Silverado Senior Living - Calabasas

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management / Non-Compliance visit today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The LPA met with Terri Weitzman and explained the reason for the visit. The last legal/non-compliance visit was conducted on 05/22/2023. The LPA and Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. Fire extinguishers were charged and last serviced within the past twelve (12) months. Planned activities are offered. Activity rooms and common spaces appeared clean and in good repair. The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. RESIDENT ROOMS: The LPA and Executive Director observed eight (8) rooms, and rooms were furnished with clean linens, furnishings and lighting. Restrooms were observed with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. At 12:34 p.m., the LPA observed a basket of personal care items and razors in Room 53. At 12:40 p.m., personal care items were in Room 67. At 12:47 p.m., personal care items were observed in Room 17. FILES: From 12:45 p.m. – 1:10 p.m., the LPA reviewed the files of the three (3) resident that had personal care and hygiene items accessible in their rooms. Out of the three (3) files reviewed, the LPA reviewed physician’s reports and identified that there was one (1) resident (Resident #1 – R1) that was deemed at risk if they have access to personal care items. All three residents had a diagnosis of Dementia. CONT 809-C MEDICATION AUDIT: From 1:20 p.m. – 2:10 p.m., a medication audit was conducted for three (3) residents. The following was noted: - Resident #2 had an as-needed (PRN) medication for acetaminophen that was administered two (2) times; however, staff only documented that R2 was assisted with the self-administration of this PRN medication one (1) time. - Resident #3 had a PRN medication for acetaminophen that was administered seven (7) times since August 2022; however, there was no documentation to confirm the dates and times that R3 was assisted with the self-administration of this as-needed medication. INCIDENT REPORTS: The LPA reviewed incident reports pertaining to Resident #4 (R4). On 06/01/2023 and 7/2/2023, R4 left the facility unassisted. During the 06/01/2023 incident, R4 was noted outdoors outside the community back patio, behind the fence, sitting on a hill. R4 was escorted back into the facility without any notable injuries. During the 7/2/2023 incident, staff noted that a window was broken in a resident room. After completing a resident count, staff observed that R4 was not in the community. Staff canvassed the surrounding areas and R4 was located by the Administrator. R4 was noted to have skin tears. Emergency services were called and R4 was hospitalized. After this incident, an in-service training on Elopement Protocols and Procedures was held. R4’s physician’s report confirmed that R4 is not able to leave the facility unassisted. On two separate occasions, R4 was able to leave the facility, unbeknownst to staff. R4 is currently out of the facility at this time due to a medical-related issue. LEGAL: On 6/29/2023, licensee has requested a reduction in the frequency of calls with CareerSmart. Per the stipulation, the licensee must have weekly calls with CareerSmart. Licensee is requesting for weekly calls to take place either bi-weekly or once a month. Approval from the Department is pending at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued via email. Signatures were obtained.the state’s words, verbatim · CDSS document, Aug 1, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Aug 1, 2023

87705(f)(1) Care of Persons with Dementia. (f) The following shall be stored inaccessible... Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as razors were observed accessible in Room 53, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Administrator agreed to do the following: 1. Secured the items upon observation. POC is cleared at this time.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(g)(1) · Plan of correction due date: Aug 1, 2023

87705(g)(1) Care of Persons with Dementia. … Residents with dementia shall be allowed to keep personal grooming and hygiene items … unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply in the section cited above for one out of three residents (R1), which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Administrator agreed to the following: 1. Secure the items by the end of the day. Inform CCL when this has taken place 2. Conduct an in-service training with care staff, regarding items that shall be inaccessible to residents with dementia. Submit sign-in sheet no later than 8/11/2023. Submit POC to CCLASCPWoodlandHillRO@dss.ca.gov, ATTN: Officer of the Day

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 2, 2023

87464(f)(1) Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that R4 did not leave the facility unassisted per the physician report, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Administrator has agreed to do the following: 1. The facility has also reviewed and held an in-service training regarding Elopement procedures. Plan of Correction met.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(d)(3) · Plan of correction due date: Aug 2, 2023

87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply in the section cited above for 2 out of 3 (R2, R3) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Administrator has agreed to do the following: 1. Host an in-service training, discussing topics that include but are not limited to: PRN documentation, checking centrally stored forms for accuracy. In-service must include nurses and medication technicians. Submit initial sign-in sheet by 8/2/2023. Training for all must be completed by 8/11/2023

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the required annual visit, the purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The LPA met with Terri Weitzman and Kaitlyn Smith and explained the reason for the visit. The last legal/non-compliance visit was conducted on 2/1/2023. Today, the LPA conducted a file review for five (5) residents and five (5) staff. A file review of five (5) resident files was conducted from 12:30 p.m. – 1:30 p.m. Files were reviewed for, but not limited to: admissions agreements, medical assessment, updated appraisals, consent forms. Resident records were in order. A file review of five (5) staff files was conducted from 1:30 p.m. – 2:30 p.m. Files were reviewed for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. Out of the five files reviewed, the following was observed: Staff #1 and Staff #2 did not have a completed job application, medical assessment, or criminal record statement on file, and Staff #3 did not have tuberculosis results on file. LEGAL: As it pertains to the Stipulation and Waiver, and Order, the following was noted: · Career Smart conducting quarterly audits: The last audit took place in March 2023; recommendations were made around organization of staff training and the availability of care plans · Compliance audit was conducted by a member of the licensee’s governing board on 02/27/2023 · Facility continues to monitor staffing levels as it relates to resident care needs and census. · Staff support group was conducted on 4/28/2023; staff encouraged to obtain the total attendance · Resident care needs are assessed monthly Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, May 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: May 31, 2023

87411(f) Personnel Requirements – General. … Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician .... This requirement is not met as evidenced by: Based on file review, the licensee did not comply to the section cited above for three out of five staff (S1, S2, S3), which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2023

Plan of correction: The Administrator agreed to do the following: 1. Obtain the completed health screenings and/or TB results for S1, S2 and S3. Submit proof by 5/31/2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(d) · Plan of correction due date: May 31, 2023

87355(d) Criminal Record Clearance. All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by: Based on file review, the licensee did not comply to the section cited above for two out of five staff (S1, S2), which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2023

Plan of correction: The Administrator agreed to do the following: 1. Obtain the completed criminal record statements for S1 and S2. Submit proof by 5/31/2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the required annual visit, the purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The LPA met with Akeema Matthew, Director of Health Services and Kaitlyn Smith, Director of Resident Family Services and explained the reason for the visit. Executive Director Terri Weitzman was unavailable during today's visit. The last legal/non-compliance visit was conducted 11/01/2022. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Residents were eating at the time of the visit. Dining room furniture appeared to be in good condition. BEDROOMS: The LPA observed a randomly selection of resident rooms, and rooms were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: The LPA observed a random selection of resident restrooms. Restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Water temperature was tested, and temperature ranged from 107.6 – 112 degrees Fahrenheit. Hand washing signs promoting good hand hygiene were observed in the common restrooms. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Infection control signs were posted at the entrance and throughout the hallways. Department required postings were found in the front lobby near the restrooms. Fire extinguishers were charged and serviced 9/22/2022. EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. INFECTION CONTROL: Staff were observed wearing appropriate face coverings. The facility continues to screen visitors and staff upon entry into the facility. The facility has an adequate supply of Personal Protection Equipment (PPE). Hand sanitizer was available for staff, residents and visitors. The facility can designate a section of the facility for isolation and quarantine purposes if the facility has a confirmed case of COVID-19. The facility keeps record of staff and resident vaccinations. LEGAL: As it pertains to the Stipulation and Waiver, and Order, the following was noted: · Career Smart conducting quarterly audits: The last audit took place in December 2022; recommendations were made around organization of staff training, medication procedures, and staffing. · Addendums that specifically discuss identified sexual and/or aggressive behaviors for new admissions continue to be utilized in resident care plans · Compliance audit was conducted by a member of the licensee’s governing board on 11/28/2022 · Facility continues to monitor staffing levels as it relates to resident care needs and census. Facility currently using agency staff to supplement for staffing levels · Staff support group was conducted on 1/30/2023, with a census of 12 staff in attendance. · Resident care needs are assessed monthly · Training documents were observed and compiled; however, the LPA was unable to easily identify if direct care staff had completed the minimum of six (6) hours of quarterly training. Recommendation was for files to be more organized so that the reviewer to confirm whether staff have received the required training. No deficiencies cited at this time. Exit interview conducted. Signatures obtained.the state’s words, verbatim · CDSS document, Feb 1, 2023

Allegation investigated: Failure to communicate resident change of condition to hospice in a timely manner Staff did not meet resident's needs

