Glen Terra Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced inspection visit. LPA met with Administrator Carlos Lara. The purpose of the visit was explained. Facility is licensed to served 155 non - ambulatory residents, of which 4 may be bedridden and has a hospice waiver for 20 residents. Facility is a 4 story building, with a lobby, dining room, 2 activity rooms, a kitchen, a small outdoor shaded patio, medication room is on the second floor, and a salon in the third floor. Fire alarm sprinkle system was observed throughout the facility. There are no large bodies of water in the property. LPA Valenzuela conducted a walk through with and observed the following: Facility is clean and free of odors in common areas. Elevators are in working condition. All bedrooms have the proper bedding, and furniture. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in May of 2023. The bathrooms were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 111.5 degrees. LPA observed seven days worth of perishable and non-perishable food. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this timethe state’s words, verbatim · CDSS document, Aug 31, 2023

Allegation investigated: Resident was not adequately supervised

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with administrator Carlos Lara and the purpose of the visit was discussed. Initial visit was conducted on 2/24/22 by LPA Kruz and consisted of the following: LPA obtained and reviewed a copy of the Staff Schedule (August, September, October and December 2021), Resident Roster, Resident #1's records (Physician report, Medical History, Resident Appraisal, Appraisal/Needs and Services Plan, Identification and Emergency Information). On todays visit, LPA Villalobos toured the physical plant and interviewed Staff #1-#5 (S1-S5) and residents #2-#8 (R2-R8) , LPA unable to interview R1 as they are not available for to be interviewed. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated Regarding the allegation of "Resident was not adequately supervised" it was alleged that the resident had not been receiving adequate supervision as guaranteed by the facility. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Interviews do not show that R1 received 1 on 1 supervision in the facility. LPA reviewed R1's Needs and Services plan, and did not observe R1 needing 1 on 1 supervision throughout the day. LPA did observe that R1 should be visited by staff throughout the day for various reasons. Interviews from staff stated that these visits were conducted regularly and R1 was assisted with anything they needed. LPA was not provided with proof of staff not providing supervision to R1 and R1 is unable to be interviewed. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 28-AS-20220217112823

Allegation investigated: Facility has inadequate record keeping

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Administrator Carlos Lara and the purpose of the visit was discussed. Initial visit was conducted on 5/13/21 by LPA Kruz and consisted of the following: LPA obtained a copy of the staff and resident roster, hospice agency information and interviewed Staff #1 and Staff #2. On todays visit, LPA Villalobos toured the physical plant and interviewed Staff #3-#5 (S3-S5) and residents #2-#8 (R2-R8) , LPA unable to interview R1 as they are not available for to be interviewed. The investigation revealed the following: Continued on LIC 9099-C Substantiated In regards to the allegation of "Facility has inadequate record keeping" it was alleged that the the facility file for R1 was not available for review as it could not be located in the facility. (4) of (5) Staff interviewed could not provide information regarding the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Details state that a Long Term Care Ombudsman staff requested documents for R1 from the facility on April-May 2021. Staff interview confirmed that the file for R1 was not able to be provided as it could not be located in the facility. Initial visit interviews conducted on 5/13/21 by LPA Kruz confirms that that R1's file could not be located in the facility. R1 was discharged from the facility on 10/25/18 and per regulations the file for R1 should have been kept for a minimum of 3 years from that date. This means R1's file should have been on site and available for review until 10/25/21. Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D. Exit Interview conducted and a copy of this report was provided. Appeal Rights were discussed and provided as well. In regards to the allegation "Resident sustained unexplained injuries while in care" it was alleged that R1 sustained unexplained bruising in their arms and legs. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents could not corroborate the allegation. LPA Villalobos reviewed the hospice agency notes for R1 and did not observe documentation of bruising to R1's legs or arms. Notes stated that R1 was receiving wound care on their arm and their wrist. Staff interviews do not show that R1 was injured by any staff or to have observed R1 injured themselves. LPA was not provided with documentation of R1 having unexplained injuries in the facility. At the time of this visit, there is no resident file for R1 as the facility only keeps records for a minimum of 3 years and R1 has not been a resident since 10/25/18. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 28-AS-20210504155709

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Aug 10, 2023

87506 Resident Records.(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This was not met as evidenced by: R1 was discharged on 10/25/18 and file for R1 was requested in April and May of 2021 but staff could not provide the file. This shows a potential health and safety risk for residents in care and supervision.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Facility to conduct in service training for management staff regarding Title 22 Regulations on Resident Records. Sign in sheet of start participating to be provided to CCL by POC due date.

Allegation investigated: Resident sustained multiple injuries while in care. Areas of potential hazard to residents with poor eyesight were not kept inaccessible to residents.

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation above. LPA met with Administrator Carlos Lara and the purpose of the visit was discussed. Initial visit was conducted on 12/7/21 by LPA Wesley and consisted of the following: LPA toured the physical plant did not observe there to be any health and safety concerns. LPA Wesley requested a copy of: staff roster, resident roster, and the following documents for resident #1 Admission agreement, Emergency Identification page(ID Page), current Physicians report, and the Appraisal needs and services plan. LPA Wesley interviewed Staff #1-#2 (S1-S2). On todays visit, LPA Villalobos toured the physical plant and interviewed Staff #1-#5 (S1-S5) and residents #2-#8 (R2-R8) , LPA unable to interview R1 as they are not available for to be interviewed. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Resident sustained multiple injuries while in care" it was alleged that R1 sustained multiple injuries in care and hospitalized due to lack of supervision. (5) of (5) Staff interviewed denied the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. It is alleged that R1 fell and broke their teeth on once occasion and then broke their shoulder because of a fall on another occasion. File review shows documentation of unwitnessed fall regarding R1 that resulted in R1 going to the hospital for a cut on their lip. Interview stated that staff were conducting a room check on 9/2/21 for R1 and noticed R1 had a cut on their lip. Due to it being an unwitnessed injury, staff called 911 to have R1 go to the hospital. There is no documentation or interviews from staff and residents stating that R1 broke their teeth in the facility. File review also shows documentation of a fall R1 had on 9/12/21 at approximately 1:45am near the facility elevator which resulted in a possible shoulder injury. According to interviews, R1 got out of bed in the middle of the night and went down the elevator. Upon stepping out the elevator R1 lost balance and fell. Staff interviews show that R1 was immediately assisted by staff. Interviews show that R1 liked to walk around the facility on their own and when they pleased. R1 did not require one on one supervision per review of their file. Staff interviews also stated that R1 was sent to the hospital that night but did not return to the facility as family relocated them. There are no further documents on file regarding R1's fall on 9/12/21. LPA was not provided any further documentation regarding the hospital visit or status of R1. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation of "Areas of potential hazard to residents with poor eyesight were not kept inaccessible to residents." it was alleged that the facility did not close off a construction zone causing R1 to fall. (5) of (5) Staff denied the allegation. (7) of (7) Residents interviewed could not corroborate the allegation. Interviews state there was a night where the facility hired an individual to fix a small section of tile in the hallway near the elevator. The work was being done between 12am-4am as to not bother residents in care or interfere with any daily activities. Signage was put upon the walls as well as caution cones places to block the area. Staff had view of the area as needed to make sure residents kept their distance. Interviews show that R1 came down the elevator from their room around this time and ignored signs and directions from staff present to not walk towards that specific area where the floor was being repaired. Based on files reviewed, observations, and interviews conducted, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 28-AS-20211206101003

