Skyhill Quality Living

Type of visit: Case Management - Other

Licensing Program Analyst LPA Alberto Lopez conducted an unannounced Case Management visit to follow up on office visit conducted on 04/26/22 regarding Quarterly Case Management visits. LPA met with Rowena P. Bacugang Caregiver and was met short later by Administrator Tina Arutytunyan and explained the purpose of the visit. LPA Lopez, with caregiver Rowena present, tested the water temperature and it measured between 105.5 to 106.8 which is within range. LPA and administrator toured five resident's rooms, common area and outside physical plant. Facility had enough nonperishable food for 7 days and perishable food for 2 days. Record of Resident's Safeguarded Cash Resource was reviewed for R1. All 3 exit door alarms were not functioning properly during visit. Deficiency cited, please see 809D for details. Exit interview conducted and copy of report provided to Administrator Tina Arutytunyanthe state’s words, verbatim · CDSS document, Dec 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87505(j) · Plan of correction due date: Dec 2, 2022

87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evident of: Facility retains dementia resident and alarms on exit doors were not working properly.the state’s words, verbatim · CDSS document, Dec 2, 2022

Plan of correction: The Administrator stated that she will fix the alarms on all 3 exit doors. Administrator will inform CCL in writing explaining how she fixed the alarms. The pictures of the doors and alarms must be submitted to CCL by POC due date. ***Administrator fixed all 3 door alarms during visit and no further actions is required***

Type of visit: Case Management - Other

Licensing Program Analyst LPA Alberto Lopez conducted an unannounced Case Management visit to follow up on office visit conducted on 04/26/22 regarding Quarterly Case Management visits. LPA met with Carmen Cunanan Caregiver and was met short later by Administrator Tina Arutytunyan and explained the purpose of the visit. LPA Lopez, cargiver Carmen, and Administrator Tina Arutyunyan toured five resident's rooms, common area and outside physical plant. Facility had enough Nonperishable food for 7 days and perishable food for 2 days. Water temperature was tested in bathroom #1 at 139.7 degrees F and in the shower at 146.7 by room #3 The kitchen sink was tested 145.3 degrees F, and bathroom #2 at 144.9 degrees F., which is not within the required 105-120 degrees F. Record of Resident's Safeguarded Cash Resource was reviewed for R1. Deficiency cited please see 809D for details. Civil penalties issued for repeat violation within 12 months. Exit interview conducted and copy of report provided to Administratorthe state’s words, verbatim · CDSS document, Sep 16, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 17, 2022

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by Bathroom 1 water temperature tested at 139.7 Degrees F at 10:38am. Shower by room #3 tested 146.7 at 10:55 am, kitchen sink tested at 145.3 at 10:21am Bathroom #2 tested at 144.9 at 10:30am which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2022

Plan of correction: Administrator agrees to adjust water temperture and send proof of correction to LPA by POC date.

Type of visit: Case Management - Other

Licensing Program Analyst(s)(LPA) Mary Flores and Alberto Lopez conducted a case management visit - plan of correction(POC) to follow up on deficiency given during a complaint investigation on 4/26/22. LPAs met with Carmen Cunanan Caregiver and explained the reason for the visit. Administrator Tina Arutyunyan arrived 15 minutes later. On 4/26/22 LPA Flores delivered findings for complaint 28-AS-20210824084953 during an office meeting at the Monterey Park Regional Office. Section 87217 (b) Safeguard for Resident Cash, Personal Property, and Values was noted on LIC 9099D. Deficiencies POC due date was 5/10/22. The deficiency was not cleared by the due date. On 5/26/22 LPA Flores noted correction for P&I funds to be return to R3 in the amount of $996 as R3 moved out of the facility on 10/27/22. During this visit LPA is providing the deficiency on LIC 809D. Exit interview was conducted with Tina Arutyunyan Administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 26, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 27, 2022

87217 Safeguards for Resident Cash, Personal Property, and Values: (b)... facility shall take appropriate measures to safeguard residents' cash resources,...which have been entrusted to the licensee.... The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure to maintain record receipts for items purchase with P&I funds for R1,R2,R4 which poses a potential health, safety, personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, May 26, 2022

Plan of correction: The licensee will refund P&I funds for R1 amount $2329, R2 amount $1104, and R3 amount $996 and proof must be submitted to the deparment by 5/27/22.

