Eilat's Manor

Allegation investigated: Staff are not adequately trained. Staff are sleeping in common areas at the facility. Staff do not accurately give residents their medications. Staff do not lock medications up at the facility. Staff do not lock up cleaning supplies at the facility. Staff are not accurately reporting incidents at the facility.

On 08/10/23, Licensing Program Analyst (LPA), Perry Scott conducted a 10-day complaint investigation at the facility listed above. LPA met with Eilat Nahum, Administrator, and Susy Susanto, caregiver, and explained the purpose of today’s visit was to investigate the allegations listed above. On 08/10/23, the investigation consisted of the following: During today's visit LPA toured the facility. LPA requested and obtained copies of the following documents: Resident and Staff Roster, Staff Training, Incident Reports, and Training Certificates. LPA interviewed staff (S1-S2) and residents (R1-R3). The investigation revealed the following: Regarding allegation #1: Staff are not adequately trained. On 08/10/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Staff are not adequately trained. All staff confirmed that they are trained on hospice, dementia, personal rights, medication, and a host of other trainings. They stated that they have training monthly. LPA reviewed the training records for staff and verified that they have the required trainings. R1-R3 stated that they were satisfied with the care the staff gives them. Report continued on LIC9099-C Unsubstantiated Based on interviews, and records reviewed there is insufficient evidence to support the allegation: Staff are not adequately trained. 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. Allegation #2: Staff are sleeping in common areas at the facility. On 08/10/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Staff are sleeping in common areas at the facility. All staff state that the staff takes their breaks in the staff room. R1-R3 corroborate that the staff takes their break in the staff room. Based on interviews, there is insufficient evidence to support the allegation: Staff are sleeping in common areas at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3: Staff do not accurately give residents their medications. On 08/10/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Staff do not accurately give residents their medications. All staff state that they give the accurate medication to all residents. They further state that when medication is given it is documented on the Medication Administration Record with dates and times. R1-R3 stated that they receive their medication as prescribed. Based on interviews and a record review, there is insufficient evidence to support the allegation Staff do not accurately give residents their medications. 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. Allegation #4: Staff do not lock medications up at the facility. On 08/10/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Staff do not lock medications up at the facility. All staff state that the medication is kept in a locked room in the living room; and it is always locked. LPA verified that the medications were locked at the time of the visit. R1-R3 corroborated with staff that the medication is kept locked in the living room. Based on interviews and observations, there is insufficient evidence to support the allegation Staff do not lock medications up at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report continued on LIC9099-C Allegation #5: Staff do not lock up cleaning supplies at the facility. On 08/10/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Staff do not lock up cleaning supplies at the facility. All staff state that chemicals and cleaning supplies are always kept in a locked cabinet in the facility. And when the items are used, they are returned to the locked cabinet. LPA toured the facility and verified that all chemicals and cleaning supplies have a designated cabinet where it is locked, when not in use. All chemicals and cleaning supplies were locked on this visit. R1-R3 corroborated with staff that the cleaning supplies are kept in a locked cabinet. Based on observations and interviews, there is insufficient evidence to support the allegation Staff do not lock up cleaning supplies at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation#6: Staff are not accurately reporting incidents at the facility. On 08/10/23, LPA interviewed S1-S2. 2 of 2 staff denied the allegation that Staff are not accurately reporting incidents at the facility. All staff state that when there is an incident at the facility, they report it to Community Care Licensing to document the incident. They further state that there has not been an incident in some time. Based on interviews, and records reviewed there is insufficient evidence to support the allegation Staff are not accurately reporting incidents at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a hard copy of this report was provided to Miriam Rudes, administrator.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 11-AS-20230801112630

Allegation investigated: Staff did not seek medical attention in a timely manner. Physician stated that the condition of the resident was severe. Residents are not getting their needs met. Staff are not reporting incidents to responsible party. Food service inadequate. Staff are unable to communicate with the residents.