Allegation investigated: Resident sustained a fracture while in care

***This report is a corrected version of the report dated 04/04/2023 due to a correction needed to the LIC9099D. Citation 87466 was incorrectly issued as a Type B citation, citation should have been issued as a Type A. The other citation 87405(d)(1) on report dated 04/04/23 was issued correctly. No other changes were made to the report. The complaint investigation findings remain Substantiated.*** Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint subsequent visit to render finding for the above allegation. LPA met with Receptionist Cecilia Espinoza and explained the reason of the visit. Shortly after, LPA met with Health and Wellness Director Anna Tupinyan and assisted with the visit. The investigation consisted of the following: On 3/29/2022, LPA conducted an initial complaint visit and a health and safety check. LPA toured the facility with Administrator and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. The following documents were collected which included: staff and resident roster and documents for Resident#1-#3. (See LIC 9099C for continuation) Substantiated The complaint was accepted by Community Care Licensing Investigation Branch (CCIB) and it was assigned to IB investigator Christine Ferris. Investigator Ferris interviewed resident (R1), Administrator (S1), R1’s Power of attorney, Health and Wellness Director, two residents, private caregiver and R1’s primary physician. USC Verdugo Hills Hospital and Glendale Memorial Hospital medical records were obtained. The investigation revealed the following: “Resident sustained a fracture while in care”, based on interviews conducted, facility documents, and medical records obtained from USC Verdugo Hills Hospital and Glendale Memorial Hospital by investigator Ferris, the findings noted R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries including a fractured finger, a fractured arm, and a fractured neck and back. During the interview, R1 stated that all the injuries were accidental. The result of R1’s falls also happened during the evening when there was no 1:1 caregiver present. On September 2020, R1’s doctor had already recommended that R1 required one on one care and it would be neglectful if R1 does not have a one on one to use the bathroom, move and from the bed and wheelchair, or getting dressed. Although R1 had a private caregiver who works seven days a week from 10am to 5pm from December 2020 to April 2022. The facility also implemented safety checks every two hours, beginning and end of shift and gave a resident a pendant to call for help, however R1 misplaced the pendant. Facility failed to take any action after each incident involving a fall for R1 to mitigate the falls. Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to the facility failed to observe changes in resident’s health which resulted in resident sustained a fracture while in care. Refer to LIC 421IM*** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report and appeal right were provided to the Wellness Director Anna Tupinyan along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jun 2, 2023 · control 28-AS-20220328103723

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 3, 2023

87466 Observation of the Resident.. The licensee shall ensure...observed for changes in physical, mental, ...functioning .... appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not take any action to mitigate the falls for R1. R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries, this poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2023

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

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

At 11:05 am. on 04/20/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the Administrator and disclosed the reason for the visit. LPA and S2 toured the facility at 2:30 p.m. No immediate health or safety concerns were observed. Regarding the allegation “Staff did not safeguard resident's personal belongings”, it was alleged Staff #1 (S1) took the purse of Resident #1 (R1). LPA interviewed staff, R1, and R1’s friend between 1:00 p.m. and 2:45 p.m. and reviewed records between 2:00 p.m. and 2:45 p.m. on 04/20/2023. Information obtained through interviews and record review revealed S1 was not a facility staff. S1 was a private caregiver hired by R1. R1 and R1’s friend confirmed that R1 found their purse this morning and the allegation was untrue. Based on interviews and record review, the allegation is deemed UNSUBSTANTIATED at this time. Unsubstantiated Regarding the allegation “Staff financially abused resident”, it was alleged S1 asked R1 for a loan, and R1 had unapproved withdrawals in their account. Record review revealed R1 was hospitalized on 04/13/2022 with a high fever and UTI which resulted in confusion. From interviews, the Administrator, S2, R1’s private caregiver, and R1’s friend confirmed that the withdrawals were payments made to R1’s private caregivers. R1’s friend confirmed R1 was confused at the hospital and made some unclear statements while there. Based on interviews and record review, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 20, 2023 · control 31-AS-20230418170420

Allegation investigated: Resident sustained a fracture while in care

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint subsequent visit to render finding for the above allegation. LPA met with Receptionist Cecilia Espinoza and explained the reason of the visit. Shortly after, LPA met with Health and Wellness Director Anna Tupinyan and assisted with the visit. The investigation consisted of the following: On 3/29/2022, LPA conducted an initial complaint visit and a health and safety check. LPA toured the facility with Administrator and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. The following documents were collected which included: staff and resident roster and documents for Resident#1-#3. (See LIC 9099C for continuation) Substantiated The complaint was accepted by Community Care Licensing Investigation Branch (CCIB) and it was assigned to IB investigator Christine Ferris. Investigator Ferris interviewed resident (R1), Administrator (S1), R1’s Power of attorney, Health and Wellness Director, two residents, private caregiver and R1’s primary physician. USC Verdugo Hills Hospital and Glendale Memorial Hospital medical records were obtained. The investigation revealed the following: “Resident sustained a fracture while in care”, based on interviews conducted, facility documents, and medical records obtained from USC Verdugo Hills Hospital and Glendale Memorial Hospital by investigator Ferris, the findings noted R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries including a fractured finger, a fractured arm, and a fractured neck and back. During the interview, R1 stated that all the injuries were accidental. The result of R1’s falls also happened during the evening when there was no 1:1 caregiver present. On September 2020, R1’s doctor had already recommended that R1 required one on one care and it would be neglectful if R1 does not have a one on one to use the bathroom, move and from the bed and wheelchair, or getting dressed. Although R1 had a private caregiver who works seven days a week from 10am to 5pm from December 2020 to April 2022. The facility also implemented safety checks every two hours, beginning and end of shift and gave a resident a pendant to call for help, however R1 misplaced the pendant. Facility failed to take any action after each incident involving a fall for R1 to mitigate the falls. Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to the facility failed to observe changes in resident’s health which resulted in resident sustained a fracture while in care. Refer to LIC 421IM*** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report and appeal right were provided to the Wellness Director Anna Tupinyan along with the Appeals Rights.the state’s words, verbatim · CDSS document, Apr 4, 2023 · control 28-AS-20220328103723

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 18, 2023

87466 Observation of the Resident.. The licensee shall ensure...observed for changes in physical, mental, ...functioning ....appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not take any action to mitigate the falls for R1. R1 had multiple falls from September 2020 to March 2022 which resulted in serious injuries which posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2023

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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1) · Plan of correction due date: Apr 18, 2023

87405 (d)(1) Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. Based on interviews conducted, the facility did not take any action to mitigate R1’s falls. Additionally, the facility did not contact R1’s PCP and failed to make updates to R1’s case plan which posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2023