Type of visit: Case Management - Other

Licensing Program Analyst(s)(LPA)s Alberto Lopez and Mary Flores conducted an unannounced Case Management visit to follow up on office visit conducted on 04/26/22 regarding Quarterly Case Management visits. LPAs met with Carmen Cunanan Caregiver and was met short later by Administrator Tina Arutytunyan and explained the purpose of the visit. LPAs Lopez, Flores and Administrator Tina Arutyunyan toured three resident's rooms, common area and outside physical plant. Facility had enough Non perishable food for 7 days and perishable food for 2 days. Water temperature was tested in bathroom #1 at 122.6 degrees F and in the shower at 122.1 by room #3 The kitchen sink was tested 123.7 degrees F., and bathroom #2 at 123.3 degrees F., which is not within the required 105-120 degrees F. LPAs and Administrator observed one knife in the kitchen drawer that was unlocked and cleaning solutions where unlocked and accessible to residents. LPAs reviewed residents files and observed facility has 3 bedridden residents out of 5 residents. Resident #1(R1), #2(R2), #3(R3) have ambulatory status noted as bedridden in physician's report. Administrator stated R1 is bedridden and will discuss status of R2 and R3 with primary physician. Record of Resident's Safeguarded Cash Resource was reviewed for R1. Deficiencies cited on 809D per Title 22 Regulations. Exit interview was conducted with Administrator Tina Arutyunyan and copy of report provided.the state’s words, verbatim · CDSS document, May 26, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(2) · Plan of correction due date: May 27, 2022

2. Hot water temperature is to be maintained between 105-120*F.(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) LPA's and admiistrator observed that the hot water measured from a low of 122.1 to degrees F. to a high of 123.7 degrees F. in the kitchen and restrooms.the state’s words, verbatim · CDSS document, May 26, 2022

Plan of correction: Licensee will adjust water temperture and provide evidence to LPA and certify that water temperture has been adjusted and within range of 105 degrees F and 120 degress F by 5/27/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(1) · Plan of correction due date: May 26, 2022

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. LPAs, Administrator and DSP observed cleaning soutions and knifes unlocked and accesible to residents.the state’s words, verbatim · CDSS document, May 26, 2022

Plan of correction: Licensee locked up the cleaning solutions and knife during visit. Deficiency is cleared as of 5/26/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: May 27, 2022

87204 Limitations - Capacity and Ambulatory Status: (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met by evidence as: Licensee did not ensure R2 and R3 ambulatory status was within the limitations of the license which allows 1 bedridden resident which poses an immediate health, safety, or personal righs risk to persons in care.the state’s words, verbatim · CDSS document, May 26, 2022

Plan of correction: Licensee will contact primary physicain for R2 and R3 and verify ambulatory status for the R2 and R3 and will submit physician's report to the department by 5/27/22.

