Bewise Home

Type of visit: Office

The purpose of this meeting was to discuss recent issues of non-compliance. Present at today’s meeting were: Administrator, Chinweike Okonkwo, Licensing Program Manager (LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Angela Panushkina. The informal conference process was explained to the Licensee and Administrator. Additionally, they were also informed that this Informal Conference is part of the administrative action process and that further non-compliance and/or citations would result in requiring the attendance at a Non-Compliance Conference meeting. Bewise Home was licensed on 02/29/2019. From the date the facility was licensed to present (07/28/203), the Regional Office (RO) received four (4)complaints. Two (2) out of four (4) complaints have been found Substantiated. During today’s conference, the following matters were discussed: · Incidental Medical and Dental Care.: a. Section: 87465(a)(1) b. Date: 07/05/23 · Reporting Requirements: a. Section: 87211(a)(D) b. Date: 07/05/23 Although, prior history of the citations and plan of corrections were discussed/received, the Licensee was asked what steps will be taken to prevent this from happening again. Licensee/Administrator provided detailed information to the Department. LPM concluded today's Informal Meeting by requesting a copy of his Administrator Certificate.the state’s words, verbatim · CDSS document, Jul 25, 2023

Allegation investigated: Staff did not prevent resident from wandering from facility Staff did not notify authorities that resident was missing

Licensing Program Analysts (LPAs) Angela Panushkina and Michael Cava conducted the 10 day investigation visit to the facility regarding the above allegations. Upon arrival LPAs met with Staff #1 who granted access to the facility. Administrator arrived shortly after, and LPAs explained the reason for the visit. During course of the investigation, interviews and record review were made. LPAs requested staff and residents roster. At approximately 11:20am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected. At 11:30am, LPAs requested copies of pertinent information which include, but not limited to R1's History and Physical reports, Hospital Discharge, etc., relevant to the investigation. Between 12:00pm – 1:00pm, LPAs interviewed the Administrator, one (1) staff and attempted to conduct an interview with three (3) residents. Continue on LIC9099-C Substantiated Allegation: Staff did not prevent resident from wandering from facility During the course of this investigation, LPAs interviewed the Administrator, S1 and reviewed R1's file and obtained relevant documentation pertaining to this allegation. Interview with the Administrator and S1 revealed R1 moved to this facility in November 2022. Interviews with staff revealed that R1 could not leave the facility unassisted due to head trauma. LPAs were also informed that R1 did not have a history nor showed signs of wondering out. Moreover, interviews with the Administrator and S1 confirmed that on 06/25/23 around 12:30pm, R1 went missing. Staff did not realize R1 was missing until 1:00pm. Once staff realized R1 was not at the facility, staff conducted a search within this facility to locate R1. The search was unsuccessful as R1 was nowhere within this facility. In addition, LPAs were informed that an incident report was submitted to LA County at 11:30pm, and on 06/26/23, the Administrator contacted the Police Department to file a Missing Person's Report. Lastly, LPAs were informed that on 06/28/23 at 11:45am, S1 observed R1 walking across the street from the facility. S1 immediately assisted R1 back to the facility. Although, R1 refused to go to an Emergency Room, 911 was requested by the Administrator and R1 was taken to the hospital and released on a following morning (06/29/23). Based on information obtained from records review and interviews, the above allegation is deemed Substantiated. Allegation: Staff did not notify authorities that resident was missing It was reported that on 06/25/23, R1 went missing from the facility and did not return until 06/28/23. Although, interview with the Administrator revealed that the LA County and the Police Department were immediately notified regarding R1's elopement, LPA reviewed Incident Reports submitted to the Regional Office and did not observe a copy of R1's incident on file. Based on interviews and record reviews, the above allegation is deemed Substantiated. Deficiencies documented on 9099D. Exit interview conducted, appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jul 5, 2023 · control 31-AS-20230629095937

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 12, 2023

Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to... This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above. Administrator admitted that R1 can't leave the facility unassisted, but on 06/25/23 R1 went missing which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Licensee/Administrator agreed to provide in-service training to all staff to address this section of the Regulation. Copy of training will be submitted to LPA

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(D) · Plan of correction due date: Jul 12, 2023

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (D) Any incident which threatens the welfare.. This requirement was not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above. by not submitting R1's incident report to the Regional Office, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: During the visit the Administrator provided the LPA with a copy on Incident Report that was emailed to the County on 06/29/23. No further correction is needed.