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

Allegation investigated: . Facility did not meet the resident's dietary needs. 2. Facility food is of poor quality. 3. Facility did not provide a variety of foods. 4. Facility did not seek medical attention in a timely manner. 5. Facility staff are not adequately trained.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit regarding the allegations listed above. LPA met with Administrator, Carlos Lara, and explained the purpose of the visit. The investigation consisted of the following: On 9/11/2020, LPA J. Katrdzhyan conducted the initial visit and requested for documents pertaining to Resident #1. On 3/14/23, LPA Chan did a follow up visit to interview the Administrator, 6 Staff, 9 Residents, and a Nutrition Consultant. The investigation revealed the following: Allegation - Facility did not meet the resident's dietary needs. It was alleged that Resident #1 (R-1) required a heart healthy diet which was ordered by the physician. According to the Administrator and kitchen staff, the cardiac or heart healthy diet means that the sodium should be limited to the resident. Unsubstantiated Per the cook, the meals are prepared with low to no salt for all the residents. The nutrition consultant hired by the company is a self-contractor who comes once a month to the facility. The consultant stated that the recipes for the meals are provided to the facility and are considered nutritious with a balanced diet. LPA toured the kitchen area and observed residents with dietary needs posted on the inside bulletin board. The resident picture and their diet ordered are marked on the diet card. Staff interviewed stated they obtain information about a resident’s diet from the Med Tech and follow the orders. In regards to R-1, staff stated R-1 ate majority of the meals at the facility and sometimes the family member brought food. Some of the staff knew of the “cardiac diet” and since the meals were prepared with low sodium, R-1 did not require anything different. Based on information gathered, there is insufficient evidence to prove this allegation. Allegation – Facility food is of poor quality. LPA toured the kitchen and observed fresh fruits and vegetables. The chef was preparing the meals and keeping the items in a warmer or covered. There were sufficient supplies of 2-day perishable and a week of non-perishable items in storage. Staff interviewed stated they used items of good quality to make the meals. They are using the fresh items and replenishing them at least once or twice a week. The nutrition consultant stated that the recipes utilizes approximately 80% of fresh ingredients and about 20% of canned goods. LPA interviewed 9 residents today. 8 out of the 9 feel that the facility uses good quality of items to cook their meals. Allegation - Facility did not provide a variety of foods. During the visit today, LPA obtained copies of the menu for the month. The menu is posted by the dining room and LPA observed a variety of foods for the week. Per the kitchen supervisor, the menu is different each week and residents have alternative meals if they do not want the main course for lunch or dinner. The alternative choices, such as sandwiches, cheese omelet, or grilled hamburger, are posted on the dining room tables. Per staff interviewed, if a resident wants something from the alternative list, they would prepare the food at the time of request. LPA interviewed 9 residents today. 2 out of the 9 do not like the food choices and feel that there is no variety of food selections. The other 7 residents stated the facility offers variety of foods. Allegation - Facility did not seek medical attention in a timely manner. It was alleged that Resident #1 (R-1) had a heart attack on 8/12/20 and asked the caregiver to call 911, but caregiver said resident was ok. LPA interviewed staff who were working on the day of incident. Staff stated that R-1 was on the video call with the family member who witnessed R-1 needing medical attention. The family member immediately contacted the facility and staff called 911 right away. The paramedics came to the facility and determined resident had a cardiac arrest with a DNR order. Administrator and Staff stated they did not observed R-1 to be in any distress prior to cardiac arrest and also stated that R-1 would have informed staff if not feeling well. The residents interviewed have not had to seek immediate medical attention but feel that the staff will intervene right away if residents need it. Allegation - Facility staff are not adequately trained. It was alleged that the facility did not have a full-time food service manager who accounts for the resident’s dietary needs. LPA obtained the personnel report and observed a kitchen manager who works 40 hours a week. The kitchen staff receive training from the manager and the Nutrition Consultant. The Nutrition Consultant stated that training are provided to the kitchen staff and to go over any updates as needed on a monthly basis. LPA interviewed 9 residents and they feel that the kitchen staff are adequately trained to prepare food. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the facility nurse, Anna Tupinyan. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 14, 2023 · control 28-AS-20200904141947

Allegation investigated: Due to neglect residents developed pressure injuries while in care Residents are left soiled for extended periods of time while in care Residents are not being provided appropriate care and supervision while in care Facility has insufficient staffing

On 02/22/2023 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA Agard met with Carlos Lara, Administrator and explained the purpose of this visit was to deliver findings for this complaint. The investigation consisted of the following: LPA toured the physical plant. The facility is licensed to served 155 non - ambulatory residents, of which, 4 can be bedridden and has a hospice waiver for 20 residents. Facility is 4-stories in height, with a lobby, dining room located on the main floor, 2 activity rooms, kitchen, a small outdoor shaded patio, medication room located on the second floor, and a salon. LPA Agard conducted interviews and reviewed records on 01/18/2023 and 01/19/2023. Cont. on 9099C Unsubstantiated The investigation revealed the following: Regarding the allegation… Due to neglect residents developed pressure injuries while in care. “It’s being alleged residents are left unattended in their rooms, not turned constantly, leading to open bed sores.” LPA interviewed 4 out of 45 staff in total. 0 out of 4 staff confirmed the allegation. S1 states, “there is only one person that’s on hospice. They have a small pressure wound and are receiving wound care from hospice. I want to say it’s at stage 2 right now.” S2 states, R1 has a wound that is just forming due to being bedridden, and she’s on hospice. The wound is very small. Hospice is taking care of the wound with me. I take care of it as well as hospice. I don’t think there are any other residents with a pressure ulcer.” S4 states, “the nurse takes care of the wound and we reposition every two hours. I don’t think the residents are neglected.” During interviews with the resident, LPA Agard attempted interviews with 11 out of 89 residents in total. 0 out of 9 residents confirmed the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “I haven’t observed anything like that. I’m never neglected, and I have a good time here. Everything is fine here with the girls.” R4 states, “no. I don’t know about that. People fall but that’s about it. I’ve never seen anything except for maybe a cut from a resident falling. I don’t feel like anyone is neglected here.” R6 states, “I don’t know anything about that claim.” R8 states, “I don’t know about any pressure injuries and no one is neglected from what I can see because I watched them.” Regarding the allegation… Residents are left soiled for extended periods of time while in care. “It’s being alleged many residents are left sitting in wet diapers and clothing.” 0 out of 4 staff confirmed the allegation. S1 states, “our residents are checked every two hours. That’s our standard. We don’t have an actual incontinent schedule. We have to check everyone regardless. We check their diapers, briefs and offer assistance to the restroom.” S2 states, “I have not observed that. The caregivers check every two hours if they are soiled. It doesn’t matter if they are bedridden or incontinent. They have to be clean before going to breakfast.” S3 states, “residents aren’t left wet or soiled. We always try to change them every 2-3 hours. Especially the ones with sensitive skin. We know the incontinent people and the people that need more attention.” S4 states, “I don’t think so. The policy is that we need to assist each resident so we can’t leave the residents wet for long periods of time. We check every 2 hours. With some residents I check every 30 minutes.” cont on 9099C LPA attempted interviews with 11 residents. 0 out of 9 residents confirm the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. All residents interviewed unanimously denied the allegation or knowing anything about it. R3 states, “not that I know of.” R5 states, “that I don’t know. I never heard anyone say that.” R6 states, “I sure have not observed that.” R8 states, “they took care of me when I needed diapers.” R10 states, “I don’t think so.” Regarding the allegation… Residents are not being provided appropriate care and supervision while in care. “It’s being alleged several residents are constantly neglected at the facility.” 0 out of 4 staff confirmed the allegation. S1 states, “we are providing very good care that’s why we are full. No residents really complain.” S2 states, “none, no, no one. Our residents are very verbal. They come to me with concerns.” S3 states, “I try to go above and beyond even if it’s not my assignment.” S4 states, “absolutely yes, if a patient needs something, we try to get it right away. If they have pain, we get the med tech if they need first aid. I don’t know why someone would say that. The families are always here too.” 0 out of 9 residents confirm the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “the care here is fine. I don’t have any problems.” R4 states, “yes, absolutely. My needs are met.” R5 states, “I’ve been here for 6 years and I haven’t had that problem.” R6 states, “they are giving me good care, yes, they are 100%.” R8 states, “they take good care of me here.” R10 states, “I can’t think of any problems. They clean my room, make my bed and give me 3 meals per day?” Regarding the allegation… Facility has insufficient staffing. 0 out of 4 staff confirmed the allegation. S1 states, “we aren’t low on staff; we have 7 caregivers on right now. In the evening we have 5. In Dec 2022, there were two times we only had 3 caregivers. It was the holidays.” S2 states, “actually, we are sufficient. We have 7 in the am, 5 in the pm and 3 overnight. I would say we are staffed with more than enough people to meet the needs.” S3 states, “I don’t think there is not enough staff. We are okay.” S4 states, “no that’s not true. We have 8 or 7 staff on shift. We usually never have less.” 1 out of 9 residents confirm the allegation. 2 residents were unable to participate in the interview due to their cognitive ability. R2 states, “90% of the time they are fully staff but there are call offs and the girls do a good job at “filling in the gaps. Overall, they do a good job.” R3 states, “no, not enough staff. Honestly, no. For the cont on 9099C number of residents that need more care, they need more people to take care of them.” R4 states, “they probably could use more. I’m not saying they can’t do it. They make it work with what they have.” R5 states, “I don’t see any difference. I can’t really say. I hear people complain sometimes but not often.” R6 states, “I think they have enough. Everyone needs are being met from what I can see.” R7states,” I think there are enough people that work here. I don’t see a problem.” During a record review, LPA Agard identified one resident that has or had a pressure injury in which they were being provided with wound care. R1 is currently receiving home health services that are addressing a stage 2 pressure ulcer. Hospice plan is dated for 11/30/2022-01/28/2023. LPA did not observe or identify any other residents with a pressure injury. LPA reviewed the resident care log for all residents for the month of January and found each resident was provided with the level of care needed, based on their care needs. LPA reviewed the staff schedule for the month of November and December 2022 and found the staffing patterns to be sufficient. Based on LPA’s observation, record review and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 28-AS-20230117091626