Licensing Program Analyst (LPA) Ana Soto conducted an unannounced visit to the facility to deliver the findings for the above allegations. LPA was met by Naome Leibov, Office manager and the purpose of the visit was explained. LPA Soto and IB investigator Lorraine Patterson conducted investigations. LPA investigation consisted of following: Interviews and Record reviews. On 12/16/20, LPA conducted a 10-Day virtual visit (via telephonically) with Licensee (Eilat Nahum) due to the situation surrounding the Coronavirus Disease (COVID-19) and to implement mitigation measures. LPA interviewed Licensee Nahum, and Staff #1. On 08/29/22, LPA interviewed S#1 -S#3, R#1 – R#5. LPA Soto conducted a virtual physical plant tour of the facility. On 12/16/20, Unsubstantiated LPA Soto requested the following documents: Pre-placement Appraisal, Physician’s Report, Admissions Agreement, Emergency Contact Info, Appraisal Needs and Services Plan, Home Health Agency Notes, Daily Log/Caregiver Notes, Menus for January 2020 – March 2020, Incident Reports, Medication Administration Records for October 2020, November 2020, and December 2020, Staff Training Records, and Mandated Reporter form (SOC 341). On 08/29/22, LPA requested the following records: Resident and Staff rosters, and Menu for August 2022. LPA observed residents as LPA was interviewing them & took pictures of the food being served for lunch. Toured room #1 & #2, living room, dining room, and kitchen. A separate investigation was conducted by Department of Social Service Investigator (Lorraine Patterson) which included review of Cedar Sanai Hospital medical records (dated 12/14/20), Home Health Agency (HHA) medical records (dated 12/15/20), and interview with facility staff and medical services staff. Allegation #1: Staff did not seek medical attention in a timely manner. IB investigator’ investigation revealed Resident #1 had bouts of agitation; and struggled to accept support with activities of daily living which may have been a contributing factor. Resident #1 was medically assessed on 09/11/20 with an infected toe. Medical records obtained revealed Resident #1 was seen by her Primary Care Physician (Dr. Allison Moser Mays) on 12/14/20. A physician’s order referral was made by the primary care physician for plan of care with home health agency – certification period to begin effective 12/15/20 – 02/21/21. HHA Skilled Nurse to perform wound care protocol to toe injury and Stage 2 pressure ulcer of sacral region. HHA Skilled Nurse to instruct resident/caregiver to report measures of preventing and treating constipation. Primary Care Physician also ordered a physical therapy plan of care for Resident #1. While, allegation may have occurred or were valid, there is a lack of preponderance of evidence to corroborate that the facility failed to seek out timely medical attention, therefore the alleged is found UNSUBSTANTIATED. Allegation #2: Physician stated that the condition of the resident was severe. IB’s investigation revealed the primary care physician reported that Resident 1’s toe injury was not “time related” to her “virtual” medical assessment on 12/14/20 and/or her “bed sore” as reported by the Home Health Agency to Resident #1’s family member on 12/15/20. As a mandated reporter, the primary care physician reported to adult protective services as to what was told to her by the resident’s family member; however, Resident #1’s family member filed the suspected elderly abuse report (via APS). Primary Care Physician further reported no evidence for and/or against neglect. When the paramedics went out to the facility on 12/11/20 to assess Resident #1, the outcome suggested by the paramedics was to have Resident #1 follow up with her primary care physician. It was further reported that it is difficult to say ongoing neglect occurred - based on what was observed during the intake assessment. It was too difficult to complete the assessment due to Resident #1 not cooperating, would refuse to be assessed and was agitated. It was also observed that one could not touch Resident #1 without her screaming and hitting the person. While, allegation may have occurred or were valid, there is a lack of preponderance of evidence to corroborate if Physician stated that the condition of the resident was severe, therefore the alleged is found UNSUBSTANTIATED. Allegation #3: Residents are not getting their needs met. LPA’s investigation revealed the facilities documented Resident #1’s blood pressure and glucose level (via Tracker) during the month of December 2020. A review of Resident #1’s records (Pre-placement Appraisal, Physician’s Report, Admissions Agreement, Emergency Contact Info, Appraisal Needs and Services Plan, Home Health Agency Notes, Daily Log/Caregiver Notes, Incident Reports, Medication Administration Records for October 2020, November 2020, and December 2020) were observed to be current. Facility instituted a daily log for resident in care and facility staff have documented notes (dated 12/01/20 – 12/16/20 regarding Resident #1. Resident #1 was provided with ongoing sponge baths, applying ointment on bedsore, cleaning of private area, combing hair, cutting nails, changing adult diapers, bed pads, and clothes; meal service, taking vitals, and administer/manage medications. Interview with R#1, was not available to be interviewed. R#2 – R#5, stated that the facility helps with all their ADL’s, such as: Sponge bath and/or showers, changing clothes, put on shoes, hair care, personal hygiene (change diapers) walking, and transferring from bed to wheelchairs. Licensee and Staff stated that they always help all residents with the ADL’s and hygiene needs. The interviews and records review did not concur with the above allegation. Allegation #4: Staff are not reporting incidents to responsible party. Interview with S#1, was adamant that all S#1’s staff report all incidents that happen at the facility and in turn S#1 will notify Family or RP if it’s necessary. The facility will report any incidents such as; injuries, miss medication, etc. depending on the nature of incident. S#2 & S#3, all agreed that they always report everything that happens at the facility to S#1. Interviews with R#2 – R#5, haven’t had incidents that required for family or Responsible Party to be notified. R#1 could not be interviewed due to R#1 mental disability. The interviews did not concur with the above allegation. Allegation #5: Food service inadequate. Interviews with S#1 – S#3, all agree that the facility offers a well-balanced meal. All 3 meals are very nutritious and very appetizing. Interviews with R#2 – R#5, all agreed that the meals are always good They all like the food and it tastes good. LPA reviewed the menus for January 2020 – March 2020, and August 2022, the menus are well-balanced and have all the four foods groups. LPA took pictures of lunch being prepared for resident and it had vegetables and protein. They were also serving fruit and juice/milk along with the vegetables and protein. The food smelled good as it was being cooked. The interviews and observations did not concur with the above allegation. Allegation #6: Staff are unable to communicate with the residents. Interview with S#1, denies not being available to communicate with her residents. S#1 has a British accent, but S#1 can communicate well with all the residents. S#2 & S#3, both stated that they speak English and can communicate very well with the residents. LPA spoke with S#1 - S#3, in English and was understood by all the staff. LPA understood all the staff also. LPA and staff did not have any problems communicated or understanding each other in any way. LPA completed the staff interviews without any need of a translator. The interviews and observations did not concur with the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated An exit interview was conducted with Naome Leibov, Office Manager, and a hard copy of report was provided.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 11-AS-20201215082923