Allegation investigated: Resident suffered a stroke due to staff not administering residents medication Staff caused injury to resident Staff handled resident in a rough manner

At 2:30 p.m. on 11/01/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted a subsequent, unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. The case was referred to the Investigations Branch (IB) on 09/07/2022 and was returned to the Woodland Hills South Regional Office for a full investigation. LPA conducted an initial visit on 09/08/2022 and interviewed residents and staff from 10:20 a.m. to 12:45 p.m. LPA interviewed the case manager of resident #1 (R1) on 09/13/2022 at 4:00 p.m. LPA conducted record reviews on 09/08/2022 at 10:45 a.m. and on 10/03/2022 at 2:00 p.m. Resident suffered a stroke due to staff not administering resident’s medication Regarding the allegation above, it was alleged the facility did not administer medication to Resident #1 (R1) which caused their stroke. From interviews, R1 claimed the facility stopped providing medication, and the resulting stress led to their stroke. Unsubstantiated R1 did not remember when or where the stroke occurred. R1’s case manager noted R1 has a history of making false or exaggerated statements. No other residents reported issues with missed medications. Staff #1 (S1) stated R1 would leave the facility for days at a time without explanation. R1 would return drunk or high on drugs. S1 provided medication when R1 was present. Regarding the stroke, S1 recalled the occasion. On the morning of 06/10/2022 at approximately 6:00 a.m. S1 saw R1 sitting outside smoking a cigarette. R1 became rigid and their eyes had rolled back into their head. S1 called an ambulance for R1. Medical records from the hospital showed PCP present in R1’s urine and noted R1 had an ischemic stroke. Record review also showed R1’s history of substance abuse and multiple, consecutive days of missed medication. Based on interview and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Staff caused injury to resident Regarding the allegation above, it was alleged S1 pushed R1 and caused bruising. From interviews, R1’s case manager revealed R1’s tendencies to make claims of physical abuse without any bruising or evidence. S1 denied ever physically abusing any residents, and all residents confirmed. From record review, two police reports were made on 07/14/2022 at 12:20 p.m. and 07/22/2022 at 11:10 a.m. The first report noted “No evidence of elder abuse” and “PR not happy at loc & requesting relocation w/ case worker”. The second report noted “No signs of evidence”. Based on interview and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Staff handled resident in a rough manner Regarding the allegation above, it was alleged S1 put their fingers in R1’s face. From interviews, S1 claimed they never put their fingers around R1’s face. Residents denied being handled roughly by staff. R1’s case manager noted R1’s tendency to make exaggerated claims. Based on interview, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Exit interview conducted. Copy of report and appeal rights issued.the state’s words, verbatim · CDSS document, Nov 1, 2022 · control 31-AS-20220907093630

Allegation investigated: Staff are not providing adequate food service to resident Staff inappropriately put crushed medication in residents food Staff did not treat resident with respect Staff did not meet residents laundry needs Facility patio is dirty