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with staff and explained the reason for the visit. During the 5/25/2022 visit, the LPA obtained documents and conducted interviews with current and former staff members from 10:00 a.m. - 12:30 p.m. During the 9/20/2022 visit, the LPA interviewed staff between 10:30 a.m. – 12:00 p.m. and reviewed documents. An interview with a representative from a hospice agency was conducted on 10/11/2022 at 9:15 a.m., and additional staff interviews were conducted on 11/01/2022 at 2:20 p.m., and on 11/03/2022 at 2:20 p.m., 2:51 p.m., 4:25 p.m., and 4:47 p.m. Hospice records were requested and reviewed. Substantiated Regarding the allegation: Failure to communicate resident change of condition to hospice in a timely manner It was alleged that facility staff failed to communicate R1’s change of condition in a timely manner as it related to R1’s aggression and behavioral challenges. As a result of R1’s behavioral challenges, it was alleged that the facility assisted R1 with the self-administration of medication without prior approval or against what was prescribed by hospice. Interviews conducted with a hospice representative noted that they often felt they received updates regarding R1’s progression during their regularly scheduled visits. It was at that point, per the interviews and record review of hospice nursing notes, that hospice was notified of R1’s behavioral changes. Interviews with facility nursing staff confirmed that staff may wait to provide updates to an outside agency if they knew they were visiting the facility regularly. A review of the facility’s ‘Service Plan Conference Sheet’ dated 11/4/2021 indicated that a conversation was had regarding R1’s agitation and behaviors. As a result of that care plan meeting, a medication change was made to address R1’s agitation. Records review indicated that R1’s ‘as needed’ medication (PRN) for Seroquel was discontinued on 11/05/2021, and a routine Lorazepam (Ativan) was prescribed twice a day. The LPA reviewed hospice nursing notes from 11/08/2021. Records from the 11/08/2021 visit indicated that facility staff communicated to a hospice representative that they had called in a ‘stat delivery’ for Seroquel over the weekend due to R1’s behaviors (Saturday, 11/06/2021 or Sunday 11/07/2021). An interview with the hospice representative and hospice nursing notes revealed that hospice reminded facility staff that the Seroquel had been discontinued. The LPA reviewed the physician’s orders and confirmed that the facility had received a written order from R1's hospice to discontinue the Seroquel, and to start Lorazepam (Ativan) twice a day. The LPA reviewed R1’s electronic medication administration record (eMAR) and observed that there were no logged entries indicating that the Seroquel was administered on 11/06/2021, 11/07/2021, or 11/08/2021. However, the dates following the 11/08/2021 date were notated as ‘discontinued’. The LPA reviewed hospice nursing notes from a 11/24/2021 visit. Records from the 11/24/2021 visit indicated that facility staff informed the hospice representative that the staff had assisted R1 with the self-administration of an additional PRN Seroquel every night prior to the 11/24 visit to R1 due to increased agitation. This allegedly was not reported to hospice nor R1’s responsible party until the hospice representative went to the facility on 11/24/2021. The LPA reviewed R1’s electronic medication administration record (eMAR) and observed that there were no entries indicating that R1 was assisted with the self-administration of PRN Seroquel from 11/17/2021 – 11/28/2021. However, the dates following the 11/28/2021 date were notated as ‘discontinued’. An interview with the hospice representative and a review of hospice notes revealed that on 11/24/2021, hospice discontinued the order for Seroquel 25mg to be administered twice daily and changed the order to start Seroquel 25mg in the morning and 50mg in the evening. A review of a hospice visit on 11/27/2021 and an interview with the hospice representative revealed that during the 11/27/2021 visit, hospice discovered that the medication change from 11/24/2021 had not been implemented. Hospice reviewed R1’s medications and observed that staff continued to administer Seroquel 25mg twice a day, yet it was previously discontinued on 11/24/2021. Hospice questioned the staff as to why the medication change had not happened, and staff was unable to provide an answer. Per the staff interviews conducted, staff were unable to recall the details of their interactions with the hospice staff that provided care to R1, nor did staff communicate to the LPA that there were challenges to assisting R1 with the self-administration of medication. Interviews revealed there had been several changes with the nursing staff during the time of R1’s stay at the facility, and hospice revealed that with the changes in staff, the nurses at the facility seemed unaware of R1’s condition or R1’s medication regimen. The LPA reviewed the facility progress notes pertaining to R1 and noted that there were no entries charted between 11/02/2021 – 12/06/2021. Progress notes did not indicate that R1’s responsible party nor the hospice agency was notified of R1’s behavioral challenges, and/or the need for additional PRN medication. However, the LPA reviewed Service Plan Conference Sheets which summarized the care plan meetings that took place regarding R1 and identified that a representative from R1’s hospice agency was present to discuss R1’s treatment plan on 11/4/2021, 11/18/2021, and 12/8/2021. A review of hospice nursing notes indicated that R1 was seen by a hospice representative at least three times a week. However, interviews with a hospice representative and a review of hospice nursing notes detailed that the facility failed to proactively communicate changes in R1’s behavior or condition, and that hospice would find out about changes in R1 when they would conduct their visits. Based on the information obtained during the course of the investigation, there is sufficient evidence to support the claim that staff failed to notify hospice of R1’s change of condition in a timely manner. Staff felt that as hospice was regularly visiting the community to see R1, staff felt that the hospice agency was regularly notified of R1’s behavior. However, there is no supporting documentation to aid in claims that the facility was in regular communication with the hospice agency. The hospice agency felt that they found out about R1’s change of condition or behavioral challenges during their visit(s), or when staff would communicate the need for additional PRN medication as a result of R1’s behavior. This allegation is deemed Substantiated at this time. Regarding the allegation: Staff did not meet resident's needs It was alleged that staff were unable to meet R1’s needs due to the facility’s inability to manage R1’s aggressive behaviors. Prior to R1 being admitted to this facility, R1’s family felt that R1 was overmedicated in their previous placement, which caused R1 to appear overly sedated and disengaged. As such, the family felt it was in R1’s best interest to discontinue R1’s medications in order to determine an appropriate medication regimen. Records review indicated that upon admission to the facility on 10/28/2021, all of R1’s medications were discontinued, except the ‘as-needed’ (PRN) medications. Records review and interviews noted that once R1’s medications wore off, R1 began displaying aggressive behaviors. As R1’s behaviors increased, routine medications were added as an attempt to manage R1’s behaviors. Staff interviews and records review indicated that the facility had worked with hospice staff on identifying a favorable medication regimen that would assist in managing R1’s behaviors. The Service Plan Conference Sheet dated 12/8/2021 indicated a 1:1 companion was needed for R1 for additional oversight and safety monitoring, as R1’s behaviors had not improved. As such, the facility attempted multiple strategies towards decreasing R1’s agitation. Notably, a review of hospice nursing notes indicated that on several occasions, R1 appeared to be aggressive or combative, which prohibited staff from assisting R1 with care. The following was observed via a record review of the hospice notes: on 10/29/2021, caregivers claimed they attempted to assist R1 with a shower or personal care but R1 began to punch and bite; on 11/02/2021, staff reported that they were unable to provide care to R1 due to increased aggression; on 11/03/2021, R1 allegedly refused a shower or personal care of ‘any kind’; on 12/08/2021, care staff indicated that R1 was soiled and became aggressive with any attempt to assist with personal care; on 12/09/2021, it was reported that attempts to provide personal care were met with violence from R1; on 12/11/2021, R1 became combative with care staff when assistance was provided. Whereas staff stated that they did their due diligence to ensure that resident care needs are met, a review of hospice nursing notes indicated that on several occasions R1 appeared disheveled or unkempt. A review of hospice nursing notes revealed the following: R1 was observed partially dressed in the facility hallway on 11/15/2021 and 11/16/2021; R1 was found in another resident’s room on 11/24/2021, surrounded by several pairs of shoes; R1 was found sitting on the floor in soiled clothing on 12/04/2021,12/08/2021 and 12/09/2021. A review of the facility’s ‘Service Plan Conference Sheet’ dated 11/4/2021 indicated that a conversation was had regarding the proposed genetic testing for medication management. Interviews revealed that the purpose of the genetic testing was to identify which medications could potentially work to assist with managing R1’s behaviors. Whereas the staff had regularly checked on the status of the genetic testing, it appeared that R1’s family never received the results of the genetic testing to determine the best medication regimen for R1. Yet based on the investigation, there is sufficient evidence to support the claim that the facility failed to meet the resident’s needs. Although facility employed multiple strategies to aid in managing R1’s increased agitation and behavioral challenges, evidence obtained in interviews and records review demonstrates that staff were unable to meet R1’s care needs on multiple occasions. The LPA reviewed the facility progress notes pertaining to R1 and noted that there were no entries charted between 11/02/2021 – 12/06/2021. As such, the LPA was unable to observe the documented efforts the facility utilized to meet R1's needs in real time. Based on the preponderance of evidence, the allegation ‘Staff did not meet resident’s needs’ is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report, and appeal rights, were provided. Regarding the allegation: Staff left resident in soiled clothing for extended period of time It was alleged that R1 was often observed in soiled clothing. Staff whom provided care to R1 confirmed that R1 had incidents where they would urinate or defecate on the floor; however, staff said that once it was observed, staff would clean R1 up and put R1 in clean clothes. Staff also noted that R1 was aggressive when staff would assist R1 with care. Yet, staff said they would either return at a later time to assist R1, would do a change of face to have another caregiver assist R1, or would request the assistance of another caregiver to provide care to R1. Staff negated claims that R1 was soiled for an extended period. In addition, staff stated that even if they had checked on R1 within fifteen minutes, R1 would still have the opportunity within that window of time to soil their pull-up or clothing due to their bowel and bladder incontinence. However, additional interviews and a review of hospice nursing notes supported claims that R1 was found in soiled clothing or in an unkempt state on 12/4/2021, 12/08/2021, and 12/09/2021. Yet, the reviewed hospice notes did not indicate the condition of the diaper, nor that it appeared that R1 had appeared soiled for an extended period of time. Based on the investigation, there is insufficient evidence to support claims that staff left R1 in soiled clothing for an extended period of time. Although the allegation may have happened or is valid, there is insufficient evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff made inappropriate comments towards resident It was alleged that facility staff made an inappropriate comment inquiring about when R1 was going to pass away. It was alleged that the tone of the comment was insensitive and suggested that staff wanted R1 to pass quickly. Staff whom had provided oversight and care to R1 during R1’s last days at the facility denied claims that they made any inappropriate comments regarding the expected time period of R1 passing. The LPA conducted an interview with a hospice representative whom provided care to R1, and they denied knowledge of this claim. The LPA reviewed summary notes from the hospice visits and did not uncover documentation that spoke to the alleged comment. Several staff stated they overheard R1’s family members inquiring about R1’s passing and made claims that they did not want R1 to be in any pain but denied claims of hearing facility staff making any insensitive comments. Based on the information obtained from interviews and records review, there is insufficient evidence to support the claim that staff made inappropriate comments towards the resident. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff did not prevent resident from eating a hazardous object It was alleged that staff observed R1 ingesting a fork. However, information obtained during the investigation did not indicate whether it was a metal or plastic fork, but it was alleged that this happened within the first four weeks of R1 being admitted to the facility. There was no information shared as to whether R1 was harmed as a result of this incident. Staff whom administered care to R1 denied knowledge of R1 ingesting a fork or any foreign object. Staff said that R1 needed assistance with all activities of daily living, including assistance with feeding. Yet staff claimed that they had not observed or overheard the claim that R1 had ingested a fork. The LPA reviewed facility progress notes for R1 and did not read notes pertaining to this incident, nor were there any unusual incident reports sent to the Department regarding this claim. Based on the information obtained from interviews and record review, there is insufficient evidence to support the claim that staff did not prevent a resident from eating a hazardous object. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff did not prevent residents from engaging in inappropriate behaviors It was alleged that on approximately 12/16/2021, a resident wandered into R1’s room and attempted to remove the blankets off of R1’s bed. This incident allegedly took place when R1 was lying in bed, and it was determined that R1 was near the end of their life. Information obtained from interviews conducted with staff whom had provided care to R1 were unable to confirm claims that this specific incident took place. However, staff confirmed that residents are out of their room for most of the day and if they are not congregating in common spaces, some residents are ambulating through the facility. Staff admitted that residents will oftentimes enter different rooms; however, due to their dementia diagnosis, residents may be unaware that there are in the incorrect room. Staff said that they do their due diligence to redirect residents to appropriate places. A review of hospice nursing notes indicated that on several occasions, R1 was observed to be in rooms other than their assigned room. However, there was insufficient evidence via interviews or records review to corroborate claims that staff failed to prevent residents from engaging in inappropriate behaviors as it relates to residents going into R1’s room. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the above-mentioned claim at the time the complaint was received. Therefore, the allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 15, 2022 · control 29-AS-20220520152640