Allegation investigated: Financial Abuse

An Office Meeting was held in the Monterey Park Adult and Senior Care Regional Office (MPASCRO). The attendees present during the meeting: Regional Manager Araceli Ramirez, Audit Department Manager Jacqueline Juarez, Licensing Program Manager(s) (LPM) Lisa Hicks, Stefanie Coronel, Naira Margaryan (Woodland Hills Regional Office (WH ASCRO)), Licensing Program Analyst(s) (LPA) Mary Flores, Noemi Galarza, LPAs WH ASCRO Rosaura Valenzuela, Yelena Avestisyan, and Tuesday Cabiness. At the time of this Office Meeting a final finding of the investigation report was delivered to the Licensee Representative Tina Arutyunyan Licensee by LPA Mary Flores. The investigation consisted of the following: On 9/1/21 LPA Flores and Luis Mora conducted a tour/health and safety check of the facility around 10:15am, LPAs interviewed resident #1(R1),#2(R2),attempted to interview resident#3(R3), and #4(R4), staff #1(S1) #2(S2) and contacted administrator over the phone. (CONTINUED ON LIC 9099C) Substantiated LPAs reviewed R1,R2,R3,R4 personal files and requested copies of admission agreement, physician's report, identification and emergency information, pre-appraisal agreement, needs and service appraisal, and DHS/ Brillance Corner documentation. Administrator will email hospice documents and Personal and Incidental (P&I) funds, and mail proof of association documents for staff #2(S2), surety bond, and cable statements. On 9/13/21 LPA Flores conducted an interview with administrator over the phone. During the course of the investigation LPA Flores submitted a request for audit services on 9/20/21. On 11/3/21 Department's audit service met with Licensee Tina Arutyunyan via Microsoft Teams. On 3/8/22 LPA Flores received complete Trust Audit Report. The investigation reveled the following: Regarding allegation: Financial Abuse. It is alleged, there is an issue of financial abuse and there are no logs to record all monthly deposits and withdrawals from each client's Personal and Incidental (P&I) funds since placement. On 9/1/21 Interviews with residents revealed 1 out 4 residents has not gone to purchase clothe and does not have need of clothes as resident is mostly in bed, 1 out of 4 residents stated to only use regular Spanish channels and does not have someone come sing to them. 1 out of 4 residents stated to have everything they need, and 1 out of 4 residents was out of the facility at the time of the visit. LPAs did not observed clothes listed on purchased receipts, furniture or make up listed in receipts was not observed. On 3/8/22 Trust Audit Report conducted by Audit Services Department revealed multiple residents did not have access to or were not distributed P&I funds. Regarding finding: Multiple Residents did not have access to or were not distribute P&I funds. Brilliant Corners provides funding for R1,R2,R4's rent and P&I amounts which are paid to the licensee in a lump sum amount. On 8/19/21 during a visit by Department of Health Services (DHS) representative interviews were conducted with residents, regarding items listed on handwritten receipts without resident's initials/signature which were requested on 6/11/21 and residents stated to not have received items listed on receipts and furniture listed on receipts were not observed by DHS representative in resident's rooms. Interviews with agencies, licensee, and residents revealed P&I funds were not distribute to residents in care. Regarding finding: Proper Documentation for expenditures was not maintained. Licensee did not maintained proper record keeping of P&I money entrusted to licensee, receipts were hand written and not signed by residents. Regarding finding: Licensee is commingling facility funds with P&I amounts. Brilliant Corners provides funding for R1,R2,R4's rent and P&I amounts which are paid to the licensee in a lump sum amount. Bank statements reviewed revealed personal account and money from funding agency for Skyhill Quality Living and Skyhill Quality Living 2 were maintain int the same account. (CONTINUED LIC (9099C) Regarding finding: Only residents identified with P&I from Brilliant Corners were affected. It was determined that residents not associated to Brilliant Corner were either able to handle their own money or had a representative on file. Regardining finding: Licensee does not have policies and procedures or proper bonding. Licensee did not ensure to obtain proper bonding for the license facility to be able to safeguard resident's P&I money, current bond covers the corporation and not the license facility. During a Microsoft teams meeting on 11/3/21 with the department and licensee, licensee was notified to keep records and distribute P&I amounts to residents. The licensee is to pay the residents all P&I amounts since each residents time of placement up to November 2021, as follow: R1 must be pay the total amount of $2329.00 R2 must be pay the total amount of $1104.00 and R4 must be pay the total amount of $1104.00. Based on interviews and documents review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Licensee Tina Arutyunyan and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 28-AS-20210824084953

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 10, 2022

87217 Safeguard for Resident Cash, Personal Property, and Values (b) Every facility shall take...measures to safeguard residents' cash resources, ... have been entrusted to the licensee...The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure to maintain record receipts for items purchase with P&I funds for R1,R2,R4 which poses a potential health, safety, personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: The licensee will refund P&I funds for R1 amount $2329, R2 amount $1104, and R3 amount $1104 and proof must be submitted to the deparment by 5/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(c)(1) · Plan of correction due date: May 10, 2022

87217 Safeguards for Resident Cash, Personal Property, and Valuables: (c)... facility shall account for any cash resources entrusted...(1) Cash resources include but are not limited to monetary gifts,...personal and incidental need allowances from funding sources such as SSI/SSP. This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure to be accountable for resident's cash resources which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will implement policies and procedures regarding resident's cash resources and valuables. Licensee will provide a copy of the policies and procedures to the department by 5/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(e) · Plan of correction due date: May 10, 2022

87217 Safeguards for Residents, Personal Property,and Valuables: (e)Cash resources... which are handled by the licensee... shall not be commingled... used as the facility funds or petty cash, and shall be separate,...from any liability ... in the use of his own or the facility's funds and valuables... This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure to maintain a separate account for residents' cash resources wihch poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will open a separate trust account fo resident P&I funds. A document regarding a new bank account will be submitted to the department by 5/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87216(a) · Plan of correction due date: May 10, 2022