At 10:00 a.m. on 09/08/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility and no immediate health and safety concerns were observed. The case was referred to the Investigations Branch (IB) on 08/18/2022 and was returned to the Woodland Hills-South Regional Office for a full investigation. At 10:20 a.m. LPA interviewed Staff #1 (S1). At 10:45 a.m. LPA conducted a record review. From 11:15 a.m. to 12:45 p.m. LPA interviewed 5 out of 5 residents. Staff are not providing adequate food service to resident Regarding the allegation above, it was alleged Resident #1 (R1) did not receive adequate portions of food. From interviews, S1 stated that when a new resident arrives, S1 asks how much food they like. S1 stated extra portions are always available, but R1 often threw away their food after eating a small amount. Resident #2 (R2) joked that they were getting “too much food” and portion size was not an issue. Other residents had no issue with portion sizes. Unsubstantiated Based on interviews although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Staff inappropriately put crushed medication in residents food Regarding the allegation above, it was alleged S1 crushed medication in R1’s food. From interviews, S1 stated that all of R1’s medications were capsules, so there was no way the medication could have been crushed. Residents reported they have never seen or tasted medication in their food. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Staff did not treat resident with respect Regarding the allegation above, it was alleged S1 was rude to R1 and blamed R1 for smearing feces in the bathroom and smoking after hours. From interviews, S1 asked R1 and Resident #3 (R3) who smeared feces in the bathroom. R1 began yelling and shouting obscenities at S1. S1 referenced similar events in which R1 called S1 names, threw laundry on the floor, told S1 to pick up the clothes, and filmed R1 without their permission. R2 and R4 reported they are glad R1 left as R1 was rude to S1 and to them. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Staff did not meet residents’ laundry needs Regarding the allegation above, it was alleged S1 only washed R1’s clothes twice during their 3 weeks stay. From record review, R1 was independent and did not need assistance with daily activities such as grooming and washing clothes. From interview, S1 instructed residents to put laundry in the washing machine and S1 cleans the clothes. S1 stated R1 would throw their clothes on the ground and demand S1 pick them up and wash them. Residents reported no issues with laundry services. Based on interviews and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Facility patio is dirty Regarding the allegation above, it was alleged the outdoor patio was dirty. LPA observed the patio during the physical plant tour and observed a clean table and seating arrangements. From interviews, S1 stated they clean the patio often as residents smoke outside every day. R2 reported staff cleaned the patio area when family came to visit. Other residents reported the patio area and furniture were clean to their liking. Based on interview and observations, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Exit interview conducted. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 8, 2022 · control 31-AS-20220907093630

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident is being physically abused while in care.

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit. It is alleged that resident #1 (R1) was physically abused by staff # 1 (S1). LPA conducted the initial visit on 7/26/22 where LPA interviewed S1 regarding the allegation. During today's visit LPA conducted interviews with residents from 12:10-12:35pm. LPA interviewed R1's case manager from Brilliant Corners over the telephone from 1:10-1:30pm. LPA previously interviewed R1 over the phone. Information from residents reveal that no one witnessed S1 hit or do anything to R1. Information from S1's social worker and hospital personnel reveal that R1 has a history of fabricating stories of abuse due to R1's diagnosis. It is said R1 will say they have have had their head bashed in and will call 911 and when R1 gets to the hospital at gets checked out there are no signs of abuse shown or R1 will recant their story. Based on the information obtained through interviews with residents, staff, and R1's social worker this allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2022 · control 31-AS-20220725110906

Allegation investigated: Wrongful eviction Facility abandoned resident

***THIS REPORT HAS BEEN AMENDED TO CORRECT TYPOGRAPHICAL ERRORS*** At approximately 9:18 AM on 01/19/22, Licensing Program Analyst (LPA) Nicholas Reed arrived for an unannounced complaint investigation for Complaint Control Number 31-AS-20220112171708. LPA met with staff and later Licensee and disclosed the reason for the visit. LPA conducted a physical plant tour at approximately 9:40 AM. LPA obtained and reviewed facility documents at 10:04 AM. LPA interviewed staff at approximately 10:10 AM and approximately 1:00 PM. Regarding the allegation “wrongful eviction”, it was alleged the facility wrongfully evicted Resident R1 without written notice. LPA interviewed staff and reviewed records on 01/19/2022 from 10:04 AM to approximately 1:00 PM. LPA discovered Licensee did not provide written notice to resident prior to eviction, and this posed a potential health and safety risk to the resident in care. Based on information obtained from records review and interviews, the above allegation is deemed substantiated. Exit interview conducted, appeal rights discussed, and a copy of report issued. Substantiated Regarding the allegation “Facility abandoned resident”, it was alleged the facility left resident at the hospital on 01/12/2022 without supervision. LPA interviewed staff and reviewed records on 01/19/2022 from 10:04 AM to approximately 1:00PM. LPA discovered Licensee instructed staff to leave resident at hospital due to nonpayment which posed an immediate health and safety risk to the resident in care. Based on information obtained from records review and interviews, the above allegation is deemed substantiated. Exit interview conducted, appeal rights discussed, and a copy of report issued.the state’s words, verbatim · CDSS document, Jan 19, 2022 · control 31-AS-20220112171708