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Nov 18, 2022

87466 Observation of the Resident. When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person… This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff did communicate changes to hospice staff in a timely manner, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2022

Plan of correction: The Administrator agreed to do the following: 1.Submit a Plan of Action/Protocol, detailing how nursing staff are expected to communicate with outside collateral agencies. Submit protocol to CCLD by 11/18/2022. 2. Review this protocol with nursing staff within the next two weeks. Submit proof of completion to CCLD, but no later than 11/29/2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 18, 2022

87464(f)(4) Basic Services. Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident … with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as staff were unable to meet R1’s care needs on multiple occasions, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Submit a Plan of Action/Protocol, detailing how staff are trained to meet care needs of those that may exhibit aggressive behaviors. Submit protocol to CCLD by 11/18/2022. 2. Schedule an in-service training for caregivers and LVNs that specifically speaks to this protocol. Training needs to be completed in the next two weeks. Submit proof of completion to CCLD, but no later than 11/29/2022

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed: - Career Smart conducting quarterly audits: The last audit took place in September from 9/6 – 9/8. - On site visits from a member of the governing board: The last visit was August; the next date is 11/18/2022. - Monthly support groups for staff – The last session took place on 10/25/2022. - Additional training hours - The facility requires the staff to complete the hours on a monthly basis. The LPA reviewed training documents to confirm that staff are receiving the required training hours. From 12:35 p.m. – 1:40 p.m., the LPA conducted a medication audit for five (5) residents. - Resident #1 experienced a medication change on 10/15/2022, in which the order was changed from receiving one capsule three times a day to receiving two capsules two times a day. Whereas the staff claim that the original medication was discontinued and was not administered to R1, staff continued to sign off as if R1 received the initial medication and the new medication dosage. - Resident #2 had an as-needed medication (Seroquel) that was administered two (2) times; however, staff only documented that R2 was assisted with the self-administration of this as-needed medication one (1) time. R2 had a PRN for acetaminophen that was administered eight (8) times in two months; however, staff documented that R2 was assisted with the self-administration of this as-needed medication three (3) out of eight (8) times. - Resident #3 had an as-needed medication administered five (5) times in two months; however, staff only documented that R3 was assisted with the self-administration of this as-needed medication three (3) times. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Nov 1, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(3) · Plan of correction due date: Nov 4, 2022

87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply in the section cited above for three out of five (R1, R2, R3) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 1, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Host an in-service training, discussing topics that include but are not limited to: PRN documentation, checking centrally stored forms for accuracy, ensuring DC orders are in, medication changes. In-service must include nurses and medication technicians. Submit initial sign-in sheet by 11/04/2022. Training for all must be completed by 11/10/2022.

Allegation investigated: Due to lack of supervision, resident hit another resident while in care

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Selene Rangel and explained the reason for the visit. During the 6/7/2022 visit, the LPA completed a file review, obtained documents, and interviewed staff from 10:20 a.m. - 11:20 a.m. Today, the LPA interviewed staff at 10:30 a.m., 10:39 a.m., 10:58 a.m., 11:15 a.m., and 11:33 a.m., and reviewed documents. It was alleged that due to lack of supervision, Resident #1 (R1) was assaulted by Resident #2 (R2). Witnesses revealed that on 5/10/2022, R1 and R2 were in the lobby. R1 was sitting in the lobby, and R2 approached R1 and asked R1 to leave the lobby with R2. R1 refused to go with R2, in which R2 responded by hitting R1 on the right side of R1’s head. R1 and R2 were immediately separated and both residents were assessed and had no visible injuries. The facility physician and the responsible parties for both residents were notified. Facility staff called 9-1-1, in which upon arrival, neither R1 nor R2 recalled the incident. Unsubstantiated Records review noted that R2 moved into the facility on 3/10/2022. A review of R2’s physician’s report dated 10/29/2021 and care plan dated 4/6/2022 indicated that R2 had a tendency to be affectionate towards other residents by way of wanting to hold their hands. Interviews and a review of Facility Progress Notes prior to the incident revealed that R2 was combative towards staff while receiving care. At the time of the incident, R2 did not display violent or aggressive behaviors towards other residents. Hence, the 5/10/2022 incident appeared to be an isolated event. R1 had resided in the facility since 2019 and staff indicated that R1 had not been violent towards anyone. A review of care plans revealed that neither resident required 1:1 supervision at that time. R2 was seen by the facility’s psychiatrist on 5/10/2022 and had a medication adjustment. Interviews confirmed that oftentimes, it was hard to predict resident behaviors and certain triggers, and witnesses to the 5/10/2022 event claimed that they were not able to intervene in time, as the behavior was sudden. In response to residents whom display aggressive behaviors, staff responses include but are not limited to: conducting frequent checks; notifying a resident’s physician regarding the escalating behavior to determine if a medication adjustment is needed; assessing for a change of condition and/or pain that may be contributing to the behavioral change; and/or potentially assigning a 1:1 companion to the resident for additional oversight and safety monitoring. However, interviews and a review of Facility Progress Notes demonstrated that R2 continued to display aggressive behavior after the 5/10/2022 incident. The facility tried several interventions in response to R2’s behavior, which included reducing outside stimuli, medication adjustments, and assigning a 1:1 companion to R2. Staff claimed there were no identifiable triggers and felt R2’s behaviors were sporadic and unpredictable. A 1:1 caregiver was assigned to R2 on 5/22/2022 as R2 was becoming increasingly aggressive when other facility residents refused to hold R2’s hand. R2 was again seen by the facility psychiatrist on 6/2/2022 due to their behaviors. The facility continued to monitor R2’s behavior and on 6/28/2022, R2 was hospitalized for a possible 51/50 due to the risk of harming others. Whereas R2 eventually returned to the facility with a 1:1 companion, R2’s behavior continued to escalate and R2 moved out of the community on 8/1/2022. Based on the information gathered, there is insufficient evidence to support the claim that due to lack of supervision, R1 was assaulted by R2. As R2's behaviors increased, the facility appropriately intervened. Regarding the 5/10/2022 incident, the police whom responded to the 9-1-1 call determined that there was no intent to harm. The allegation is Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was emailed for signature.the state’s words, verbatim · CDSS document, Sep 20, 2022 · control 29-AS-20220603162155

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed: A. Licensee shall operate the facility in substantial compliance with regulations and statures governing the operation of a residential care facility for the elderly. The LPA focused on the physical plant and the infection control protocol. Signs were observed in common areas that promoted guidance around COVID-19, appropriate masking, physical distancing, and the disinfection protocol. The facility continues to monitor the vitals, symptomatic screening, and temperatures of the staff and visitors that come into the community. Hand sanitizer was available throughout the community. Staff were observed wearing appropriate face coverings. The LPA observed residents engaging in group activities, which were led by staff. Activity rooms and common spaces appeared clean and in good repair. Common restrooms were observed, and the LPA observed signs in the restrooms that promoted good hand hygiene. At 9:35 a.m., the hot water measured in the common restroom at 113.1 F. Restrooms were stocked with paper towels and soap. The LPA observed appropriate outdoor furniture in the gated courtyards, with a covered shaded area for residents. The exterior and interior grounds were free of clutter and/or obstructions. The community has a swimming pool, which is locked. B. Career Smart will conduct quarterly audits and have weekly calls with the Administrator. Staff confirmed that weekly calls are still taking place, every Wednesday. The two-day audit last took place on 6/1/2022 and 6/2/2022. Career Smart will be in the community to complete the audit on September 7th and 8th. C. Licensee will include specific inquiries regarding sexual behaviors and aggressive behaviors during the initial evaluation of new residents Reappraisals will address sexual behaviors and aggressive behaviors when such conduct is evident. The community has not admitted anyone with these specific behaviors within the past two months, but this addendum is included in the assessment for all residents. D. A member of the licensee’s governing board shall, on a quarterly basis: conduct on site facility visits, review both reports generated by outside consultant and those from CCLD, prepare written reports to the licensee’s governing board, and ensure POCs are completed and submitted timely. On August 9th, a visit was conducted by Loren B. Shook. E. Department shall conduct quarterly inspection during the probationary period. Today, 8/30/2022. F. Licensee shall provide a thirty-minute overlap of direct care staff between each shift. Staff communicated that the time frame is indicated on the staffing assignments to demonstrate the 30-minute overlap. LPA reviewed staffing sheets to confirm appropriate coverage. G. Licensee shall chart any reportable resident injuries on each shift and communicate such injury to direct care staff prior to initiating their shift. Shift change form was created and is being utilized daily. The nurses sign this form during shift change. H. Licensee shall continue to maintain adequate staffing to meet the specific needs of individual residents in care and population as a whole. Staff are continuing to monitor their staffing numbers. Staffing is reassessed every day, every shift. Agency staff are still being utilized as needed. Additional associates have been added and hiring is ongoing. I. Licensee shall form a client/resident assessment management that consists of the certified administrator, nursing personnel, and supervising/direct care staff who shall meet at least once a month, in order to reassess the appropriateness of continued placement retention or relocation residents to facilities offering a higher level of care. Yes, this took place on 8/29/2022. LPA reviewed meeting minutes. J. Licensee shall conduct a monthly support group facilitated by an outside professional approved by the Department, providing an opportunity for associates to share issues/concerns and have a safe environment for communication and sharing without management presence. Session took place on 8/23/2022. The LPA reviewed the past three months to confirm that sessions have happened monthly. The sessions are two hours - one hour for a group session and one hour for individual check-ins. K. Licensee shall provide direct care staff a minimum of 6 hours of quarterly training on Title 22 regulations ... The facility holds in-service trainings two hours a month, to ensure that hours are all completed for direct care staff. The LPA reviewed training documents to confirm that staff are receiving the required training hours. L. Licensee will designate one employee who is fully trained as a caregiver on all shifts as a float staff. This is indicated on the staff schedule and the daily staffing sheet. M. Licensee shall assign qualified staff to assess residents who lack the cognitive or physical ability to communicate their needs or injuries on a regular basis as determined by their initial care plan. Documentation of the direct care staff’s observation of any newly identified resident needs or injuries, including pressure injuries, shall be reported to the direct care staff’s immediate supervisor on a daily basis and to the Department, when applicable. On a monthly basis, all residents are assessed for any changes in needs. This is in addition to care plan/service plans that are created for residents. The LPA observed that this was completed for July 2022 and is pending completion for August 2022. During today’s visit, the LPA checked to ensure that Staff #1 (S1) was not working at the facility. S1 has not been in the facility since May 2022. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 30, 2022