Allegation investigated: Facility did not issue refund to resident or resident's representative

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint investigation at the above facility. LPA spoke with facility staff via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to investigate the allegations listed above and was allowed entry to the facility. The investigation consisted of the following: On 5/3/2022 LPA Cifuentes spoke with Administrator Eliat Nahume and staff Naome Leibov. LPA toured the facility grounds, reviewed facility files and requested and received copies of documents pertinent to the investigation. LPA Cifuentes interviewed (S1-S4), residents (R2-R5) and witnesses (W1-W2). Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility did not issue refund to resident or resident's representative It is alleged that facility staff did not issue a refund to a resident or their representative. LPA spoke with staff Naome Leibov, who stated facility refund policy is upon death of resident or with thirty days’ notice given to vacate. LPA reviewed facility records and noted that out of those reviewed, three did not have any details filled out regarding refund policy but were signed by residents/representatives. Review of facility files also showed that a preadmission's policy was being charged but a written statement detailing pre-admission costs, stating the fee is refundable and describing those refund options was not found. LPA spoke with residents (R2-R5) regarding the allegation. Two were unable to answer due to diagnosis, but the other two stated they did not know anything about facilities refund policies. LPA spoke with staff (S1-S4) regarding allegations. Of the staff questioned, two stated they did not know facility refund polices, and the other two stated refund policy is upon death of resident or with thirty days’ notice given to vacate. LPA interviewed witnesses (W1-W2) regarding the allegation and both stated the facility refund policies were not clear. Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. Records review of admissions agreement and supporting paperwork does not offer residents or their representatives a written statement detailing pre-admission costs, stating the fee is refundable or describe those refund options. Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. Exit interview conducted, appeal rights were discussed, and a copy of this report and appeal rights were provided to Jomar Fernando.the state’s words, verbatim · CDSS document, May 3, 2022 · control 11-AS-20220425152124