87216 Bonding: (a) Each licensee,... entrusted to safeguard...cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement is not met as evidence by: Based on document review the licensee did not ensure to obtain a proper surety bond prior to handling the resident's cash resources which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will obtain a required surety bond. A proof of adequate bond will be submitted to the department by 5/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2-3)(5) · Plan of correction due date: May 10, 2022

Administrator - Qualifications and Duties.The administrator shall... If the licensee is also the administrator, all requirements...apply. (2) Knowledge of and ability to conform to... laws, rules and regulations. (3) Ability to maintain or supervise... financial and other records. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidence by: Based on documents review licensee did not ensure to maintain accuracy of financial records which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee will attend continued education classes provided for Administrators. Licensee will secure the appoitment to attend classes and provide proof of enrollment by 5/10/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87215 · Plan of correction due date: May 10, 2022

87215 Commingling of Money: Money and valuables of residents entrusted to the licensee of one community care facility licensed under a particular license number shall not be commingled with those of another residential care facility... This requirement is not met as evidence by: Based on documentation reviewed licensee did not maintain a separate checking account for facility from personal account which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee is to maintain a separate checking account for facility funds and a separete account for P&I funds, facility expenses and revenue and submit proof of account designated to facility by 5/10/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Apr 29, 2022

87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure to provide accurate information and records to teh LPAs and other agency representatives which poses a health, safety, or personal rights risk for the persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training related to the cited section as well as 87408:Denial or Revocation of a Certificate 87777: ExclusionsPersonal Rights. Verification of scheduled training with the trainers credentials will need to e submitted by 4/29/2022 and completed by 5/13/2022.

Type of visit: Office

An office meeting was held at the Monterey Park Adult and Senior Care Regional Office (MP ASCRO) to deliver the Final Findings of a Trust Audit Report involving the following facilities: Skyhill Quality Living #2 197609098: [complaint investigation - Control#:28-AS-20210824090807], Skyhill Quality Living 197608910, Our Sweet Home Inc 197607711, Our Sweet Home Inc #2 197608083, and Our Sweet Home Inc #3 197608084, Attendees present during the meeting were: Licensee/Administrator Tina Arutyunyan,Administrator Akop Ekymyan CCLD Regional Manager Aracely Ramirez, CCLD Audit Department Manager, Jacqueline Juarez, Licensing Program Manager(s) Lisa Hicks, Naira Margaryan, Stefanie Coronel, and Licensing Program Analyst(s) Noemi Galarza, Mary Flores, Yelena Avetisyan, Tuesday Cabiness, and Rosaura Valenzuela. The purpose of the meeting was explained to Licensee Ms. Arutyunyan. On 08/24/2021 Community Care Licensing Division (CCLD) received complaints against all above noted facilities operated by the same Licensee. The complainant was alleging financial abuse of the residents' Personal and Incidental (P&I) funds. An initial investigation visit was conducted on 09/01/2021. As a part of the complaint investigation, the complaints were referred to the CCLD Audit Department for a Trust Audit. The audit investigation conducted by Jacqueline Juarez concluded the following: * The Licensee/Administrator Misappropriated residents Personal and Incidental (P&I) funds. Multiple residents did not have access to, or were not distributed P&I funds. * The Licensee/Administrator failed to maintain adequate safeguards and records for residents' cash resources. Proper documentation for expenditures was not maintained. * The Licensee/Administrator Commingled the residents P&I monies with facility funds. See 809-C for report continuation. On today's date, CCLD Audit Manager Jacqueline Juarez delivered findings on the Trust Audit Report and discussed required plan of corrections (POCs). The Licensee/Administrator was notified that she will need to complete the following: * Refund all residents' enrolled in the Brilliant Corners program the amounts identified in the Trust Audit report and submit proof of repayment. * Provide proof of Surety Bond that covers each facility license and not the corporation. * Submit a written plan on how they will distribute P&I funds to residents and bank statements showing that P&I funds have been deposited in a separate trust account. *Submit an updated Plan of Operation reflecting the changes in population that will be served. On 10/8/2022, Licensee/Administrator is to submit to the Audit Section the LIC 405's and corresponding receipts for each facility to ensure proper record-keeping. The deficiencies related to the complaint allegation were also discussed during today's Office meeting, and were disclosed in the final complaint investigation report delivered to the Licensee Ms. Arutyunyan. See complaint control number 28-AS-20210824090807. During the initial complaint investigation visit dated (9/1/2021) resident's files were reviewed. Based on record review observation, LPA observed the resident files were incomplete and/or missing required forms i.e. personal and incidental (P & I) records, original receipts, hospice care plans, and admission agreements were missing authorized representative parties contact information. 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. Update all facility admission agreements to include contact information for all residents’ representative parties. Licensee was informed that Quarterly Case Management visits will be conducted. Technical Support Program brochure was email to licensee during this meeting and a referral will be submitted to Residential Technical Support Program for the facility. Per Title 22 Regulations, Division 6 Chapter 8, Article 09, a deficiency was cited. See LIC 809D. An exit interview was conducted and a copy of this report was issued to Licensee Tina Arutyunyan.the state’s words, verbatim · CDSS document, Apr 26, 2022