Allegation investigated: Resident is left unattended Facility staff did not accompany resident to the hospital Facility interfering with resident's medical care

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Administrator Carlos Lara, who assisted with the visit. The investigation consisted of the following: Interview(s) with Administrator, Staff #1 - Staff #3, Resident #1, Resident #1's son, Resident #1's companion, and review of resident #1's file. Regarding the allegation that resident #1 is left unattended and that facility staff did not accompany resident #1 to the hospital, the investigation revealed that resident #1 has lived at the facility since October 9, 2021. Resident #1 experienced a fall on 8/9/22, when she was going to a doctor appointment on her electric wheelchair. Resident #1 suffered a fractured tibia and was hospitalized. Review of resident #1's physician's report does not indicate that resident #1 is not able to leave the facility unassisted. Administrator and facility staff interviewed stated that resident #1 always refuses to have any facility staff assist her on her medical appointments. Unsubstantiated Regarding the allegation that facility is interfering with resident #1's medical care, Administrator and staff interviewed denied the allegation. They stated that resident #1's doctor called and spoke with staff #1 after resident #1's fall, and advised that resident should have a caregiver accompany her on doctor appointments. Administrator and staff stated that they are now ensuring that resident #1 has someone accompany her on appointments and outings. Resident #1 confirmed that since she fell, she is no longer going to her appointments by herself. Resident #1 stated that she does not believe the facility is interfering with her medical care. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Carlos Lara.the state’s words, verbatim · CDSS document, Dec 5, 2022 · control 28-AS-20221129161405

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angelica Rea conducted a case management visit for the purpose of issuing a deficiency. During the course of complaint investigation for complaint #28-AS-20221129161405, LPA observed that facility staff did not submit a special incident report following resident #1's fall on 8/9/22 and subsequent hospitalization. Deficiency attached on 809-D.the state’s words, verbatim · CDSS document, Dec 5, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Dec 9, 2022

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not being met as evidenced by: LPA observed during complaint investigation that Special Incident was not submitted for resident #1 fall and hospitalization.the state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: Administrator will ensure that special incident reports are submitted to community care licensing as required. Adminstrator will conduct staff training regarding reporting requirements and will submit proof of training to LPA by POC due date.

Allegation investigated: Resident was exposed to amphetamines while in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver the finding for the allegation listed above. LPA met with Administrator, Carlos Lara, and explained the purpose for the visit. The investigation consisted of the following: On 9/23/21, LPA Chan conducted the initial visit. LPA toured the facility with Administrator Lara and selected 10 residents' rooms to inspect. There were adequate food supplies of 2 days perishable and at least a week of non-perishable. LPA did not observe any health and safety concerns during the visit. LPA obtained copies of the staff roster, resident roster, and documents pertaining to Resident #1. The Department of Social Services Investigations Branch (IB) Investigator Peter Zertuche conducted a further investigation. (continue on LIC9099C) Unsubstantiated The investigation revealed the following: Allegation - Resident was exposed to amphetamines while in care. Interviews were conducted the Administrator, facility staff, Medical Professionals, Resident #1 (R-1), and Resident #1's family members. The Administrator and Staff were not aware of Resident #1 (R-1) having amphetamine drugs in the system until R-1's family reported it to the facility. At approximately 11am on a Friday, R-1's family member came to visit and saw resident on the floor. R-1 was later taken to the hospital and according to the medical records, the blood tests revealed a "presumptive positive" for amphetamines. Staff stated R-1 appeared to be fine and did not notice any unusual activity. R-1 was interviewed and stated that resident lost his/her balance and fell. R-1 also stated the doctor informed of drugs in his/her system but resident did not know who gave it and did not think that the staff or family member would have given the drug. A case was opened with the Glendale Police Department alleging that a family member provided the drugs to R-1. Per Detective Shores, the case is closed under no crime as there was no evidence to support the allegation. Based on interviews completed by Investigator Zertuche, there were no witnesses to this allegation. Administrator and Staff did not know how amphetamines were found in R-1's system. They stated that family members are able to visit R-1 and allowed unmonitored visits. Family member denied giving drugs to R-1 during their visits. Family expressed they are happy with the care the facility is providing. Therefore, there is insufficient evidence to prove resident was exposed to amphetamines while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Lara. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 28-AS-20210922155543

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Alberto Lopez conducted a continuation annual visit at the facility to review medication for residents. Initial visit was on 8/11/2022. LPA Met with Wellness Director Ana Tupinyan, Carlos Lara Administrator and Tony Rios Director of Community Relations and explained the reason for the visit. . During this visit LPA reviewed medication for 8 residents. Medication was found in compliance. Staff files and residents’ files were not reviewed. During the initial visit LPA observed medication in room 201 and reviewed file to confirmed that resident can administer own medication. LPA also did walk through and verified that POCs issued during initial visit were completed. During today's visit LPA Lopez did not find any deficiencies. Exit interview was conducted with Carlos Lara, Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 16, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Alberto Lopez conducted an unannounced annual visit focusing on the infection control domain. LPA was greeted by front desk receptionist Cecilia Espinosa and took tour of facility with driver Rosa Bibian. Director of Community relations Toni Rios showed up later and LPA explained the reason for the visit. Facility is licensed to served 155 non - ambulatory residents, of which 4 may be bedridden and has hospice waiver for 20 residents. Facility is a 4 story building, with a lobby, dining room, 2 activity room, a kitchen, a small outdoor shaded patio ,medication room in the second floor, and a salon in the third floor. Fire alarm sprinkle system was observed throughout the facility. There are no large bodies of water in the property. LPA Lopez conducted a walk through with Driver Rosa Bibian and observed the following: Facility is clean and free of odors in common areas. Elevators are in working condition. LPA choose random rooms to observe and tested water temperature in each room: room #406 tested at 105, bathroom sink tested at 104.9 #402 tested at 105.2 , #307 bathroom sink tested at 103.5, #318 tested at 108.1, #331 tested at 107.4, #232 tested at 107.2, Coffee room tested at 105.5 #221 tested at 106.3, #201 tested at 105., #105 tested at 105, #131 tested at 108.9. All bedrooms have the proper bedding, and furniture. LPA inspected outside and inside of facility and doors where dumpsters are housed are in disrepair and off the frames. 7 day perishable food has most of it with expired dates and 2 day perishable food (vegetables) was old and state. LPA was not able to complete the annual visit and will return another day to complete. Deficiencies cited for today’s visit (see 809D for details) Exit interview conducted and copy of report left with Directo of community Relations Toni Riosthe state’s words, verbatim · CDSS document, Aug 11, 2022