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(g)(C)(1) · Plan of correction due date: May 31, 2022

Admissions Agreement If a licensee charges a preadmission fee the licensee must provide the applicant...a written...statement describing all costs associated with...preadmission fee charges...stating that the preadmission fee is refundable...describing conditions for the refund This requirement was not as evidenced by: During records review on 5/3/2022, LPA did not observe any written statements provided to residents or their applicants detailing preadmissions fees. This is a potential safety risk to the residents in carethe state’s words, verbatim · CDSS document, May 3, 2022

Plan of correction: Licensee will amend admissions agreement to include a written statement detailing preadmissions fee charges, stating fee is refundable and outlining conditions for the refund. Revised admissions agreement is due to CCLD via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(g)(5)(E)(1)(b) · Plan of correction due date: May 31, 2022

Admissions Agreement Preadmission fees shall be refunded according to the following...: A 100 percent refund of a preadmission fee shall be provided to an applicant or...representative if: The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement was not met as evidenced by: During records review on 5/22/2022 it was noted that R1's application noted a pre-admissions fee but did not offer details as required by regulation. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2022

Plan of correction: Licensee will provide R1 or thier representative with a 100 percent refund of preadmission fee and confirmation will be submitted to CCLD via fax by POC due date.

Type of visit: Case Management - Deficiencies

On 05/3/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a Case Management - Deficiencies visit to the above facility and met with Eilat Nahum Administrator. During investigation of complaint 11-AS-20220425152124 LPA Cifuentes noted during file review that Admissions agreements did not all include refund conditions. Deficiencies cited on attached 809-D A copy of this report was provided to Eilat Nahum, Licensee.the state’s words, verbatim · CDSS document, May 3, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(g)(5)(A) · Plan of correction due date: May 31, 2022

Admissions Agreement Refund conditions. Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement was not met as evidenced by: During complaint investigation LPA reviewed records and noted that 3 out of 5 records reviewed did not have refund conditions. THis is a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 3, 2022

Plan of correction: Licensee will amend admissions agreement to include details and conditions for refunds. Revised admissions agreement is due to to CCLD via fax by POC due date.

Type of visit: Case Management - Health Checks

On 04/01/2022 Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Ulysses Coronel conducted a Case Management - Health and Safety Check to the above facility and met with Eilat Nahum Administrator. During today visit LPA and LPM conducted a tour of the facility and interviewed R1 who was a former resident of Beit Shalom #197608630. No deficiencies were cited. A copy of this report was provided to Eilat Nahum, Licensee.the state’s words, verbatim · CDSS document, Apr 1, 2022

Type of visit: Case Management - Health Checks

01/27/22 Licensing Program Analyst (LPA) Ernand Dabuet initiated a Case Management – Health Check visit. LPA was met by Naome Leibov the house manager, and explained the purpose of today’s visit. LPA and the house manager toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.6 F. A comfortable temperature of 72 degrees was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility had a fire extinguisher that was charged, smoke detectors, and carbon monoxide was operable. LPA reviewed Medication Administration Records (MAR) revealed accurate and maintained in order. Several working landline telephones were observed at the facility. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD. Evaluation Report continues on LIC 809C LPA reviewed resident service records and found missing physician's reports for resident #3 and #5 (R3 - R5) and was not available for review during the inspection visit. The facility is caring for residents diagnosed with dementia and has not conducted fire drills and did not have an Emergency Disaster Plan in place. During the plant inspection, LPA observed signs posted in the kitchen area and refrigerator preventing residents' access to accommodations and equipment. LPA observed the facility did not have a current administrator on file and did not notify the Department of the change of administrator. During record review an active administrator was observe for Miriam Rudes which is not in compliance with PIN 21-24 CCLD. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8, Deficiencies are issued and an exit interview is conducted with Noame Leibov. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Jan 27, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 10, 2022