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

87506 Personal 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 requireement is not met as evidence by: Based on record review observations during the visit dated 9/1/21 in reference to complaint # 28-AS-20210824090807, residents' files were incomplete and/or missing required forms i.e. P & I ledgers, hospice care plans, original receipts of P & I expenditures, and authorized representative contact information. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: Licensee agrees to ensure that all resident records are complete and accurrate.Administrator is to review Title 22 regulations section 87506(b)(1-17) as a guide to required resident record information. Submit a signed statement of understanding and intent to abide by the cited regulation.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of an annual required. LPA met with S1 and S2, an explained the purpose of today's visit. At 10:15 Administrator Arutyunyan arrived and assisted with the remainder of the visit. Upon arrival LPA checked association and observed S2 not on the association list. S2 confirmed that she has worked here for a week. Facility is licensed to serve 6 over the age of 60. 6 of which is non-ambulatory, and 1 can be bedridden. Hospice waiver approved for 4 residents. Facility is a one-story house in a residential area. LPA made a complete tour of facility which included: 6 bedrooms, 2 bathrooms, living room, kitchen, dining room, laundry area, outdoor area, and garage. Administrator certificate #6002858740 expires 4/5/2023. The following was observed, reviewed, and inspected: Bedrooms #1-5 are designated for residents. Bedroom #6 is designated for staff. Each bedroom contained the required furniture and linens as mandated. Bathroom was observed to contain working fixtures, and were equipped with necessary grab bars. Resident bathroom was missing non-slip mat. Water temperature measured in the residents bathroom at 123.6 degrees F, which is not in the required range of 105-120 degrees F. Kitchen was inspected and no deficiencies observed; cleaning materials and knives were secured in a locked cabinet, appliances were clean and operational, and an adequate supply of 2 days perishable and 7 days non-perishable. LPA observed sufficient linen,required documents were posted in the office area, trash cans with tight fitting lids. Smoke detector and carbon monoxide detectors were tested and operable, fire extinguisher(s) fully charged, front and back yard clean and free of debris. Staff files for administrator, S1 and S2 was reviewed. Administrator stated S2 do not have a file yet because she is newly hired. Medication for all residents was reviewed. The last disaster drill was conducted on March 4th 2022 . Report continued on 809C Pursuant to Title 22 Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties issued/ Exit Interview Conducted / Appeal Rights provided / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Mar 30, 2022