Allegation investigated: Resident's apartment smells malodorous

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Carlos Lara Administrator and explained the reason for the visit. The investigation consisted of the following: On 1/28/22 , LPA Chan toured the facility and gathered a copy of the staff roster, resident roster, and the housekeeping schedule for a week. On 7/19/22 LPA Flores conducted a tour of rooms #201,202,208,301,302,304, 401,402,404,406, alley/waste - trash containers/septic tank area, interview resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10), administrator (S1), staff #2(S2),#3(S3),#4(S4),#5(S5). The investigation revealed the following: Regarding allegation: Resident's apartment smells malodorous. It is alleged apartment smells like sewage and that the smell is making resident sick. Interviews with residents revealed 6 out of 10 residents stated they have not experienced malodorous smells in their rooms or inside the facility. 2 out of 10 residents stated to have experienced sewer smell that comes into their rooms. (CONTINUED ON LIC 9099C) Unsubstantiated 1 out of the 2 residents stated that as long as the windows are closed the smell does not come inside the room. 1 out of 10 residents refused to be interview at the time of the visit, and 1 out of 10 residents was unable to be interview due to cognitive skills. Interviews with staff revealed 4 out of 5 staff stated to have noticed a smell produced by the cleaning of the septic tanks that lingers in the air outside for a couple of hours, however when the windows of the dining room and apartments in that area are closed the smell does not come inside the building and goes away within 30 minutes to 2 hours. Administrator stated that the smell is not a consequence of the septic tanks however a result of the sewage system in the alley and the smell does become stronger during the summer. The city has come to clean the sewage but workers have said that the heat will continue to create the smell in the area. Administrator stated that R9 has been offered to switch rooms at no additional cost but has refused to move from current room. During the tour of the facility conducted on 7/19/22, LPA Flores did not smell any malodorous smells in the residents rooms, dining room area, or facility hallways observed. LPA did noticed sewage smell while walking by the alley outside of the facility, and the smell was very faintly and did not rise above ground level. Documents reviewed revealed staff area assigned areas and rooms to clean on a daily basis and JR Grease Services provided septic pumping services on 1/13/22 and 5/12/22. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Anna Tupinyan - Wellness Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 19, 2022 · control 28-AS-20220125164903

Allegation investigated: Staff removed resident's personal belongings without permission Facility did not communicate removal of personal belonging to responsible party

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Administrator Carlos Lara and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, conducted a tour of room number 126, and interviewed the Administrator, Resident 1 (R1), and R1's Social Worker. The investigation revealed the following: regarding the allegation "staff removed resident's personal belongings without permission", it is alleged that the facility staff removed an electrical burner from R1's room without permission. Interviews conducted with R1 and social worker revealed that it was not the staff that removed the electrical burner. R1's power of attorney (POA) removed the electrical burner and did not notified the facility. The social worker found out it was the POA yesterday during a telephone meeting. (CONTINUED TO LIC 9099C) Unsubstantiated The investigation revealed the following: regarding the allegation "facility did not communicate removal of personal belonging to responsible party", it is alleged that the facility did not notify R1's responsible party of the removal of the electrical burner from R1's room. However, interview conducted with the administrator revealed that they were not aware that the electrical burner was removed from R1's room. It was found out yesterday during a telephone meeting between the administrator, R1's son, R1's social worker, R1's power of attorney that it was R1's power of attorney that took the electrical burner and did not notify the facility. 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. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 19, 2022 · control 28-AS-20220715161618

Allegation investigated: Facility did not provide resident adequate supervision.

On 04/22/2022 approximately 10:30 am, Licensing Program Analyst (LPA) Gail Johnson and Licensing Program Manager (LPM) Ulysses Coronel arrived at Glen Terra Assisted Living and conducted an unannounced complaint investigation. LPA and LPM met with Administrator Carlos Lara and the purpose of the visit was explained. The investigation consisted of the following: On 08/10/2021 LPA Bonnie Tao interviewed five (5) staff and one (1) resident. LPA Tao obtained a copy of staff records and resident records. On 04/22/2022, LPA Johnson and LPM Coronel interviewed toured the facility, reviewed facility and client R1’s records and interviewed administrator Lara. Report continues on LIC9099-C. Substantiated Regarding the allegation: “Facility did not provide resident adequate supervision.” It is alleged that the facility failed to supervise R1 which resulted to R1 leaving the facility unassisted. On 04/22/22 reviews of R1’s physician’s report and needs and services plan indicate that R1 is not able to leave the facility unassisted. On 08/10/21 Administrator Lara stated that on 07/29/21 the facility door was left open by non-facility staff around 7:30pm. Staff discovered that R1 was missing between 8:05pm and 8:40pm. Regarding the allegation: “Facility did not provide resident adequate supervision.” The “preponderance of the evidence” standard has been met, therefore the allegation is Substantiated. Division 6 Chapter 8 is being cited, please see LIC9099D. Plans of Correction were developed. An exit interview was conducted. A copy of this report and Appeals Rights were provided to Administrator Lara. The investigation revealed the following: Regarding the allegation: “Facility did not report resident missing. “It is alleged that “The facility did not report facility missing in a timely manner.” On 08/10/21 Administrator Lara stated that on 07/29/21, Staff reported that R1 was missing around 8:20pm and were instructed to look for resident within the facility and to call the police if not found within 10 minutes, in about 10 minutes the police brought resident back to the facility. Regarding the allegation: “Facility did not report resident missing.” The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted. A copy of this report was provided to Administrator Lara.the state’s words, verbatim · CDSS document, Apr 22, 2022 · control 28-AS-20210802105346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(I)(6) · Plan of correction due date: Apr 29, 2022

87705(I)(6) Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidenced by: Based on interviews & record done by LPA Tao the licensee did not ensure that locked gates do not substitute staff to meet supervision needs of residents, on 7/29/21 R1 left the facility unsupervised which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2022

Plan of correction: The administrator agreed to create a plan to ensure that Locked exterior doors or perimeter fences with locked gates will not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. Proof of correction will be submitted via email to gail.johnson@dss.ca.gov.

Allegation investigated: Staff failed to meet resident's medical needs. Staff are not allowing visitors. Staff failed to provide resident with a comfortable environment.

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial complaint investigation visit for the above allegations. LPA Irra met with Carlos Lara (Facility Administrator) and Tony Rios (Director of Communication Relations) and discussed the purpose of today’s visit. During this investigation, LPA interviewed Staff #1 through Staff #5. LPA also interviewed Resident #1 (R-1) and reviewed R-1’s file and obtained relevant documentation. LPA was unable to interview Resident #2 (R-2) as R-2 is non-verbal. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff failed to meet resident's medical needs. During this investigation, LPA interviewed Staff #1 through Staff #5. LPA also interviewed Resident #1 (R-1) and reviewed R-1’s file and obtained relevant documentation. (3) out of (5) staff interviews revealed that R-1 manages their own medication. (3) out of (5) interviewed Staff indicated they have a copy of R-1’s physician orders for medication including R-1’s oxygen order (concentrator and portable). Per (3) out of (5) staff interviews, R-1’s oxygen (portable) is delivered weekly by a medical supply company. Interviewed Staff indicated they do not “force” Residents to take any medication. R-1 indicated R-1 manages their own medication as well. Staff and Resident interview do not corroborate this allegation. Allegation: Staff are not allowing visitors. During this investigation, LPA interviewed Staff #1 through Staff #5. LPA also interviewed Resident #1 (R-1). (4) out of the (5) staff interviews revealed that on 04/13/2022 R-1 received a visit from a family friend which took place outside (patio) for approximately 2 to 3 hours. Staff interviews revealed that R-1’s visitor became upset when asked to provide status of COVID-19 vaccination and/or negative COVID-19 test results. Per staff interviews, R-1’s visitor was very upset in which the facility was unable to offer a COVID-19 antigen test. S-2 indicated S-2 spoke to R-1’s family friend the following day and COVID 19 antigen testing was discussed. Per S-2, R-1’s family friend did not come in for testing and has not visited R-1 since 04/13/2022. R-1 indicated the family friend visited R-1 on 04/13/2022 and the visit was outside (patio) for approximately 3 hours. Visitation was not denied as the visit took place in the patio area of this facility. Interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff failed to provide resident with a comfortable environment. During this investigation, LPA interviewed Staff #1 through Staff #5. LPA also interviewed Resident #1 (R-1). Room relocation: (4) out of the (5) staff interviews revealed that R-1 was offered different rooms for relocation as R-1 indicated R-1’s roommate sleeps during the day time, is awake all night and disturbs R-1. R-1 also indicated staff offered R-1 different rooms, however, R-1 did not like the rooms being offered. Laundry services: (5) out of (5) interviewed staff indicated residents’ clothes are washed separately from other residents. Interviewed staff indicated each resident has their own hamper. LPA was provided with a staff lesson plan/training that was conducted with Staff which specifically covers personal laundry procedures and states “laundry will be washed separately”. Interviewed staff indicated R-1’s roommate is not left wearing soiled/dirty diapers all night and that staff conduct rounds every (2) hours. However, staff do not keep a log of the rounds that are being conducted. Interviewed staff indicated they have not observed nor received any complaints in regards to resident being left soiled. LPA toured R-1’s bedroom and did not smell any strong odors. Per, interviews and per observation, this allegation cannot be corroborated. 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. Exit interview was conducted, a copy of this report and Appeal Rights were provided to Carlos Lara.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 28-AS-20220414141042

Allegation investigated: Staff are not preventing the spread of an outbreak.