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Based on interview and record reviews the Licensee failed to adhere to Title 22 regulations. Licensee did not have physician's report for R3 and R5. This citation poses a potetntial health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: The licensee will ensure that all residents have complete resident's service records which includes a physician's reports. The licensee will submit complete files for R3 and R5 by POC due date 02/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(2) · Plan of correction due date: Feb 10, 2022

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(2)The Emergency Disaster Plan, as required in Section 87212, addresses the safety of residents with dementia. This requirement was not met as evidenced by: Based on interview and record reviews the Licensee failed to adhere to Title 22 regulations. The licensee did have a record of the Emergency Disaster Plan in place for review. This citation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: The licensee will ensure that the facilty has a Emergency Disaster Plan and conducts routine fire drills with records. The licensee will submit correction by POC due date: 02/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 10, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observation and interview, the licensee had signs posted preventing residents from accessing the kitchen and refrigerator. This citation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: The licensee will adhere to Title 22 Section 87468. The licensee will perform knowledge of and conforms to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 02/10/22 This violaton was corrected during visi on 01/27/22. House manager removed posted signs and will review Title 22 section 87468.1.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Feb 10, 2022

87405 Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator...The administrator shall have ... other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... This requirement was not met as evidenced by: Based on observation and interview, the licensee did not have an authorized administrator file with CCLD. This citation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: The licensee will adhere to Title 22 Section 87405. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 02/10/22 with documentation for authorized facility administrator.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(g)(2) · Plan of correction due date: Feb 10, 2022

87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (2) Date he/she assumed his/her position. This requirement was not met as evidenced by: Based on interview and record reviews the Licensee failed to adhere to Title 22 regulations by reporting a change of administrator. This citation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: The licensee will send a notification in writing of change of adminsitrator with the qualified documents for certified administrator.Plan of correction will be submitted by POC due date 02/10/22.

Allegation investigated: Staff allowed resident's to wander away from the facility. Facility not administering medications as prescribed.

On 12/24/20 Licensing Program Analyst, LPA/Don Senaha initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via zoom with Eilat Nahum/Administrator and staff (S1). On 12/09/2021 Licensing Program Analyst (LPA) Don Senaha conducted a subsequent unannounced complaint visit to this facility and met with House Manager Naome Leibov. The purpose of this visit is to investigate and deliver the findings of the investigation completed. The investigation consisted of the following: LPA requested resident roster, staff roster and other service documents on 12/24/2020. On 12/09/21, LPA requested updated resident roster and staff roster and conducted interviews with residents (R1-R5), (S1-S3) and witness (W1-W2). Resident (R4) was admitted to the facility yesterday 12/08/21 at around 6pm and was sleeping. Resident (R5) declined to be interviewed. Unsubstantiated A plant inspection of the facility was conducted on 12/20/2020 virtually and in person on 12/09/2021. Investigation revealed: Allegation: Staff allowed residents to wander away from the facility. It is alleged the staff allowed residents to wander away from the facility. Residents (R1-R3) did not have any concerns regarding the care and supervision being provided to them by the staff. Resident (R1) is non-ambulatory and stated she requires staff to help push on her chair to go outside. Resident (R2-R3) stated they do leave the facility but at their own will and let the staff know anytime they leave the facility. Staff (S1-S3) stated they have never had a missing/AWOL resident. LPA spoke to witness (W1) and he stated he has never seen or had an issue with resident (R6) wandering away from the facility. LPA spoke to witness (W2) and she stated there has been no issue of “getting lost” and staff follows resident (R5) if he goes outside. LPA did not see any incidents reported regarding a resident ever missing/AWOL. Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated Allegation: Facility not administering medications as prescribed. It is alleged the facility is not administering medications as prescribed. Residents (R1-R2) stated they have not had an issue with medications being administered. Residents (R1-R2) stated they have never missed taking their medications. Staff (S1) stated there has been medication training for each staff. Staff (S1) stated staff (S1) monitors/audits the medications administered for all staff for the facility daily. Staff (S1) stated staff (S1) ensures medications are being given as prescribed and the Medication Administration Records (MAR) are being kept up to date. LPA spoke to witness (W1) and he stated there has never been an issue with medications and the facility has the meds under lock and key. LPA spoke to witness (W2) and she stated no issues with medications as prescribed. LPA received medication training logs for staff. LPA reviewed current MAR and found no issues. Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated An exit interview was conducted with House Manager Naome Leibov and a hard copy was provided.the state’s words, verbatim · CDSS document, Dec 9, 2021 · control 11-AS-20201217143740

