained that S2 hit R1 heavily on the back on 03/10/21 as witnessed by S1. The allegation is therefore deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 29, 2022 · control 31-AS-20210318171317

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Jan 31, 2022

Enumerated rights; severability - (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on LPA interview, the licensee failed to ensure that R1's personal rights was observed and respected by the staff. This poses an immediate safety and personal righs risk to the resident in care.the state’s words, verbatim · CDSS document, Jan 29, 2022

Plan of correction: Facility staff agreed to inform the Executive director to train all staff regarding residents' personal rights and submit a copy of proof of training including but not limited staff attendace to CCL on or before the POC date.

Allegation investigated: Staff did not report incident to resident's responsible party. Resident suffered from significant weight loss.

Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA was screened for COVID 19 and met with Executive Director (ED) Johnny Ortiz. ----- Staff did not report incident to resident's responsible party. It was alleged that staff did not report incident to resident's responsible party. To investigate these allegations, on 10/26/2021 at 3:30pm, LPA spoke with staff and other parties. In addition, on 10/26/2021 at 4:10pm, LPA observed resident #1 (R1), requested R1’s facility files and researched prior incident reports. After careful review, it was determined that R1 did sustain a small injury, there were hazardous materials found in R1’s room, it was reported to staff, but an incident report was not filed, and the responsible party was not notified timely. Based on the information from interviews and records review, the allegation is SUBSTANTIATED at this time. ----- Resident suffered from significant weight loss. It was alleged that resident has significant weight loss since she moved in. To investigate these allegations, on 10/26/2021 at 3:30pm, LPA spoke with staff and other parties. In addition, on 11/17/2021 at 12:30pm, LPA requested documents from R1’s most recent doctor’s visit. Record review revealed that R1 has a diagnosis of dementia with behavioral disturbances, lost significant weight, that the facility reported a change of condition (decreased appetite, won’t sit during meals) to the doctor and doctor responded, “At this time there is no new order.” On 11/17/2021 at 11:30am, LPA observed R1 in the dining room during an unannounced visit and R1 was eating independently with other residents. Based on the observations, information from interviews and records review, the allegation is SUBSTANTIATED at this time, however, NO CITATION was issued as the weight loss was not caused by neglect of the facility, but rather R1’s medical condition. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 3, 2022 · control 31-AS-20211020154028

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 13, 2022

87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D).. Any incident which threatens the welfare, safety or health of any resident....This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not file an incident report and did not notify the resident’s responsible party. This poses a potential health safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 3, 2022

Plan of correction: Executive Director will provide training to staff for reporting requirements. Proof of completion of trainings will be submitted by e-mail by the plan of correction due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Venca Avivi, Nurse for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and throughout the facility. The facility has a designated outdoor visitors' area located in the courtyard. The facility has sufficient stock of PPE in a storage room located in the nurse’s office and storage. The facility has a total of one hundred thirty-four (134) bedrooms of which thirty-nine (39) are in the memory care (MC) building. There are ninety-five (95) bedrooms in the main building, each with its own bathroom and of the thirty-nine (39) bedrooms in MC, thirty (30) are Jack and Jill (one bathroom for every two bedrooms) and ten (10) bedrooms have their own bathroom, eleven (11) public restrooms for both residents and staff and one (01) staff only restroom. The facility is fire cleared for one hundred sixty (160) non-ambulatory of which sixty-seven (67) may be bedridden and a hospice waiver for ten (10). The facility is currently occupying one hundred thirteen (113) residents of which seventy-nine (79) are non-ambulatory and six (06) are in hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are stored in the laundry room and in a locked cleaning supplies room. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days (continued on LIC 809-C) non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature between 73-76°F throughout. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility, observed to be full and last inspected on 11/15/2021. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by both themselves and the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. There was enough clean linen available in the residents' rooms. LPA observed medication to be locked in a mobile cabinet and inaccessible to residents, located in the Med Tech room. There is also a complete first aid kit located in the nurse’s office. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 24, 2021