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit. LPA conducted a physical plant tour to ensure no immediate health and safety issues from 10:45-11:15pm. No immediate health and safety issues were noted. LPA observed staff to be wearing mask throughout the facility and hand sanitizers were available throughout the facility. LPA conducted the intial visit on 4/1/2020 where interview was done with the administrator. It is alleged that facility staff failed to wear mask consistently around the facility and were not ensuring that residents were social distancing from one another. Since this complaint came in facility had an annual visit on 8/3/21 and a case management visit on 10/5/21. During both visits it was noted that staff were not wearing mask properly and that residents were not observed to be social distancing by the LPA's who conducted those visits. Deficiencies were cited on both visits and since then deficiencies have been cleared. Due to those visits happening after this complaint came in this allegation is deemed Substantiated however no deficiency will be cited due to the facility already correcting the deficiencies issued on visits on 8/3/21 and 10/5/21. Substantiated Exit Interview conducted.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 31-AS-20200325144834

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Christine Wong conducted an initial complaint investigation at the facility and during the complaint investigation and LPA toured of the facility including some residents' rooms including Rm#111, #120 and #214 and LPA measured the hot water temperature at three of the residents' rooms and they tested between 122.6 and 124.7 which is out of the range of Title 22 regulations. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation. An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Administrator Carlos Larathe state’s words, verbatim · CDSS document, Mar 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 30, 2022

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained as follows: (2)(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). The requirement was not met as evidenced by LPA observation, LPA inspected RM#111, #120 and #214 and hot water was measured between 122.6 to 124.7 which posed an immediate risk to the residents in carethe state’s words, verbatim · CDSS document, Mar 29, 2022

Plan of correction: The administrator will fix the hot water temperature immediately and send the hot water log to LPA for seven days on 04/05/22 via fax

Allegation investigated: Facility is not following COVID-19 outbreak guidance.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Carlos Lara, the Administrator. The purpose of the visit was explained. The investigation consisted of the following: LPA Chan toured the facility with the Administrator. LPA obtained copies of the staff and resident rosters, COVID-19 Mitigation Report, and In-Service training logs. LPA also interviewed the Administrator, 7 Staff, and 10 Residents. The investigation revealed the following: Regarding allegation, Facility is not following COVID-19 outbreak guidance. LPA toured the facility and observed the following pertaining to the allegation: The Staff are all wearing their surgical/N95 masks correctly. Substantiated Although the residents are not required to wear masks, staff stated that residents are reminded at times but do not force residents if they do want to wear masks. LPA observed social distancing in the common areas which include the lobby, activity rooms, and dining room. Although the dining room and activity rooms are open, they have reduced the number of residents at one time to allow social distancing. Residents were observed sitting a few feet apart from each other while in the lobby area and while participating in the activities. The dining room had only 2 chairs for each table. All the staff interviewed stated that there are social distancing in place at the facility. 8 out of 10 residents said they observe social distancing. In regards to testing residents for the Coronavirus, none of the residents interviewed stated they have been tested for the COVID-19 virus recently. Per Administrator, they had only tested all the staff and about 30 residents recently for the confirmed COVID-19 case dated 1/19/22. According to the Community Care Licensing PIN 21-32.1-ASC, "As soon as possible after one (or more) COVID-19 positive individuals (resident or facility staff) is identified in a facility, perform serial retesting at least weekly with molecular testing or a minimum of twice weekly with antigen testing of all residents (excluding independent Continuing Care Retirement Community residents, unless they have been in communal settings with other residents) and facility staff, regardless of vaccination status. Serial retesting should continue to be performed until no new cases are identified in sequential rounds of testing covering a 14-day period." It was determined that the facility did not fulfill this testing guidance. Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 28, 2022 · control 28-NP-20220125080926

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 11, 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. Based on interviews, the licensee did not ensure all the residents get the covid-19 testing which poses a potential health, safety, and personal rights to residents in care.the state’s words, verbatim · CDSS document, Jan 28, 2022

Plan of correction: The licensee shall review the Provider Information Notices PIN 21-32.1-ASC on testing guidance. In addition, the licensee shall perform weekly covid-19 testing to all staff and residents until no new cases are identified in sequential rounds of testing covering a 14-day period. The licensee shall submitted a statement acknowledging the PIN has been reviewed and to ensure that testing are performed until the testing is fulfilled by POC due date 2/11/22.

Allegation investigated: Facility is not reporting COVID-19 cases.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegations listed above. LPA arrived unannounced and met with Carlos Lara, the Administrator. The purpose of the visit was explained. The investigation consisted of the following: LPA Chan toured the facility with the Administrator. LPA obtained copies of the staff and resident rosters, COVID-19 Mitigation Report, and In-Service training logs. LPA also interviewed the Administrator, 7 Staff, and 10 Residents. The investigation revealed the following: Regarding allegation - Facility is not reporting the Coronavirus (COVID-19) cases. Based on the interviews with the Administrator and Staff, they all indicated that if there are positive COVID-19 cases at the facility, everyone is informed. Staff are aware of the recently confirmed positive case. (Continue on LIC9099C) Unsubstantiated Per Administrator, when they have any confirmed COVID-19 cases, residents are informed through memos that are left outside their door mailboxes, families are informed, and notification to Community Care Licensing (CCL), Los Angeles County Public Health, and local Ombudsman. LPA interviewed 10 residents, and 4 out of the 10 stated the facility did not inform them about the positive COVID-19 cases. LPA verified that the most recent positive case was reported to CCL on 1/20/2022. 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 Administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 28, 2022 · control 28-NP-20220125080926

Allegation investigated: Residents are being subjected to second-hand smoke. Facility has pest infestation. Facility is not notifying residents of bedbugs.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator, Carlos Lara, Director of Community relations, Tony Rios who assisted with today's visit. Regarding the allegation that residents are being subjected to second -hand smoke, the investigation consisted of interviews with Licensee, Administrator, Director of community relations and resident #1 - resident #8. Staff interviewed stated that they have been notified by some residents that resident #1 has smoked in his room. Staff stated that smoking is not allowed in the facility. Staff interviewed said that there is a designated smoking area on the patio, and they have reminded resident #1 that smoking in resident rooms is not permitted. Resident #1 denied that he smokes in his room. He stated that he is aware of the house rules, and complies with them. 8 out of 8 residents interviewed, stated that they are not being subjected to second hand smoke. They stated that they are not aware that any residents are smoking in their room. Unsubstantiated Regarding the allegation that the facility has a pest infestation and the allegation that the facility is not notifying residents of bedbugs, the investigation consisted of interviews with Licensee, Administrator, Director of community relations and resident #1 - resident #8. Staff interviewed denied that the facility has a pest infestation of any kind. Staff also denied that the facility has bed bugs. Staff interviewed, stated that they have a contract with a pest control company, and they service the facility weekly. Staff provided copies of recent pest control invoices for several months. Based on review of pest service invoices, there is no indication that the facility has bed bugs. 8 out of 8 residents stated that they have not observed that the facility has a pest infestation. 8 out of 8 residents stated that the facility does not have a bed bug problem at this time. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Carlos Lara.the state’s words, verbatim · CDSS document, Dec 30, 2021 · control 28-AS-20211223152217