Allegation investigated: Staff hit the resident.

On 9/6/21 at Licensing Program Analyst (LPA) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent visit in order to render investigation findings for the above allegation. LPA met with Harrix Manuel, the Caregiver and the purpose of the visit was explained. On 4/22/21, LPA Brown and LPM Hammond conducted a Health & Safety visit that consisted of the following: Toured the facility physical plants, LPA and LPM conducted interviews with Administrator and Staff #S1. LPA requested the following documentation: Resident & Staff Roster, Residents #1-2 files, Staff #1-3 records. The investigation consisted of the following: Staff hit the resident. LIC 9099-C is on the next page. Unsubstantiated On 4/22/21, LPA interviewed the reporting party regarding the above allegation. RP stated resident #1 s was being hit on the shoulder by residents and staff. RP stated there were no injuries reported. RP stated R1 has limited speech but was able to make a mad gestured to show how was hit. On 4/22/21, LPA interviewed the Administrator regarding the above allegation. Administrator stated residents were not hit by other residents or staff. Administrator stated no one had address any concerns to her. On 5/11/21 LPA interviewed staff #1-2 and residents #2-3. Staff stated they did not see any residents being hit by residents or staff. LPA attempted to interview R1, but the resident was unable to verbally communicate. LPA interviewed residents #2-3 and they stated were not hit by residents or staff or did they see any other residents being hit. LPA was unable to interview resident #4 due to the resident unable to communicate. Although the allegations are valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and provided.the state’s words, verbatim · CDSS document, Sep 16, 2021 · control 11-AS-20210415120420

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Martessa Brown and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Garrix Manuel, Caregiver and the purpose of today’s visit was explained. The facility is licensed to serve 6 Residential Care Elderly. There are currently (6) residents at the facility, 6 Non-Ambulatory of which 1 may be bedridden. LPA and LPM observed all 6 residents were fine. The facility is a single story structure located in a residential neighborhood. Home consists of the following: 5 bedrooms, 2 bathrooms, family room/dining room, kitchen, living room, outdoor shaded area. LPA and staff toured the physical plant with the Caregiver. There are no bodies of water or firearm/ammunition on the premises. All residents bedrooms were checked. Beds and bedding were in good condition, adequate lighting provided. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 102 F. A comfortable temperature is maintained in the facility. 2nd bathroom was designated for staff only. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available which is stored properly. Fire extinguisher was in the medicine cabinet and not mounted on the wall, smoke detectors were operable but there was no Carbon Monoxide at the facility. LIC 809-C is on the next page During the visit, LPA observed did not observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings. LPA did not observe an isolation room with the required postings throughout the facility. LPA did observe the facility During the visit, LPA observed did not observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff were wearing face coverings. LPA did not observe an isolation room with the required postings throughout the facility. LPA did observe the facility as a 30-day supply of Personal Protective Equipment (PPE). LPA observe a couple of “No Visitors signs” that should be removed. Administrator should continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. Deficiencies may be issued at a later date. Exit interview held. A copy of the report was provided to Caregiver.the state’s words, verbatim · CDSS document, Sep 16, 2021