Allegation investigated: Resident sustained injury while in care. Resident's room is not being cleaned. Resident's hygiene needs are not being met. Staff did not ensure that resident's room was free of hazards.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with Johnny Ortiz, Executive Director (ED). The purpose of the visit was discussed. --- Resident sustained injury while in care. It was reported that the resident sustained injury while in care, staff did not ensure that resident’s room was free of hazard. To investigate these allegations, on 10/26/2021 at 2:15pm LPA spoke to ED, the Care Staff, Med Tech and Housekeeper. Interviews revealed that Resident #1 (R1) sustained a minor cut on the index finger measuring less than one (01) cm in length, that may not be visible during hygiene assistance. The injury was self-sustained and resulted from R1 handling a broken picture frame. R1 never complained of any injuries or pain. Staff also reported that they remove any hazardous items from the room when discovered. (Please see continuation page) Unsubstantiated --- Staff did not ensure that resident's room was free of hazards. It was alleged that Staff did not ensure that resident's room was free of hazards. To investigate these allegations, on 10/26/2021 at 11:10am LPA spoke to facility staff. Interviews indicated that the resident’s room is cleaned daily by staff and the housekeeper deep cleans weekly. During the investigation conducted on 10/26/2021 at 11:15am the resident’s room was inspected by the LPA and the room appeared to be clean at the time of the visit. During a subsequent complaint investigation visit conducted on 11/17/2021 at 11:30am the resident’s room was again inspected by the LPA and the room appeared to be clean and free from hazard at the time of the visit. Staff also reported that they remove any hazardous items from the room when discovered. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. The broken frame was stored with R1’s personal items and staff had no knowledge of it. A broken picture frame was discovered by R1’s family member who came to visit R1. On 10/26/2021 @ 11:00am LPA Duguma inspected the room and noted that the picture frame was previously stored in a place that may not be checked by the care staff. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --Resident's room is not being cleaned. It was reported that resident’s room is not being cleaned. The floor in R1’s room is sticky. To investigate these allegations, on 10/26/2021 at 11:10am LPA spoke to facility staff including housekeepers. Interviews indicated that the room is being picked up daily as needed and deeply cleaned once a week. During the investigation conducted on 10/26/2021 at 11:00am, randomly selected rooms were inspected by the LPA which included R1’s bedroom. The floors appeared to be clean and free from hazard. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Resident's hygiene needs are not being met. It was alleged that R1’s teeth were not brushed for a few days. To investigate these allegations, on 10/26/2021 at 11:30am LPA spoke to facility staff. Interviews indicated that the resident is assisted with teeth brushing and other hygiene related daily functions. During investigation conducted on 11/17/2021 @ 11:45am the resident was inspected by the LPA and the resident appeared to be clean and well-groomed. Based on interviews, inspection and observation, there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Please see continuation page)the state’s words, verbatim · CDSS document, Nov 17, 2021 · control 31-AS-20211020154028

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff failed to meet resident's needs

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegations. LPA had his temperature checked, COVID-19 related questions asked and vaccine verification requested before being allowed entry. Allegation 1. Facility staff failed to meet resident's needs At about 9:30 AM, the LPA was able to tour the facility in response to this allegation. At 9:45 AM, LPA began interviewing residents in the memory care portion of the facility. At 10:15 AM, LPA was able to speak with the resident in question (R1) regarding the allegation. R1 indicated that the staff are very nice and will assist R1 anytime R1 requires assistance. R1 also indicated that R1 feels safe at the facility and believes that staff will assist R1 in an emergency. LPA was also able to interview 6 other residents in memory care who also indicated that staffing is sufficient and that they feel safe. All residents questioned, stated that they feel safe and that the staff are able to meet their needs. Continues on LIC 9099-C Unsubstantiated At 11:00 am, LPA was able to interview the staff in the memory care portion of the facility. Staff indicated that there are always 4 staff available during the day and PM shifts to assist with residents needs. A review of the staffing schedule, conducted at 11:30 AM, indicated that there are at least 4 staff working the memory care portion during the day and PM shifts and 3 staff working the overnight shift. All staff staff interviewed feel that they are able to meet the needs of all the residents in care. Based on interviews with residents and staff, as well as a review of the staffing schedule, this allegation is deemed to be Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 31-AS-20190719090527