Allegation investigated: Resident smoking at the facility where oxygen is in use.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit to investigate the above allegation. LPA met with Administrator Carlos Lara and explained the reason of the visit. The investigation consisted of the following: LPA obtained copies of Resident & Staff Rosters, Admission Agreement, House Rules, Physicians Report and Resident Appraisal for Resident #1. LPA interviewed Staff #1 - Staff #5 and Resident #1 - Resident #9. LPA also toured the facility which included the common areas and random sample of resident rooms. The investigation revealed the following: in regards to the allegation "resident smoking at the facility where oxygen is in use", it is alleged that there are residents in the 2nd floor of the facility that are smoking in their rooms. Interview conducted with Administrator revealed that residents are not allowed to smoke in their rooms. There is a designated smoking area in the facility which is located in the front of the facility. (CONTINUED ON 9099C) Unsubstantiated Administrator indicated that R1 recently moved into the facility on 11/01/21 and it has been brought up to his attention that R1 will smoke in his room. Administrator has spoken to resident about not smoking in his room. There are no oxygen tanks in R1's room. LPA reviewed Facility House Rules which states "no smoking is allowed in apartments" and "smoking is permitted in the designated area only". Administrator indicated he is trying to work with R1 as he is a new resident, however he has told the resident that smoking in the room will not be allowed. 8 out 9 residents interviewed indicated that they do not smoke in their rooms and they have not observed any other residents smoking in their rooms. All residents interviewed indicated that they are aware of the smoking area located in the front of the facility. 5 out of 5 staff members interviewed indicated that residents are not allowed to smoke in their rooms however some residents do. Staff members interviewed indicated that they will tell residents not to smoke in their rooms and will notify management when they observe it. Staff members interviewed indicated will assist residents to the smoking area if needed. LPA toured and observed the designated smoking area. LPA toured a random sample of resident rooms and did not observe any residents smoking in their rooms or smell any smoke in the hallways of the facility during the tour. Although it was verified that R1 has smoked in his room, facility is actively taking appropriate steps to address the situation with the resident. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2021 · control 28-AS-20211124164511

Allegation investigated: Staff threatened to evict resident illegally. Front door not working properly. Elevators are not working properly. Staff do not respond to pendents in a timely manner. Food service is inadequate.

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator, Carlos Lara and explained the reason of the visit. The investigation consisted of the following: LPA interviewed ten residents (R1-R10), administrator and five (5) staff (S1-S5) and obtained copy of the documents included residents roster, faciltiyn dining service menu, R1's Identifiction and Emeregency Information, Admission Agreement, Physician Report. Appraisal/Needs and Service Plan, Resident Appraisal and 30 day eviction notice dated on 10/9/2021. The investigation revelaed of the following: Allegation#1 "Staff threatened to evict resident illegally." LPA interviewed ten residents and nine residents reported there are no staff ever threatened them. (See LIC9099C for continuation) Unsubstantiated Administrator reported the facility provided a 30 day eviction notice to R1's son via email who was his power of attorney and also denied ever threatening R1 about the eviction. R1's son also confirmed receiving the 30 day eviction notice via email and did notify R1 verbally and copy of notice was sent to R1 via text message. Allegation#2 "Front door not working properly. " LPA interviewed ten residents and nine residents denied the allegation and reported the front door is working well and overall the building is working properly without any problems. LPA interviewed five staff and all denied the front door is not working properly. Staff stated no resident ever complained about the front door is not working good. Administrator reported due to COVID-19, the front door currently cannot be opened from outside because they have to control who's coming in and out but each facility resident has their own key to open the front door from outside. Allegation#3 "Elevators are not working properly." LPA interviewed ten residents and nine residents reported both of the elevators in the facility are working well and never had any major issues. LPA interviewed five staff and all denied the allegation and reported the elevators are always working and no resident ever got stuck in the elevator. LPA also observed the two elevators in the facility and they are both working well. Allegation#4 "Staff do not respond to pendents in a timely manner." LPA interviewed ten residents and nine residents denied the allegation and reported the staff are able to meet their needs. The staff never took two hours to respond the pendant. The residents reported the longest the staff took maybe only within 30 minutes. LPA interviewed five staff and all denied the allegation and reported when they saw the pendant/light on for the residents room, they usually go right away but sometimes they cannot leave the resident right away while they are assisting them. Allegation#5 "Food service is inadequate." LPA interviewed ten residents and nine residents denied the allegation and reported the food is more than adequate. There's plenty of food for them to choose. They can get as much as they want and they never get hungry. LPA interviewed the staff and all denied the allegation. There's no resident ever complained about the food service is inadequate. Residents can always get second and they can choose the substitute food if they do not like the menu of the day. Based on LPA’s observations, interviews which were conducted and record review(s), although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. a copy of the report and appeal right was provided to administrator, Carlos Lara.the state’s words, verbatim · CDSS document, Nov 23, 2021 · control 28-AS-20211115134302

Allegation investigated: Resident's colostomy bag is not being regularly changed

This report supersedes report created on 8/10/21 to correct resident #1 to resident #4 and residents' interview finding. On 8/10/21 Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegation. LPA Flores met with Jessica Almendarez receptionist and explained the reason for the visit. Administrator Carlos Lara arrived an hour later. The investigation consisted of the following: LPA Flores requested staff/resident roster, interviewed executive director, wellness director, staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5), and residents #1(R1),#2(R2), #3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8), reviewed residents files and requested copies of needs and care plan, physician's report, and care notes for all 8 residents. The investigation revealed the following: Regarding allegation: Resident's colostomy bag is not being regularly changed. It is alleged facility doesn't change resident's colostomy bags timely and bag had not been changed in 14 hours and was starting to leak. (CONTINUED LIC 9099) Unsubstantiated During interviews with residents 2 out of 8 residents stated to not need assistance from nurse at the facility and are independent and have observed others obtained assistance right away. 3 out of 8 residents stated that wellness team has responded right away or in a considerate amount of time to residents' needs. 2 out out of 8 residents stated it could take the wellness team up to 30 minutes to 90 minutes to provide assistance, and 1 out of 8 residents interviewed stated that wellness team does not respond when assistance is needed. During interviews with staff 3 out of 5 staff stated residents with colostomy bag are changed as needed or at least twice a day. 1 out of 5 staff stated residents with colostomy bag are change every other day, and 1 out of 5 staff stated not to know how often the colostomy bag is changed. Wellness director stated that home health care is assigned to residents with colostomy bag to assist during wellness director's days off, and administrator stated that facility's policy for the wellness director to check on residents with colostomy bags upon arriving to the facility and before leaving the facility, and it may be change as needed per residents' request, and facility is responsible for that care. LPA reviewed residents' documents and it was revealed R4 needs assistance with changing colostomy bag. R4's physician's report states the following "colostomy bag - needs bag changed every 4 days or sooner PRN". Although R4 may request assistance with colostomy bag more often, the documentation reviewed and interviews conducted supports the facility is providing R4 with assistance per physician written orders and resident's request. Based on LPA's observations, interviews and documents reviewed the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Exit interview was conducted with Carlos Lara and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 5, 2021 · control 28-AS-20210806114742

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit regarding COVID 19 recommendations and guidelines. LPA Flores met with Carlos Lara administrator and explained the reason for the visit. LPA Flores observed the following; upon arriving at the facility LPA Flores observed receptionist Jessica Almendarez in the receptionist desk with surgical mask under her chin, there were residents sitting in wheelchairs about 4 feet distance from the receptionist and other residents sitting in the lobby area. Per PIN 21-38 ASC "All ASC residential facilities must sctrictly adhere to current CDPH Masking Guidance." Deficiencies will be noted on LIC 809D per Title 22 Regulations. Civil Penalties were assess for a Repeat Violation within 12 months for the amount of $250.00. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 5, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 6, 2021