Allegation investigated: Resident sustained injuries from a fall while in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation for the allegation listed above. LPA met with Staff, Maria Limaco, and explained the purpose of the visit. The licensee, Tina Arutyunyan, arrived shortly thereafter. The investigation consisted of the following: LPA Chan obtained copies of the resident roster, staff roster, and documents pertaining to Resident #1 (R1). LPA toured the facility with the licensee and conducted interviews with the licensee, Administrator, 3 Staff, 2 Residents, R1, R1's family member, and Staff at Cedar Assisted Living facility. R1 is no longer residing at the facility. (Continue on LIC9099C) Unsubstantiated The investigation revealed the following: In regards to allegation, resident sustained injuries from a fall while in care. It is alleged that Resident #1 (R1) fell and sustained bruises underneath the eyes and swelling around the nose. LPA interviewed the Staff #1 (S1), who was on duty for the overnight shift but did not witness the fall. S1 stated that the fall occurred around 2 a.m. When S1 heard R1's fall, S1 immediately went into the room to observe R1 by the end of the bed and already standing up. S1 checked on resident for any injuries and asked what had happened. R1 responded by saying that R1 might had slipped on the wet floor but there was no pain. R1 agreed to take a Tylenol as a precaution and went to sleep right after but S1 did not observe any bruising or swelling in the face at that moment or in the morning. Per R1's family member, R1 stated that R1 either fainted or lost balance while trying to get up. R1 also refused to go to the doctor when family member went to visit that morning and noticed some redness by the nose. The licensee showed LPA a photo of R1's alleged injury from the fall but also stated it is difficult to determine if the fall caused any bruising or swelling since R1 normally has puffiness underneath the eyes. LPA interviewed the Marketing Director of Cedar Assisted Living who stated that the R1's sister informed her that R1 had a fall at the former facility. R1 was not observed with any swelling or bruises in the eye or nose area upon admission at new facility. According to interviews conducted with facility personnel, Resident #1 (R1) does not require much assistance and is able to ambulate on own. All the staff reported that R1 moves around the house using a walker sometimes but does not need staff to assist with mobility, which is also mentioned on the Appraisal/Needs and Services Plan and/or Physician's Report. However, Staff check on all residents regularly and respond right away when they hear residents' calls. LPA also interviewed 2 out of 3 residents which both stated Staff check on them and assist with their needs. Although R1 had fallen, there is no supporting evidence indicating a lack of supervision or neglect from the staff. In addition, there is no evidence to show that the fall caused any form of bruising or swelling in the eyes and nose area. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with the licensee via telephone. A copy of this report along with the appeal rights were provided to the Staff whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Nov 4, 2021 · control 28-AS-20211101125943

Type of visit: POC

Licensing Program Analyst(s) LPA Mary Flores conducted a plan of correction (POC) visit at the facility for deficiencies given on 9/1/21. LPA Flores met with Tina Arutyunyan administrator and explained the reason for the visit. On 9/1/21 LPA Flores conducted a complaint investigation visit and conducted a physical plant review. During the visit LPA cited type A deficiencies due on 9/2/21 and type B deficiencies. Today's visit LPA Flores conducted a POC visit to cleared the deficiencies due on 9/2/21 and 9/7/21. The following type A deficiencies were cited on 9/1/21: 87303(e)(2) - Maintenance and Operation - Facility's water temperature was tested at 145 degrees F in bathroom #1 and 144.5 degrees F in bathroom #2. LPA Flores measured water temperature in bathroom #1 and tested at 118.8 degrees F and bathroom #2 tested at 117.5 degrees F. 87355(e)(1) - Criminal Record Clearance - Staff #2 was observed working since 8/20/21 and does not have a criminal background clearance. LPA Flores observed staff leave the facility during the visit of 9/1/21 and did not observed staff working at the facility. 87303(a) - Maintenance and Operation - Resident #3's dresser and closet door are not in good repair, and living room smoke detector is not working. LPA Flores observed dresser in room #5 removed from room, receipt for purchased dresser was email to LPA during the visit, closet door was repaired and smoke detector was tested and working properly. (CONTINUED LIC 809C) 87307(a)(3)(C) - Personal Accommodations and Services - Resident #1 and #3 did not have all required bedding items. LPA Flores observed the following items in Resident #1 and #3 beds; have bottom sheet, flat sheet, blanket, room #4, #1, and #3 have a comforter, pillow, and pillow case. Closet with linens have additional blankets and comforters. 87307(a)(3)(B) - Personal Accommodations and Services - administrator did not ensure each resident in Room #4, #2, #1 have a night stand. LPA Flores observed a night stand in room #1,#2,#4. Exit interview was conducted with Tina Arutyunyan administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 13, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(s) Mary Flores and Luis Mora conducted a case management for deficiencies observed during a complaint investigation visit on 9/1/21. LPAs met with Paula Castro and explained the reason of the visit. The investigation consisted of the following: LPAs conducted a tour of the facility around 10:15am. LPAs observed the following: Kitchen staff was preparing meals and stated to have sharps cabinet and cabinet under the sink with chemicals unlock as she was using items. Living room smog detector had battery sticking out and not functioning. Cabinet in hallway with cleaning supplies was unlock and linen closet had sufficient linens, no blankets observed. LPAs tested water temperature in bathroom #1(B1) and tested at 145.0 degrees F, and bathroom #2 (B2) was tested at 144.5 degrees F. which is not under the required 105 to 120 degrees Fahrenheit. LPAs observed vacant room #1(R1) bed does not have padding, top sheet, blanket, comforter, pillow, and pillow case, LPA observed a blanket in the closet and pillows. Room #2(R2) and #3(R3) with half bed rails, Room #5(R5) no mattress padding, no top sheet, no blanket, no comforter, dresser has a broken drawer, and broken closet door, Room #4(R4), R2, R3,and R1 do not have a night stand. Staff #1 has been working since 7/29/21, who is not associated to the facility administrator will email transfer request and mail verification to LPAs email by 5:00pm, and staff #2 has been working since 8/20/21 and does not have a criminal record background clearance after checking in criminal background system. Deficiencies were cited under Title 22 Regulations on LIC 809D. Exit interview was conducted with Paula Castro, lead caregiver and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 1, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 2, 2021