Allegation investigated: Licensee allowed employee to work in the facility prior to obtaining criminal record clearance

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day complaint visit. The LPA met with Administrator Vida Gwinn and explained the reason for the visit. During today’s visit, the LPA interviewed staff from 11:15 a.m. - 11:20 a.m. and audited staff records from 11:20 a.m. – 1:00 p.m. It was alleged that the licensee allowed staff to work at this facility prior to obtaining criminal record clearance. The LPA compared the staffing list to the Department clearance list and identified two employees (Staff #1, Staff #2) had worked in this facility either without a valid criminal record clearance, or the clearance status was set to ‘In Process’. Based on interview and records review, this allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued. Substantiatedthe state’s words, verbatim · CDSS document, Jun 1, 2022 · control 29-AS-20220531142636

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jun 2, 2022

87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply in the section cited above for two staff (S1, S2), which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2022

Plan of correction: The Administrator agreed to the following: 1. The two identified staff will not work in the community until appropriate clearance is obtained. Staff will submit a Statement of Understanding, confirming this action, no later than 6/2/2022.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Legal Non-Compliance inspection at the facility today. The purpose of today’s visit was to ensure the facility was maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. Areas discussed: A. Licensee shall operate the facility in substantial compliance with regulations and statures governing the operation of a residential care facility for the elderly. During today’s visit, the LPA reviewed a random sample of ten staff records. Out of the ten files reviewed, the following was noted: a. Four out of ten staff (Staff #2, Staff #3, Staff #6, Staff #7) had a job application that was either incompletely filled out, blank, or missing b. Four out of ten staff (Staff #1, Staff #6, Staff #7, Staff #8) had a health screening that was either incompletely filled out or blank c. Three out of ten staff (Staff #2, Staff #3, Staff #7) did not have first aid certification on file d. Three out of ten staff (Staff #1, Staff #3, Staff #8) require tuberculosis results B. Career Smart will conduct quarterly audits and have weekly calls with the Administrator. Last quarterly was 3/4/2022 and today, 6/1/2022. Staff confirmed that weekly calls are still taking place. LPA obtained a copy of the quarterly report from 3/4/2022. C. Licensee will include specific inquiries regarding sexual behaviors and aggressive behaviors during the initial evaluation of new residents Reappraisals will address sexual behaviors and aggressive behaviors when such conduct is evident. Addendum has been added, per licensee. LPA obtained a copy of the addendum. There was one move-in for April and May of 2022 in which facility utilized the new addendum. Copies are kept in a file at the facility. D. A member of the licensee’s governing board shall, on a quarterly basis: conduct on site facility visits, review both reports generated by outside consultant and those from CCLD, prepare written reports to the licensee’s governing board, and ensure POCs are completed and submitted timely. On 4/5/2022, Loren B Shook and Michelle Egerer went to the facility. LPA obtained copy of the compliance report. E. Department shall conduct quarterly inspection during the probationary period. This took place today, 6/1/2022. F. Licensee shall provide a thirty-minute overlap of direct care staff between each shift. Staff communicated that the time frame is indicated on the staffing assignments to demonstrate the 30-minute overlap. LPA obtained copies. G. Licensee shall chart any reportable resident injuries on each shift and communicate such injury to direct care staff prior to initiating their shift. Shift change form was created and is being utilized daily. The nurses sign this form during shift change. H. Licensee shall continue to maintain adequate staffing to meet the specific needs of individual residents in care and population as a whole. Staff are continuing to monitor their staffing numbers. Staffing is reassessed every day, every shift. I. Licensee shall form a client/resident assessment management that consists of the certified administrator, nursing personnel, and supervising/direct care staff who shall meet at least once a month, in order to reassess the appropriateness of continued placement retention or relocation residents to facilities offering a higher level of care. LPA obtained copy of the meeting notes; staff recently met on 5/31/2022. J. Licensee shall conduct a monthly support group facilitated by an outside professional approved by the Department, providing an opportunity for associates to share issues/concerns and have a safe environment for communication and sharing without management presence. Dr. Jill Brink came last Thursday 5/26, To maintain confidentiality, the facility is only collecting invoices and the LPA recommended that they include the census. The sessions are two hours - one hour for a group session and one hour for individual check-ins. K. Licensee shall provide direct care staff a minimum of 6 hours of quarterly training on Title 22 regulations, including but not limited to: Section 87707 and observation of residents, facility’s internal procedures to ensure that observations are included in accurate and up to date charting consistent with facility policy, client behaviors including intimacy and sexual behaviors, interventions with memory impaired residents whom exhibit aggressive behaviors, medication, suspected elder abuse detection and mandated reporting requirements, preparing and providing timely incident reports, proper resident hygiene, health conditions, care of individuals with dementia, the preparation of restricted health condition care plans and the preparation of needs and services plan. The facility holds in-service trainings two hours a month, to ensure that the hours are all completed for direct care staff. L. Licensee will designate one employee who is fully trained as a caregiver on all shifts as a float staff. Assignment sheets reflecting the person assigned shall be provided to licensing staff during quarterly inspections or whenever requested. If admin/manage met personnel are used as substitute direct care staff, they must engage in direct care during the entire time they are serving in that role. This is indicated on the staff schedule and the daily staffing sheet. M. Licensee shall assign qualified staff to assess residents who lack the cognitive or physical ability to communicate their needs or injuries on a regular basis as determined by their initial care plan. Documentation of the direct care staff’s observation of any newly identified resident needs or injuries, including pressure injuries, shall be reported to the direct care staff’s immediate supervisor on a daily basis and to the Department, when applicable. On a monthly basis, all residents are assessed for any changes in needs. This is in addition to care plan/service plans that are created for residents. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Jun 1, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 10, 2022

87411(a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above for four out of ten staff (S2, S3, S6, S7), which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Obtain the missing items. Inform the Department when this has taken place, but no later than 6/10/2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Jun 10, 2022

87411(f) Personnel Requirements - General. (f) Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above as for four staff (S1, S6, S7, S8) need a health screening and three staff (S1, S3, S8) need TB results, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Obtain the missing items. Inform the Department when this has taken place, but no later than 6/10/2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Jun 10, 2022

87411(f) Personnel Requirements - General. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply in the section cited above in three out of ten staff (S2, S3, S7) need TB results, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 1, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Obtain the missing items. Inform the Department when this has taken place, but no later than 6/10/2022

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

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial complaint visit. The LPA met with Esther Chico-Gutierrez and explained the reason for the visit. During today’s visit, the LPA interviewed staff at 9:35 a.m., 10:00 a.m., 10:45 am., and 11:35 a.m.; and reviewed records from 10:20 a.m. – 10:35 a.m. Regarding the allegation: Facility staff failed to meet resident's hygiene needs. It was alleged that Resident #1’s (R1) hygiene needs were neglected, as R1 was found with mucus covering their clothing and face, and their overall appearance was unclean. Interviews and video surveillance supported claims that on 4/10/2022, R1 was observed sitting on a bench in the facility with their nose running, and a large amount of mucus had accumulated on R1’s clothing and the facility bench. Substantiated Staff were alerted to R1’s appearance, yet it appeared that R1 had been sitting there for an undetermined amount of time. R1’s care plan revealed that R1 requires assistance with grooming and hygiene needs. Based on the information obtained during the course of the investigation, the allegation ‘facility staff failed to meet resident’s hygiene needs’ is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted. A copy of the report, and appeal rights, were provided. Interviews revealed when R1 was temporarily relocated, R1’s clothing, furniture, and some personal items were placed in the temporary rooms. During that time, it appeared that some of R1’s items went missing. In addition, staff admitted that they believed that R1 was better suited for a different location in the facility due to their care needs. During this time, staff questioned whether R1 would be moved to a different room after the facility was cleared of the COVID-19 outbreak. However, additional discussion was had with R1’s responsible party and facility management regarding a suitable location for R1. At this time, R1 is currently residing in their original room. In addition, interviews confirmed that R1’s personal belongings have been located and returned to R1’s room. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to safeguard resident’s personal belongings. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff neglected resident while in care It was alleged that Resident #2 (R2) is often found on the floor, and that staff were neglecting R2’s needs. Interviews confirmed that R2 oftentimes places themselves on the floor and that it was a reoccurring behavior for R2. Staff stated that they make attempts to assist R2 and move R2 to a more appropriate location, yet staff claim that R2 will place themselves back on the floor. The LPA reviewed R2’s care plans and identified that this behavior is notated on the care plan and that R2’s responsible party is aware. Staff recognize that although they clean and vacuum the facility that the flooring can appear unsanitary due to persons walking throughout the community. As such, staff claim that they want to ensure that R2’s personal rights are respected but also try to assist R2 to a more appropriate location as needed. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff neglected resident while in care. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is not following proper protocol for COVID-19 It was alleged that R1 was hospitalized on 2/8/2022 and while in the hospital, was diagnosed with COVID-19. It was also noted that R1 was accompanied by facility staff and further alleged that because the staff was exposed to R1, the staff should have not returned to work. Interviews and records review revealed that R1 was accompanied to the hospital by Staff #1 (S1). Hospital discharge paperwork revealed that R1 tested positive for COVID-19, however, R1 was asymptomatic. Information obtained from an interview with S1 revealed that they were unaware that R1 was COVID-19 positive when they left the hospital. During that time, the facility was undergoing response-testing and S1 was tested for COVID-19. It was confirmed that S1 did not test positive for COVID-19 during the months of January-April 2022, S1 did not display any symptoms after going to the hospital with R1, and S1 was fully vaccinated at the time the incident occurred. Per the Provider Information Notice (PIN) 21-23 issued to facilities on 4/20/2021, “Fully vaccinated facility staff who are asymptomatic do not need to be restricted from work for 14 days following an exposure to COVID-19, per updated Centers for Disease Control and Prevention (CDC) guidance.” Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility did not follow proper protocol for COVID-19. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is not following the visitation protocol It was alleged that the facility was not following the visitation protocol. Interviews revealed that the facility preferred have outdoor visitation as it poses a lower risk of transmission. However, staff stated that indoor visitation was allowed if the resident’s visitor was either vaccinated or had evidence of a negative COVID-19 test within one day of visitation for antigen tests, or within two days of visitation with a PCR test. Staff stated that if there were repeat visitors that preferred to have indoor visitation, they ensured that all visitors followed protocol as communicated by the local health department and Community Care Licensing. Staff mentioned that most visitors are comfortable with outdoor visitation but stated that indoor visitation was not denied. Staff stated that when the facility had a COVID-19 outbreak, they had separate outdoor visitation areas for residents whom resided in the Red Zone (positive residents), Yellow Zone (exposed residents, awaiting results), and Green Zone. Staff also shared that for those who were unable to leave the room or that fell under essential visitors, residents were allowed indoor visitation. Staff communicated that they understood the parameters for allowing indoor visitation, especially for visitors in critical condition. Staff denied claims that residents were denied visitation per protocol. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that the facility is not following the visitation protocol. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 19, 2022 · control 29-AS-20220412150231