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 andcomfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on observation licensee is not ensuring receptionist is wearing a face mask at all times which poses an immediate personal rights, health, and safety risk to persons in care. *Civil Penalities for Repeat Violation were assess in the amount of $250.*the state’s words, verbatim · CDSS document, Oct 5, 2021

Plan of correction: Administrator will ensure all staff are following COVID 19 recommendations and guidelines per state mandates at all times. Administrator will certify with LIC 9098 and

Allegation investigated: Facility is not providing comfortable living accommodations to resident

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation regarding the above allegation. LPA Villalobos met Administrator Carlos Lara and explained the reason for the visit. The investigation consisted of the following: LPA Villalobos requested staff/resident roster, interviewed staff #1-#5 (S1-S5), and residents #1-#6 (R1-R6), LPA toured the facility and observed rooms #111, # 222, #325 and #402. The investigation revealed the following: In regards to the allegation, "Facility is not providing comfortable living accommodations to resident " it was alleged that residents with wheelchairs could not access the bathrooms sinks. (5) of (5) staff interviewed denied the allegation. (6) of (6) residents interviewed could not corroborate the allegation. LPA observed that each resident room has a private bathroom... Continued on LIC 9099-C Unsubstantiated The resident bathrooms in the facility are all identical with low height bathroom sinks. LPA observed R1 and R2 using their wheelchair and accessing the bathroom sink on their own. Interviews show facility staff will provide assistance to residents if needed and when residents ask for help. Based on LPA's observations, interviews and documents reviewed the preponderance of evidence standard has not been met, therefore the above allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Carlos Lara and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 22, 2021 · control 28-AS-20191127133704

Allegation investigated: Facility staff did not safeguard resident's personal property

Licensing Program Analysts (LPAs) Nune Margaryan and Tony Vasallo conducted subsequent visit to the facility to further investigate the above noted allegation. LPAs met with Administrator Carlos Lara and explained the purpose of this visit. It was alleged that facility resident #1’s (R1’s) personal property was stolen at the facility. The stolen items include wedding ring and “stimulus card”. The initial visit was conducted by LPA Joe Katrdzhyan on 04/21/21. During the visit LPA Joe Katrdzhyan obtained the following documents: • Admission Agreement • Pre-placement Appraisal Information • Appraisal/Needs and Services Plan • Physician's Report • Functional Capability Assessment • Client/Resident Personal Property and Valuables Form • Resident Roster • Staff Roster Today's investigation consisted of the following: Request Resident's and staff roster; obtained theft and loss policy, interviewed five (5) staff and eight (8) residents. con. 9099C Unsubstantiated The investigation reveal the following: Documents revealed that R1 or their responsible party refused to inventory their personal belongings the time of admission. Interviews conducted with the residents did not corroborate the allegation. Residents denied having any valuable items missing from the room. Staff interviewed denied the allegation. They did not have any information that staff has stolen from the residents. When Administrator learn about allegation, called the police and made a report. Based on LPA's observations, interviews and documents reviewed the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED. Exit interview held. A copy of the report provided to Anahit Tupinyan.the state’s words, verbatim · CDSS document, Aug 27, 2021 · control 28-AS-20210412091729

Allegation investigated: Resident's colostomy bag is not being regularly changed

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unnounced complaint investigation regarding the above allegation. LPA Flores met with Jessica Almendarez receptionist and explained the reason for the visit. Administrator Carlos Lara arrived an hour later. The investigation consisted of the following: LPA Flores requested staff/resident roster, interviewed executive director,wellness director, staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5), and residents #1(R1),#2(R2), #3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8), reviewed residents files and requested copies of needs and care plan, physician's report, and care notes for all 8 residents. The investigation revealed the following: Regarding allegation: Resident's colostomy bag is not beign regularly changed. It is alleged facility doesn't change resident's colostomy bags timely and bag had not been changed in 14 hours and was starting to leak. During interviews with residents 2 out of 8 residents stated to not need assistance from nurse at the facility and are independent and have observed others obtained assistance right away. (CONTINUED LIC 9099C) Unsubstantiated 3 out of 8 residents stated that wellness team has responded right away or in a considerate amount of time to a pendant call for assistance. 2 out out of 8 residents stated it could take the wellness team up to 30 minutes to 90 minutes to respond to a pendant call for assistance, and 1 out of 8 residents interviewed stated that wellness team does not respond to pendant calls. During interviews with staff 3 out of 5 staff stated residents' with colostomy bag are changed as needs or at least twice a day. 1 out of 5 staff stated residents' with colostomy bag is change every other day and 1 out of 5 staff stated not to know how often the colostomy bag is changed. Wellness director stated that home health care is assigned to residents' with colostomy bag to assist with care and administrator stated that facility's wellness director checks on residents' with colostomy bags upon arriving to the facility and before leaving the facility, it may be change as needed per residents request, and facility is responsible for that care. LPA reviewed residents documents and it was revealed R1 needs assistance with changing colostomy bag. R1's physician's report states the following "colostomy bag - needs bag changed every 4 days or sooner PRN". Although R1 may required assistance differently the documentation reviewed supports the current care provided to the resident. Based on LPA's observations, interviews and documents reviewed the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Exit interview was conducted with Executive Director, Carlos Lara and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 10, 2021 · control 28-AS-20210806114742

Allegation investigated: Staff did not assist resident with their medication in a timely manner Staff did not assist resident with their toileting needs in a timely manner Staff did not assist resident with their oxygen administration in a timely manner

Licensing Program Analyst (LPA) Jose Villalobos initiated a complaint investigation for the allegation(s) listed above. Today’s complaint investigation was conducted with Administrator Carlos Lara and purpose of the visit was discussed. Today's investigation consisted of the following: LPA Villalobos interviewed staff #1-#4 (S1-S5) and residents #1-#6 (R1-R6). LPA also obtained and reviewed copies of the following documents in reference to R1; Admission Agreement • Pre-placement Appraisal Information • Appraisal/Needs and Services Plan • Physician's Report • Resident Roster • Staff Roster Todays investigation revealed the following: In regards to the allegation " Staff did not assist resident with their medication in a timely manner" it was alleged that staff took more than an hour to provide R1 with their medication on 7/16/21 after reaching out to them. Continued on LIC 9099-C Unsubstantiated (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. Review of documents show that R1 received medications scheduled at 8am 12pm 5pm and 8pm on 7/16/21. Based on interviews conducted and records reviewed there is not enough evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated. In regards to the allegation "Staff did not assist resident with their toileting needs in a timely manner" it was alleged that staff took more than an hour to assist R1 with their toileting needs on 7/16/21. (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. LPA observed facility caregiver staff assisting R1 with their toileting needs between 11:30am-12:pm. R1 could not provide LPA with more information on times that staff would have taken long to assist but did state staff arrive to assist multiple times throughout the day. Based on interviews conducted and records reviewed there is not enough evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated. In regards to the allegation "Staff did not assist resident with their oxygen administration in a timely manner" it was alleged that staff did not assist R1 with their oxygen administration in a timely manner on 7/16/21. (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed denied the allegation. Review of R1's file show that R1 requires oxygen management. R1 stated to LPA that staff assist with the oxygen management daily. Staff interviews show that staff will check on R1 multiple times throughout the day as they are aware of R1's needs. Based on interviews conducted and records reviewed there is not enough evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore this allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with Executive Director Carlos Lara and a hardcopy was provided via email for signature. Signatures on hardcopy.the state’s words, verbatim · CDSS document, Jul 21, 2021 · control 28-AS-20210716081320