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal ...shall deliver hot water... maintained to ... a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by: Based on observation administrator did not ensure water temperature is maintain within the required 105 to 120 degrees F; LPAs tested water temperature in B1 at 145 and B2 at 144.5 degrees F which poses an immediate Health, Safety, and Personal Rights risk to 4 out of 4 persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will adjust water heater to deliver water temperature between 105 to 120 degrees F and submit LIC 9098 by 9/2/21. Administrtor will maitain a 7 day log of water temperature and will submit to the department by 9/9/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Sep 2, 2021

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidence by: Based on LPAs observation and records administrator did not ensure S2 does not have a criminal background clearance which poses an immediate Health, Safety, and Personal Rights risk to persons in care. *Civil penalties are being assessed in the amount of $ 500.00.*the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Admistrator is to ensure all staff obtain a criminal record background clearance. S2 should not return to work until cleared and associated to the facility. Administrator is to submit LIC 9098 to certify, and copy livescan and transfer request and submitted to the department by 9/2/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 7, 2021

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on LPAs observation administrator did not ensure R3's dresser and closet door are in good repair, and living room smoke detector is working properly which poses a potential Health, Safety, or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will ensure facility is in good repair at all time, will replace dresser and fix closet door in R3, and will replace smoke detector in living room. Administrator to take pictures and submit to the department by 9/7/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(3)(C) · Plan of correction due date: Sep 7, 2021

87307 Personal Accomodations and Services: (a) Living accommodations... shall...(3) Equipment and supplies necessary for personal care...(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads,... This requirement is not met as evidence by: Based on LPA observation administrator did not ensure R1 and R3 did not have all required bedding which poses a potential Health, Safety, or Personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will ensure R1 is readily for new admission and that R3 maintains all bedding items available at all times. Administrator will submit pictures to the department by 9/7/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(B) · Plan of correction due date: Sep 7, 2021

87307 Personal Accomodations(a) Living accommodations and grounds shall be...(3) Equipment and supplies necessary... (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidence by: Based on observation administrator did not ensure each resident in R4, R2, R1 have a night stand which poses a potential Health, Safety, or Personal rights to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will ensure that each resident has a night stand in R1, R2, and R4 and will submit pictures to the department by 9/7/21.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was greeted by administrator Tina Arutyunan and discussed the purpose of today's visit. This single-story home contains six (6) bedrooms, three (3) bathrooms, a living room, kitchen, dining area, backyard, and attached garage. The following was observed/inspected: The facility had a universal entrance screening area including a thermometer, hand sanitizer and sign-in sheet. A temperature check log was present but not updated. COVID-19 signage was placed in several areas including entrance, hallway, and bathrooms. Facility maintained a 30-day supply of PPE. One (1) out of three (3) bathrooms were in disrepair including the toilet, sink, and shower. There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. Cleaning solutions and sharps were locked and inaccessible. Water temperature was measured in kitchen/bathrooms and were within required 105-120 degrees F. Each room contained required furniture including bed, dresser, night stand, lamp and chair. Medications were locked and centrally stored. Medications were reviewed for four (4) residents and facility did not maintain a 30-day supply of medications. Staff wore face masks throughout their shift. Smoke detectors/carbon monoxide detectors were present and operable. At least one (1) fire extinguisher was observed to be fully charged and serviced. Client files were inspected and emergency contact information was up to date. Administrator qualifications were checked and administrator certificate expires on 4/2023. Obstructions were observed in the outdoor area as two bed springs and headboards were placed there and were not properly discarded. Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the administrator.the state’s words, verbatim · CDSS document, Aug 17, 2021

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.