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Apr 22, 2022

87464(f)(4) Basic Services. Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as R1's hygiene needs were not met, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 19, 2022

Plan of correction: The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how the facility will maintain compliance with ensuring that residents are regularly observed and hygiene needs are met for all residents. Submit the Plan of Action to CCL no later than 4/22/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 1:00 p.m. This annual had a specific emphasis on infection control practices and procedures. In attendance included Public Health Nurses Lynn Tobola and Myra Valencia, and virtually, parties were joined by Dr. Al-Ahmad with the Los Angeles County Department of Public Health, and Licensing Program Manager Jeralyn Pfannenstiel. All parties met with Health Services Director Kim Davis and Esther Chico-Gutierrez and explained the reason for the visit. The physical plant area was toured to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At the time of the visit, the facility has active COVID-19 cases. Hence, the purpose of today’s visit was to provide technical assistance as it related to the current outbreak. FRONT DESK: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. Staff were instructed to update the exposure notification form to reflect the current outbreak; said postings were found on the front entrance to the facility and in the staff break room. In addition, staff were instructed to post the notification form in a visible location. KITCHEN: Kitchen appliances were in operable condition. At this time, residents whom are designated in the yellow and red zones have separate dining halls. Staff are limiting the number of residents at a table, and some residents are being served in their room. RESTROOM: Restrooms were stocked with soap and paper towels. Hand-washing signs promoting good hand hygiene were observed. Staff were instructed to label restrooms designated for staff, and to ensure that hand-washing signs were posted consistently in both English and Spanish formats. CLEANING: Staff stated that all high-touch surfaces were being cleaned every two hours. In addition, all tables and areas are wiped down after every meal. Staff were reminded to be mindful of the appropriate contact time as it pertained to the cleaning solution. At this time, the facility’s cleaning protocol is adequate. VISITATION: In-person visitation is on hold at this time. However, the facility is allowing for alternative forms of communication (virtual, telephone calls), and essential visitation is allowed at all times. LAUNDRY: If possible, there should be separate staff assigned to wash the clothing of residents in the yellow versus the clothing of residents in the red zone. Best practices were shared regarding how staff are minimizing exposure risk; hence, staff will take a different route of entering the laundry room during the duration of the outbreak. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Required postings promoting physical distancing, mask wearing, and promoting good hand hygiene were posted. Staff were reminded to be mindful of the maximum number of persons that can be in an enclosed space. Staff were also instructed to post appropriate signs in the staff break area to promote regular disinfecting of commonly touched surfaces. INFECTION CONTROL: All parties spoke Health Services Director regarding the facility’s infection control practices. Staff were reminded that during the duration of the outbreak, staff must properly wear an N95 mask at all times. All staff have been properly fit tested for an N95 mask. It was communicated that the facility has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies as needed. At this time, there is a separate red zone for residents with a confirmed diagnosis of COVID-19. Staff were observed wearing full PPE in the red zone. During today’s visit, there were no immediate health or safety hazards observed. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 8, 2022

Allegation investigated: Facility has a scabies outbreak Facility did not seek medical treatment for the residents

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to deliver the findings for the above allegations. The LPA met with Health Services Director Kim Davis and explained the reason for the visit. During the initial virtual visit on 03/12/2021, the LPA interviewed Executive Director Taylor Giunto and requested records. Additional staff interviews were conducted on 4/14/2021 at 4:50 p.m. and 6/14/2021 at 12:45 p.m. During the 9/13/2021 visit, the LPA conducted a records review at 11:00 a.m. and conducted staff interviews from 10:44 a.m. – 3:20 p.m. During the 11/29/2021 visit, the LPA reviewed documentation pertinent to the investigation and interviewed Executive Director Taylor Giunto. Regarding the allegation: Facility has a scabies outbreak It was alleged that residents at this facility had a scabies outbreak. Interviews revealed that the presence of a rash was observed on approximately five (5) residents in February 2021. However, the time of the observation, the facility had active COVID-19 cases in the facility. Unsubstantiated At that time, there was a demand for hospital and medical-based services in the surrounding community due to the surge in COVID-19 cases. The facility thought it was best to mitigate additional risk and treat the residents in house. Interviews and records review revealed that on February 12, 2021, a tele-health visit was held with the facility Medical Doctor, in which there was a discussion of approximately five (5) residents whom had rashes. Documentation revealed that the Medical Doctor felt that one (1) out of five (5) residents (Resident #1) had the appearance of scabies. Interviews revealed the facility made the decision to treat the five (5) residents in-house rather than send residents to the hospital due to COVID-19. Per the tele-health visit, the Medical Doctor treated the five (5) residents as if they had scabies. Interviews with the Maintenance Director and Executive Director confirmed that a community-wide clean-up took place at the end of February, which included laundering all the resident clothing, washing the carpet, and sanitizing and cleaning all common spaces. In addition, all residents and staff were treated with topical cream for preventative measures. The family of Resident #1 (R1) took R1 to see a dermatologist in April 2021, in which it was confirmed that R1 had scabies. Thereafter, the Executive Director contacted the local health department, whom did not open a case for the community as they only had one confirmed case at the time of the call. Based on the investigation, there is insufficient evidence to support the claim that the facility had a scabies outbreak. When the facility had a confirmed case of scabies, it was reported to the Department and the local health department. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility did not seek medical treatment for the residents It was alleged that residents developed scabies and it was left untreated. Documentation confirmed that at the suspicion of the rash, the facility had a tele-health visit with the facility Medical Doctor on February 12, 2021 and sought treatment advice. Interviews confirmed that for precautionary reasons, the facility treated all residents and staff with topical cream. Interviews and documentation confirmed that the initial residents whom were identified with rashes in February 2021 received a prescription medication to treat the rashes. R1 was sent out to a dermatologist in April 2021 and was also prescribed topical medication. Based on the evidence obtained, there is insufficient evidence to support the claim that the facility did not seek medical treatment for residents. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 1, 2022 · control 29-AS-20210305165753

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20210305165753. During the investigation, interviews revealed that at least five (5) residents had rashes in February 2021. A tele-health visit was held with the facility Medical Doctor, in which there was a discussion of approximately five (5) residents whom had rashes. Documentation revealed that the Medical Doctor felt that one (1) out of five (5) residents had the appearance of scabies. Interviews with the Maintenance Director and Executive Director confirmed that a community-wide clean-up took place at the end of February, which included laundering all the resident clothing, washing the carpet, and sanitizing and cleaning all common spaces. In addition, all residents and staff were treated with topical cream for preventative measures. It was communicated that upon notice of the rashes, the facility made the decision to treat the five (5) residents in-house rather than send residents to the hospital due to COVID-19. Whereas the complaint came in early March 2021, the rashes were observed on at least five residents in February 2021. The facility failed to report the suspicion of scabies and/or the rashes to Community Care Licensing. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of the report, and appeal rights, were provided.the state’s words, verbatim · CDSS document, Feb 1, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 11, 2022

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events...: (D) Any incident which threatens the welfare, safety or health of any resident .... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the presence of a rash on five residents was not reported to CCL in February 2021, which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 1, 2022

Plan of correction: The Licensee agreed to do the following: 1. Submit incident reports for the five residents by the POC due date.

Allegation investigated: Facility staff failed to provide proper care and supervision to Resident #1 (R1) which resulted in R1’s death.

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced subsequent complaint visit to the above facility. The LPA met with Executive Director Taylor Giunto and explained the reason for the visit. On 01/31/2019, the Department issued findings of Substantiated for the above allegation. The licensee was cited for violating California Code of Regulations (CCR) Title 22, 87464(f)(1) Basic Services, in which “Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2.” An immediate civil penalty of $500 was also issued. An appeal was issued by the licensee, and the deficiency was dismissed. After further review, the Department has determined that the allegation, “Facility staff failed to provide proper care and supervision to Resident #1 (R1) which resulted in R1’s death” will be changed from Substantiated to Unsubstantiated. The $500 penalty will be dismissed. Although the Department is no longer substantiating the above allegation, the Department found that facility staff failed to provide proper care and supervision to Resident #1 (R1), which resulted in serious bodily injury and will be addressed in a Case Management visit. Exit interview conducted. A copy of the report was issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 29, 2021 · control 31-AS-20180703114242

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Resident(s) sustained a fracture while in care.

Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent visit to deliver the findings for the above allegations. The LPA met with Executive Director Taylor Giunto and explained the reason for the visit. On 07/21/2021, the Department received a complaint, alleging that Resident #1 (R1) and Resident #2 (R2) sustained fractures while in care. Several allegations were listed, including that the facility restrained R1 and failed to follow physician’s orders for medical equipment needed for multiple residents. Community Care Licensing Division’s Investigations Branch (IB) Investigator Dennis Douglas was assigned to the case. On 11/5/2020, the LPA interviewed the Executive Director and requested documents. Additionally, the LPA conducted staff interviews on 1/19/2021 at 2:23pm, 2:35pm and 2:56pm; and, on 1/22/2021 at 1:57pm, 2:46pm, 3:01pm, and 3:17pm. Investigator Douglas interviewed three staff on 12/1/2020; interviewed R1’s doctors on 12/11/2020 and 1/15/2021; interviewed R2’s family member on 1/14/2021; interviewed R1’s family member on 1/15/2021; and, reviewed pertinent documentation. Substantiated Regarding the allegation: Residents sustained a fracture while in care It was alleged that R1 and R2 suffered numerous falls, some resulting in significant injuries, including a fracture. A review of documents for R1 revealed that R1’s initial Comprehensive Assessment and Service Plans dated 10/4/16, 6/29/17, and 8/2/18 did not indicate any falls and R1 was not deemed a fall risk at that time. The Service Plan dated 4/9/19 noted that R1 suffered falls on 12/25/18 and 3/27/19, yet further assessment did not deem R1 a fall risk, nor did it note that R1 needed further assistance. Service Plans dated 10/14/2019 revealed that R1 suffered falls on 9/18/19 and 10/08/19. Whereas no injuries were sustained as a result of these falls, further supports were noted as being put in place, including fall mats, and ‘hip protectors’ to be worn at all times. At that time, it was deemed that R1 was a fall risk. Interviews and documentation revealed that R1 often did not wear the hip protectors as documented in the service plan. R1 ultimately suffered another fall on 10/17/2020, which resulted in a hip fracture. It was discovered that R1 was not wearing hip protectors at the time of the fall, which may have protected R1 from sustaining a hip fracture. Comparatively, R2 also suffered numerous falls in the facility. Per various reports presented in R2’s file, it was indicated that R2 sustained a fall or was found on the floor on the following dates: 4/29/2018, 5/2/2018, 5/7/2018, 12/7/2019, 1/25/2020, 3/5/2020 and 6/12/2020. After reviewing R2’s Comprehensive Assessment and Service Plan dated 10/25/2018, whereas the falls were mentioned, no plan was mentioned on how to address the falls, nor was R2 noted as a fall risk. The Comprehensive Assessment and Services Plans dated 4/9/2019 and 10/10/2019 were provided at the request of the Investigator; however, page 4 was missing from those service plans, which is the page in which documented falls and subsequent fall prevention strategies are mentioned. R2 suffered a fall on 6/12/2020, and R2 was hospitalized and diagnosed with a hip fracture. Interviews revealed that further discussion regarding fall prevention and assistance regarding R2 did not transpire with R2’s responsible party. Based on the investigation, there is sufficient evidence to support the claim that due to lack of care and supervision, residents sustained numerous falls, with some resulting in serious injury. R1’s service plan indicated that R1 would wear hip protectors at all times, yet the investigation revealed that R1 wore them inconsistently. In addition, R2 suffered numerous falls, yet the investigation did not cover any documented plan or course of action to address R2’s propensity to fall. Whereas all falls cannot be prevented, the supports allegedly put in place were not adequate. Based on the investigation, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D).Exit interview conducted. A copy of this report and appeal rights were issued. Regarding the allegation: Staff restrained resident It was alleged that Resident #2 (R2) was allegedly restrained to the bed by way of staff tying R2’s foot to the bed. Interviews and records review revealed that on 6/12/2020, R2 suffered a fall at the facility, which resulted in R1 suffering a closed fracture of the right hip. Hospital discharge paperwork described R2’s treatment, which included a 5lbs bucks traction, which according to the US National Library of Medicine, is an apparatus for maintaining proper alignment of a fracture, typically used for a hip or leg fracture. Regular use of this reduces pain and maintains length in fractures. Facility Progress Notes documented that R2 was discharged from the hospital on 6/16/2020, with orders for the 5lbs Bucks traction. Subsequent Facility Progress Notes confirmed that the apparatus was observed on R2 as ordered. Interviews with R2’s family member confirmed the use of this leg traction and stated that it could have been mistaken for a restraint. Based on the investigation, there is insufficient evidence to support the claim that staff restrained R2 to the bed by their foot. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Licensee failed to follow physician’s orders for medical equipment needed for resident(s) It was alleged that residents, including R1, were prescribed to wear hip protectors from their primary care physicians, yet staff did not ensure that they were using them. Interviews with two (2) of the medical professionals responsible for R1’s care confirmed that they did not prescribe R1 to wear hip protectors. However, the third medical professional, whose name was on the Service Plan which stated to use hip protectors, did not respond to the investigator’s request for a comment. In addition, there was no documentation to support the claim that the hip protectors were ordered. Whereas documentation does confirm that R1 was supposed to wear hip protectors, this provision appeared to not be at the request or order of R1’s doctors, but more so a safeguard provided by the facility to assist in fall prevention. Based on the investigation, there is insufficient evidence to support the claim that the licensee failed to follow physician’s orders for medical equipment needed for residents. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 29, 2021 · control 29-AS-20201104103913

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 1, 2021

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 and R2 suffered falls while in care which resulted in serious injuries, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 29, 2021

Plan of correction: The Administrator agreed to do the following: Submit a Plan of Action, documenting how the facility identifies whether a resident is a fall risk and the subsequent supports put in place to best assist resident needs. Submit plan by 12/1/2021. Review protocol with nursing staff. Submit proof that staff have reviewed protocol no later than 12/6/2021 Repeat citation; immediate civil penalty assessed.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management visit to the above facility. The purpose of the visit is to follow up on the substantiated allegation of neglect/lack of care and supervision. The LPA met with Executive Director Taylor Giunto and explained the reason for the visit. On July 3, 2018, the Department received a complaint which contained the allegations: Facility staff failed to provide proper care and supervision to Resident #1 (R1) which contributed to R1’s death; and, facility staff failed to seek timely medical attention for R1. The above allegations were substantiated, and on January 31, 2019, the licensee was cited for violating California Code of Regulations (CCR) Title 22, 87464(f)(1) Basic Services due to failure to provide R1 with proper care and supervision relating to assistance with activities of daily living. Citations were also issued under 87465(g) Incidental Medical and Dental Care for failure to obtain timely medical attention for R1 by failing to call 9-1-1 immediately upon finding R1 in an unresponsive state. The licensee was further cited under section 87411(a) Personnel Requirements – General for not having competent staff to ensure R1 was monitored and ate after receiving insulin, and subsequently failing to contact emergency services for R1 in a timely manner. Lastly, the licensee was issued a citation under section 87405(d)(1)(2) Administrator – Qualifications and Duties for the administrator not providing staff with appropriate training to ensure R1 was afforded appropriate care and supervision, which ultimately contributed to the death of R1. On January 31, 2019, an immediate civil penalty of $500 was also assessed for the violation of CCR Title 22, Section 87464(f)(1) Basic Services. An appeal was issued by the licensee, and the deficiency 87464(f)(1) Basic Services was dismissed. On November 29, 2021, the allegation “Facility staff failed to provide proper care and supervision to Resident #1 (R1) which resulted in R1’s death” was changed from Substantiated to Unsubstantiated and the $500 civil penalty was dismissed. On August 23, 2021, the Department issued a civil penalty per Health and Safety Code §1569.49 in the amount of $9,500 for a violation that the Department constitutes as serious bodily injury. Today, the Department is assessing a $500 civil penalty for the facility staff’s failure to provide proper care and supervision to R1, which resulted in serious bodily injury. Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 809-D). Exit Interview Conducted. Civil penalty issued. Appeal Rights Discussed. A Copy of Report Issued.the state’s words, verbatim · CDSS document, Nov 29, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 29, 2021

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff failed to provide proper care to R1 after administering insulin, resulting in R1 becoming hospitalized, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 29, 2021

Plan of correction: No additional POC will be required at this time, as the facility submitted a comprehensive plan on what steps would be taken to ensure residents’ needs were met. Original POC was due 2/1/2019 and cleared 2/4/2019 An immediate civil penalty of $500 will be assessed. As this is a repeat violation, an additional civil penalty of $1,000 will be assessed today.