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 19, 2022

87464 Basic Services (f) 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 information obtained through records review and interviews, LPA determined Licensee abandoned resident at the hospital and did not provide care and supervision. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jan 19, 2022

Plan of correction: Licensee returned resident to facility where staff provide care and supervision.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(1) · Plan of correction due date: Feb 18, 2022

87224 Eviction Procedures (a) The licensee may evict a resident... Thirty (30) days written notice to the resident is required ... (1) Nonpayment of the rate for basic services within ten days of the due date. This requirement is not met as evidenced by: Based on information obtained through records review and interviews, LPA determined Licensee failed to provide written notice prior to eviction. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jan 19, 2022

Plan of correction: Licensee will issue a 30 day eviction to resident and LPA.

Type of visit: Required - 1 Year

At approximately 9:18 AM on 01/19/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit using the Infection Control Domain. LPA met with staff and disclosed the reason for the visit. Census: 3 Entry: Upon entry, LPA met with staff and heard an auditory alarm when the front door opened. LPA did not observe signs regarding the facility’s visitation policy posted on the front door. Staff told LPA of a recent Technical Assistance Visit from Public Health in which staff were told there was no longer a need for the signs. LPA recommended the signs be replaced at the front entry. Screening: Staff took LPA’s temperature and requested documentation in the visitor log. LPA observed a visitor log with names, temperatures, and times of visits. LPA recommended staff also screen all visitors for symptoms of COVID-19 and document. Staff adjusted the visitor log to include symptom checks Staff noted all visitors show proof of vaccination and proof of a recent, negative COVID test. Common Areas: LPA observed common areas to be clean and tidy. Floors were clean and furniture was in good repair. Signs related to COVID-19 precautions, such as Cough Etiquette, Signs and Symptoms, Handwashing Instructions, Cleaning Procedures, and Droplet Precautions, were present throughout. Kitchen: LPA observed cleaning supplies locked in a cabinet below the kitchen sink. LPA recommended all sinks have Handwashing Instructions signs posted nearby, and staff made the adjustment immediately. Staff noted residents stagger meal times or eat in a socially distanced fashion. Laundry: LPA observed two laundry machines near staff rooms by the eastern side of the facility. Staff sanitize the machines between loads using bleach and sanitizing wipes. Bedrooms: The facility has 5 bedrooms in total. 3 bedrooms are designated for residents and 2 bedrooms are for staff. Bedroom #1 is occupied and private, Bedroom #2 is vacant and private, and Bedroom #3 is occupied and shared. All bedrooms were clean and orderly. Bedroom #2 was locked and contained a sharps disposal bucket. Bedroom #3 had beds which were at least 6 feet apart. Bathrooms: LPA observed 2 bathrooms. One is adjacent to Bedroom #3 and contained fully stocked soap, toilet paper, and a shower with a seat and a non-skid mat. Since the bathroom is used by one resident, there is a personal use towel for drying hands. The bathroom for staff and other residents contained liquid soap, a shower with a non-skid mat, and a trash can with no lid. LPA recommended the facility acquire a trash can with a tight-fitting lid for infection control purposes. Isolation: LPA spoke with staff about infection control practices in case of a COVID positive resident. Staff noted they would isolate in the facility with residents due to their live-in status. All meals and medication could be provided to residents in care. Staff have been trained on PPE donning an doffing. The vacant bedroom could be used for isolation purposes. LPA conducted exit interview and issued a copy of report.the state’s words, verbatim · CDSS document, Jan 19, 2022