Type of visit: Case Management - Other

On September 21, 2021, Licensing Program Analyst (LPA), Teresa Camara conducted an unannounced Case Management visit to follow up on a substantiated allegation of lack of supervision. The LPA met with Director of Healthcare Services Kim Davis and informed them of the reason for the visit. On August 23, 2021, the Department issued findings regarding the complaint received on July 16, 2019, alleging that due to the facility’s failure to provide appropriate care and supervision, Resident #1 (R1) sustained injury(ies). More specifically, the complaint alleged that on July 13, 2019 Resident #2 (R2), a 71-year-old male without warning pushed R1, an 88-year old male, in the back and he was hospitalized for serious lacerations to his forehead, mouth, and nose. The allegation was substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, §87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities., in which “Residents shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.” On August 26, 2021, an immediate civil penalty of $500 was assessed; in addition, the Department also assessed a $1000 civil penalty due to the citation being a repeat violation of the same subsection. continued on 809-C (page 2) The investigation revealed that on July 13, 2019, at approximately 11:50 a.m., per Staff #1 (S1) she observed R1 standing in the hallway when R1 was pushed on the back by R2, causing R1 to fall face first on the ground. S1 observed lots of bleeding from R1’s nose, mouth, and forehead, as well as bruising to R1’s forehead and stomach. Staff #2 (S2) mentioned that they were standing near R1 when the incident occurred and stated that R2 had pushed other residents in the past. Staff #3 (S3), the facility Licensed Vocational Nurse (LVN), was in her office, which is near the location of where the incident occurred, rendered first aid, but was unable to stop the bleeding. S3 contacted 9-1-1 and R1 was admitted to a local hospital emergency department at approximately 12:51 p.m. Hospital medical records reflect R1 was admitted from the hospital emergency department to the hospital intensive care unit (ICU) on the same day at 5:01 p.m. Per hospital records R1 was admitted with the following diagnoses: stable burst fracture of the first cervical vertebra; acute respiratory failure-unspecified with hypoxia or hypercapnia’ anterior displaced type II dens fracture; contusion of abdominal wall, contusion of right front wall of thorax; fracture of nasal bones; and laceration without foreign body of nose. A ‘burst’ fracture, according to Cedars Sinai, is a descriptive term for an injury where the vertebra is crushed in all directions and is more severe as the bones spread out in all directions and can damage the spinal cord. According to the US National Library of Medicine, an anterior displaced type II dens fracture, occurs most typically when the cervical spine hyperflexes, pushing the vertebrate forward to the point of fracture. According to the US National Library of Medicine, hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain homeostasis, which can be caused by airway obstruction. continued on 809-C (page 3) R1 was in the ICU and on a ventilator until July 22, 2019 when the family made the decision to extubate him and he passed away. The death certificate lists the immediate cause of death as respiratory failure. According to the National Heart, Lung, and Blood Institute, respiratory failure is a serious condition that develops when lungs can’t get enough oxygen into the blood, which can be a condition that is often caused by a disease or injury to the lung or spinal cord. As a part of the investigation, R2’s resident file was reviewed. R2 was admitted to the facility on November 8, 2018 and his August 17, 2018 physician’s report indicated a primary diagnosis of Alzheimer’s Disease and Anxiety. His April 23, 2019 Comprehensive Assessment and Service Plan reflected R2’s behavior of wandering/pacing, a history of Alzheimer’s Dementia, anxiety, paranoia, combative, uncooperative with activities of daily living (ADL) assistance. Other facility records and staff interviews revealed since placement R2 had incidents of aggressive behaviors, verbally and physically, towards facility staff and residents, as well as being hit by other residents. Some of the incidents include: December 8, 2018 female resident bit him on arm; April 13, 2019 R2 bit a caregiver who was providing ADL care; July 1, 2019, R2 hit a caregiver on the arm, and later hit a resident on the hands; July 9, 2019, R2 hit a facility staff member; and July 12, 2019 after being grabbed on the arm, R2 responded by hitting the resident on the shoulder. Reportedly none of these incidents required medical intervention. Staff interviews revealed additional aggressive incidents, including picking up a male staff and slamming him against a wall three times. There is no written evidence that the licensee made efforts to increase his supervision, until after the assault of July 13, 2019 against R1, when the 1 on 1 caregiver was assigned. continued on 809-C (page 4) Based on the interviews conducted and records reviewed, there was sufficient evidence to substantiate the allegation of lack of care and supervision, which led to R1 sustaining significant injuries leading to his death. The facility failed to implement adequate safety measures to address and manage R2’s repeated aggressive behavior, which posed an immediate health and safety risk to the other residents in care and staff. On August 23, 2021, the Licensee was informed that a civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation which resulted in the death of R1. Today, September 21, 2021, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $15,000 for a violation that the Department determined resulted in the death of R1. However, since an immediate civil penalty of $500 was previously issued on August 26, 2021, the amount of the civil penalty issued is reduced to $14,500. A copy of the LIC 421D was given to the Director of Healthcare Services Kim Davis and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Director of Healthcare Services Kim Davis' signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 21, 2021

Allegation investigated: Residents sustained pressure injuries while in care.

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced subsequent complaint visit to the above facility to conclude an investigation initiated by LPA Heffernan on 10/18/2019. Upon arrival, the LPA met with Executive Director Taylor Giunto and explained the reason for the visit. On 10/14/2019, the Department received a complaint alleging residents sustained pressure injuries while in care. The allegation was specifically focused on three residents. On 11/26/2019 at 11:10am, LPA interviewed the Executive Director Giunto, who stated Resident #1 (R1) previously had a wound on R1’s heel, but it had since healed. The Executive Director was unaware of any pressure injuries sustained by Resident #2 (R2) or Resident #3 (R3) but noted that all three residents were receiving hospice services while residing at the facility. An additional interview with staff on 11/26/2019 at 2:54pm, revealed R1 had a small wound on R1’s right heel due to boots that rub against R1’s wheelchair feet which causes friction. CONT 9099-C Substantiated However, staff prop R1’s feet up at night so that R1’s heels are dangling and not touching the bed. In addition, staff stated R2 had started to develop a pressure injury on R2’s coccyx recently but was being treated by hospice. Staff confirmed R3 may have had one pressure injury on R3’s hip or lateral thigh, but confirmed R3 had suffered a bad reaction to medication which caused R3 to turn red and make R3’s skin peel. The facility provided an opti-foam padding on R3’s mattress for extra support. A review of records on 03/12/2020, beginning at 9:30am, indicated R1 was admitted to the facility on 02/26/2019 and hospice services were initiated on 04/10/2019. Hospice notes indicate during R1’s initial assessment on 04/10/2019, wound care was performed on a stage III pressure injury measuring 5 cm X 5 cm X 0.2 cm on R1’s left heel. R2 was noted to have pressure injuries on R2’s buttocks and right ankle but receiving wound care from 12/11/2019-2/17/2020. However, hospice services were initiated for R2 on 01/13/2017. R3 was admitted to the facility on 09/25/2015 and hospice services were initiated on 04/01/2017. In summary, R1 was admitted to the facility on 02/26/2019 and a stage III pressure injury was noted on R1’s left heel during the initial assessment for hospice care on 04/10/2019. Whereas R2 and R3 sustained pressure injuries, the above-mentioned pressure injuries for R2 and R3 received appropriate care under the supervision of an appropriately skilled professional. There was no evidence to determine that R1 received appropriate wound care from either a home health or hospice agency prior to the assessment of the stage III pressure injury on 04/10/2019. A file review revealed that an exception was not filed to retain R1 in the facility with a stage III injury prior to receiving hospice care, nor did documents confirm that R1 received any wound care prior to the 04/10/2019 assessment date. Based on the investigation, there is sufficient evidence to support the claim that R1 sustained pressure injuries while in care. This allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Sep 13, 2021 · control 31-AS-20191014113600

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 15, 2021

87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained … (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as R1 was retained in the facility with a stage III pressure injury, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 13, 2021

Plan of correction: The Administrator agreed to do the following: 1. Host an in-service training with care staff, regarding regulation 87615 Prohibited Health Conditions and 87631 Healing Wounds. Communicate scheduled date to the Department by 9/15/2021. Training must be completed within two weeks.

Allegation investigated: Facility does not provide a safe environment Facility staff lack training

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Taylor Giunto and explained the reason for the visit. During the initial virtual visit on 4/22/2020, LPA Kelly Dulek interviewed Taylor Giunto and requested records. During today’s visit, the LPA conducted a records review at 11:00 a.m. and conducted staff interviews from 10:44 a.m. – 3:20 p.m. Regarding the allegation: Facility does not provide a safe environment It was alleged that residents and staff are being hurt by aggressive, combative residents, which further creates an unsafe environment. Interviews confirmed that there were some residents that displayed aggressive behaviors, but it may be due to their dementia diagnosis and the staff employ different methods to ensure that residents do not pose a danger to themselves or others. Staff communicated that if residents display aggressive behaviors, they will either give the resident space, employ the assistance of another staff member to aid in resident care, or will alert management. Staff also recognized that aggressive behaviors may be a result of a medical concern, to which they would then elevate the concern to the facility nursing staff. Unsubstantiated It was also communicated that staff understand that the aggressive behavior is a result of the dementia diagnosis and is not perceived as a personal attack, and that understanding is reinforced in training and in understanding the varied needs of the residents in the community. In general, it was communicated that the community did its best to foster a safe environment. Based on the information obtained, there is insufficient evidence to support the claim that the facility does not provide a safe environment. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility staff lack training It was alleged that staff were not properly trained. During today’s visit, the LPA conducted a file review from 11:00 a.m. – 11:45 a.m., and reviewed ten staff files, all of which were randomly selected. The file review revealed that the direct care staff had, at minimum, twenty hours of training within the past twelve months. The training included the required eight hours of dementia care training and the four hours of training which were specific to postural supports, hospice care, and restricted health conditions. File reviews also revealed that staff may complete a competency quiz to test the comprehension and understanding of the training topic(s). Said quizzes are not required by regulation. Staff interviews revealed that staff felt properly trained to perform their job duties and expressed that staff felt equipped to manage aggressive behaviors. Based on the investigation, there is insufficient evidence to support the claim that facility staff lack training. This allegation is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 13, 2021 · control 31-AS-20200413143815

Allegation investigated: Staff mismanaged medication Staff failed to follow reporting requirements

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Taylor Giunto and explained the reason for the visit. During the initial virtual visit on 11/17/2020, the LPA toured the facility with ED Taylor Giunto at 3:30 p.m. During an in-person visit on 5/17/2021, the LPA met with Regional Administrator Jason Russo, toured the facility at 11:23am, and conducted staff interviews from 11:45am - 4pm. In addition, interviews were conducted with two staff members on 07/02/2021 at 8:39 a.m., and 4:12 p.m. During today’s visit, the LPA conducted a medication audit at 3:23 p.m. and conducted staff interviews from 10:44 a.m. – 3:20 p.m. Regarding the allegation: Staff mismanaged medication It was alleged that a former staff member was fired for multiple medication errors and for stealing narcotics. Interviews conducted with current staff could not corroborate the above-mentioned claims, and current staff denied having knowledge of any staff, former or current, engaging in any medication-related issues. Unsubstantiated Interviews and records review revealed that the former staff in question was written up for various reasons but was not fired from the community due to mismanaging medication. Whereas additional interviews revealed that there was speculation surrounding the firing of a former staff member, sufficient evidence could not be obtained to validate such claims. The LPA conducted a medication audit with the assistance of the Director of Health Care Services at 3:23 p.m. The medication audit did not reveal any discrepancies or medication errors. Based on the investigation, there is insufficient evidence to support the claim that staff mismanaged medication. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to follow reporting requirements It was alleged that unusual incidents involvement the mismanagement of medication was not appropriately reported to the Department. Interviews and records review surrounding the allegations revealed insufficient evidence regarding the claim that staff mismanaged medication. Records review revealed that on several prior occasions, the community has submitted Unusual Incident Reports pertaining to medication errors. As such, there was no indication that the community failed to report a medication error and staff understand the requirements as it pertains to reporting. Based on the investigation, there is insufficient evidence to support the claim that the staff failed to follow reporting requirements. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 13, 2021 · control 29-AS-20201116081608

Allegation investigated: Due to facility lack of care and supervision, Resident #1 (R1) sustained injury(ies).

Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint visit to the above facility. The purpose of today’s visit is to conclude an investigation initiated by LPA Desaree Perera on 07/17/2019. The LPA met with Taylor Giunto and explained the reason for the visit. Entrance interview conducted. It was alleged that due to facility lack of care and supervision, Resident #1 (R1) was pushed by Resident #2 (R2) on 07/13/2019. R1 fell face first right on to the floor and was bleeding profusely from R1’s forehead, nose and mouth. It was further reported that R2 has had multiple incidents where R2 was aggressive towards other residents and staff. On 07/17/2019, LPA Perera conducted an initial 10-day visit, at which time a file review was conducted, and copies of pertinent documentation were obtained. LPA Perera also conducted a brief tour of the physical plant at 9:20am. Investigator Dennis Douglas from Community Care Licensing Division’s Investigation Branch (CCLD’s IB) conducted the investigation. Substantiated On 08/14/2019, 11/02/2019 and 11/06/2019, Investigator Douglas conducted interviews with facility staff and residents. On 08/14/2019, 08/20/2019, 8/22/2019, 09/19/2019 and 10/25/2019, Investigator Douglas conducted interviews with Detectives from Los Angeles County Sheriffs Homicide Division. On 11/06/2019, interviews were conducted with Home Care Assistance personnel, which was the private agency who provided one-on-one (1:1) supervision for R2. Investigator Douglas obtained and reviewed Hospital Medical Records on 07/25/2019. Moreover, facility video surveillance footage and other pertinent documentation was also reviewed by Investigator Douglas. Record reviews and interviews conducted regarding the incident revealed that, on 07/13/2019, R2 pushed R1 in the back causing R1 to fall face first on the ground and R1 was observed bleeding from R1’s nose, mouth and forehead. The attack was unprovoked and without warning. Several staff members were present in the area of the facility where the incident occurred and witnessed the attack as it occurred. As a result of the injuries, R1 was transported to the Emergency Room (E.R). Per medical record review, R1 was admitted to the E.R. on 07/13/2019 and was diagnosed with the following: stable burst fracture of the first cervical vertebra, acute respiratory failure - unspecified with hypoxia or hypercapnia, anterior displaced type II dens fracture, contusion of abdominal wall, contusion of right front wall of thorax, fracture of nasal bones, laceration without foreign body of nose. R1 was terminally extubated per family request and ultimately passed away at the hospital on 07/22/2019. Documents reviewed and interviews conducted revealed that R2 was admitted to the facility on 11/08/2018. Per R2’s physician report dated 08/17/2018, R2 has a primary diagnosis of Alzheimer’s dementia and anxiety. The report further notates, R2 is confused/disoriented, has inappropriate and wandering behavior. The report did not indicate R2 had aggressive behaviors. However, records reflected that R2’s aggressive behaviors dated as far back as 11/16/2018. R2’s Comprehensive Assessment and Service Plan dated 04/23/2019, indicates R2 has some behavioral concerns such as “yelling” and “attempting to strike CG (caregivers).” The assessment further noted that R2 “bit” a caregiver on 04/13/2019. Investigation further revealed that prior to the incident that occurred on 07/13/2019, R2 had a history of numerous aggressive behaviors both verbally and physically towards staff and other residents. On 07/01/2019, R2 hit a caregiver on the arm and once redirected, went into a resident room and hit a resident on the hands. On 07/09/2019, R2 hit a facility staff member. On 07/12/2019, another resident grabbed R2’s arm, and R2 hit the resident on the shoulder in response. As a result of the incident that occurred on 07/13/2019, R2 was placed on one-on-one care from 07/13/2019 (post-incident) through 07/26/2019. Based on all information gathered and reviewed during the course of the investigation, the department has sufficient evidence to determine that due to lack of care and supervision, R1 was pushed by R2, which resulted in R1 sustaining serious injuries. The facility staff were aware of R2’s behaviors; however, they failed to implement adequate safety measures to address and manage R2’s repeated aggressive behavior. It was foreseeable and regularly documented that R2’s aggression posed a risk to other residents in care. Therefore, the above allegation “Due to facility lack of care and supervision, Resident #1 (R1) sustained injury(ies)” is SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The licensee was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report has been issued.the state’s words, verbatim · CDSS document, Aug 23, 2021 · control 31-AS-20190716075339

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 24, 2021

Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was pushed by R2 and sustained multiple injuries due to lack of care and supervision, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 23, 2021

Plan of correction: The Administrator has agreed to do the following: 1. Submit a Plan of Action/Protocol, detailing how staff are trained to proactively manage aggressive behaviors with residents diagnosed with dementia. 2. Schedule an in-service training for caregivers and LVNs that specifically speaks to managing aggressive behaviors. Submit proof of completion to CCLD. Facility was cited for this on 3/30/2021, civil penalty of $1000 assessed for repeat violation.

Type of visit: Case Management - Other

On August 23, 2021 Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management visit to the facility today to follow up on the substantiated allegation of neglect/lack of care and supervision. The LPA met with Executive Director Taylor Giunto and informed them of the reason for the visit. On July 3, 2018, the Department received a complaint which contained the allegations: Facility staff failed to provide proper care and supervision to Resident #1 (R1) which contributed to R1’s death; and, facility staff failed to seek timely medical attention for R1. The above allegations were substantiated, on January 31, 2019, the licensee was cited for violating California Code of Regulations (CCR) Title 22, 87464(f)(1) Basic Services due to failure to provide R1 with proper care and supervision relating to assistance with activities of daily living. Citations were also issued under 87465(g) Incidental Medical and Dental Care for failure to obtain timely medical attention for R1 by failing to call 9-1-1 immediately upon finding R1 in an unresponsive state. The licensee was further cited under section 87411(a) Personnel Requirements – General for not having competent staff to ensure R1 was monitored and ate after receiving insulin, and subsequently failing to contact emergency services for R1 in a timely manner. Lastly, the licensee was issued a citation under section 87405(d)(1)(2) Administrator – Qualifications and Duties for the administrator not providing staff with appropriate training to ensure R1 was afforded appropriate care and supervision, which ultimately contributed to the death of R1. On January 31, 2019, an immediate civil penalty of $500 was also assessed for the violation of CCR Title 22, Section 87464(f)(1) Basic Services. R1’s physician report dated June 27, 2018, revealed that R1 had a primary diagnosis of vascular dementia and Type I diabetes and was confused with times and dates. R1 had a continuous glucose monitor implanted on R1’s arm which transmitted glucose levels to a bedside monitor every five (5) minutes. The display unit was programmed to sound an alarm when R1’s glucose levels dropped below 80 milligrams per deciliter (mg/dl). Based on the interviews conducted, a review of facility documentation and R1’s glucose monitor records, on July 1, 2018, Staff #1 (S1), who is a facility Licensed Vocational Nurse (LVN), checked R1’s blood glucose level prior to breakfast. R1 was given six (6) units of Novolog, plus two (2) additional per sliding scale due to R1s blood glucose reading of 274 mg/dl. At approximately 11:46 a.m., R1’s blood glucose level was checked again by S1 and was noted to be at 146 mg/dl. Therefore, S1 administered R1’s afternoon injection of six (6) units of Novolog Insulin and seven (7) units of Tresiba Insulin and instructed R1 to eat. Staff was instructed by R1’s family that R1 must eat a meal after having any of R1’s insulin injections. Per interviews, two (2) caregivers inquired if R1 wanted to eat; however, R1 refused to eat, which the caregivers reported to S1. Per records obtained from R1’s Dexcom monitoring unit, a sharp and rapid drop of R1’s blood glucose level was noted from 11:46 a.m. to 1:45 p.m. and R1’s glucose level dropped below 80 mg/dl at 1:45 p.m. No evidence from facility documentation or the interviews conducted indicated that R1 was monitored by staff from 11:46 a.m. until the sounding of the alarm at 1:45 p.m. At approximately 1:45 p.m., S1 was conducting afternoon rounds and heard R1’s glucose monitor alarming and noted R1’s blood glucose was dropping to 50 mg/dl. Per interviews, S1 offered R1 chocolate and pudding. However, R1’s glucose did not rise. S1 then contacted Staff #2 (S2) for assistance. S2 and Staff #3 (S3) responded to the call and noted R1 appeared lethargic, sluggish and was not able to answer and soon became unresponsive. S2 then placed a call to R1’s primary care physician (PCP) regarding R1’s condition and awaited directions. Facility staff contacted 9-1-1 at 2:33 p.m. after receiving instructions from R1’s PCP to send R1 to the hospital. Los Angeles County Fire Department (LACFD) arrived at the facility at 2:38 p.m. At 2:39 p.m., R1’s pulse, respiration, and systole (heartbeat) were all reported to be zero (0) and R1 was pronounced deceased at 2:40 p.m. Per R1’s death certificate, the cause of death was noted as cardiopulmonary arrest, probable respiratory failure, probable congestive heart failure. Other significant conditions contributing to death, but not resulting in the underlying cause, was noted to be diabetes mellitus type I uncontrolled, stroke, and vascular dementia. An autopsy was completed on July 9, 2018, which noted the final diagnosis as juvenile diabetes mellitus, severe cardiovascular arteriosclerosis, early pulmonary fibrosis with pleural adhesions and severe right and left sided cardiac osseous metaplasia (heart calcification). As per the Mayo Clinic, “Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than normal. Hypoglycemia needs immediate treatment when blood sugar levels are low. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L), or below should serve as an alert for hypoglycemia. The investigation consisted of interviews with facility personnel, residents, medical professionals, law enforcement and other relevant parties. Copies of supportive facility documentation, medical records, the autopsy report and additional pertinent documentation was also obtained and reviewed. Based on interviews, the licensee failed to monitor R1 for change of condition after administering the insulin injection. In addition, the licensee failed to seek timely medical care for R1 after R1 was found in an unresponsive state. Therefore, the allegations that facility staff failed to provide proper care and supervision to R1; and, facility staff failed to seek timely medical attention for R1 were substantiated. On January 31, 2019, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code §1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Today, August 23, 2021, the Department is issuing a civil penalty per Health and Safety Code §1569.49 in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on January 31, 2019, the amount of the civil penalty issued is reduced to $9,500. A copy of the LIC 421D was given to Taylor Giunto and originals were signed. Exit interview conducted. A copy of the report issued. Appeal Rights provided. Taylor Giunto’s signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 23, 2021