Villa Catherine Senior Care Facility

Allegation investigated: Staff transfer resident in a rough manner resulting in bruising. Staff yell at resident. Staff make inappropriate comments towards resident.

Licensing Program Analyst(LPA) Sandra Urena conducted an initial unannounced visit to investigate the allegations above. The LPA arrived at 10:00a.m., and was greeted by staff. The staff contacted the Administrator via phone, and the LPA explained the reason for the visit. Administrator arrived at 10:44 a.m. At 10:10 a.m. the LPA conducted a brief tour of the physical plant. From 10:15 a.m. to 10:25 a.m. LPA Urena interviewed residents, and from 10:45 a.m. to 11:30 a.m., the LPA interviewed the Administrator. Continues on LIC 9099C... Unsubstantiated Staff transfer residents in a rough manner resulting in bruising. On the allegation that ‘Staff transfer residents in a rough manner resulting in bruising’; it is the complainant’s concern that the staff transfers the residents very aggressively, and move them in any type of way they can to get them transferred. To investigate the complaint, LPA attempted to interview the residents, and two(2) out of five(5) residents revealed that they are ‘ok’, however their expressive language was limited, and could not provide full sentence answers. Three (3)residents were unable to answer questions due to their conditions. The LPA interviewed the Administrator, and they stated that they are not aware of the staff being aggressive with residents, while being transferred or at any time of the day. On 03/21/2023, the LPA interviewed R1’s responsible party (RP) who stated that while R1 was at the hospital, R1 had multiple IVs, which R1 attempted to remove forcefully. R1 has been prescribed blood thinners since they left the hospital. RP stated that R1 returned to the facility, and the bruises on R1’s arm may have been a result of the IVs, and R1 attempting to remove them. RP was made aware of the bruises on R1’s chin by the administrator, and was brought to the attention of the hospital staff by the administrator. While interviewing residents, the LPA conducted a visual inspection of residents, and all appeared to be ok, no bruising was noted on their exposed skin. Based on the information obtained through observation and interviews, there is not sufficient evidence to support the allegation that Staff transfer residents in a rough manner resulting in bruising Therefore, the allegation is deemed Unsubstantiated at this time. Staff yell at residents On the allegation that ‘Staff yell at resident’; it is the complainant’s concern that the staff’s tone of voice was condescending, rather than encouraging towards the resident, and yelling to the resident#1(R1), when giving instructions to R1. To investigate the complaint, LPA Urena interviewed two out of five residents. The interviews revealed that they are ‘ok’ Additionally, the LPA interviewed the Administrator and responsible parties(RP). The Administrator stated that the staff (due to their ethnicity) tend to be dry in their expressive language, and tend to use a higher tone of voice, which may appear to visitors that they are yelling. Additionally, because the residents are hard of hearing, the staff may raise their tone of voice. Administrator stated that they are not aware of staff yelling at residents. The LPA interviewed R1’s responsible party, and the RP stated that since R1 has been at the facility, they have observed facility staff to be kind, sweet, and loving towards R1. R1 seems to be happy and smiling since they have been at facility. Continues on LIC 9099C... Although the allegation may have happened, based on the information obtained through observation and interviews, there is not sufficient evidence to support the allegation that staff yells at residents. Therefore, the allegation is deemed Unsubstantiated at this time. Staff make inappropriate comments towards resident. On the allegation that ‘Staff make inappropriate comments towards resident’; it is the complainant’s concern that the staff are making inappropriate comments about R1’s appearance. To investigate the complaint, LPA Urena interviewed residents. However, the residents were unable to answer the questions asked by the LPA due to their conditions. The LPA interviewed the Administrator about staff making inappropriate comments, and the administrator stated that they have never witness staff make inappropriate comments, they continuously work with staff, and train them on how to work with the residents. The LPA interviewed the residents’ responsible parties(RP), and the interview revealed that staff appear to be patient, and kind to the residents. Although the allegation may have happened, based on the information obtained through observation and interviews, there is not sufficient evidence to support the allegation that staff make inappropriate comments towards resident. Therefore, the allegation is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted via phone with the Administrator. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 22, 2023 · control 29-AS-20230316141904

Allegation investigated: Resident sustained an injury while in care.

On 01/31/2023, Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced initial10-day visit to investigate the allegation listed above. The LPA arrived at the facility at 11:08 a.m. and was greeted by staff. Staff contacted the Administrator via telephone. Administrator stated they were on their way to the facility.The LPA met with the Administrator Ruzanna Sukiassyan, at 11:20 a.m. and explained the reason for the visit. At 11:25 a.m. the LPA and the Administrator conducted a brief tour of the physical plant. The LPA interviewed the Administrator from 11:30 a.m. to 12:02 p.m., and conducted records review at 12:05 p.m. Continues on LIC 9099 C... Unsubstantiated On the allegation that ‘The resident sustained an injury while in care’, the complainant’s concern is that the resident (R1) sustained a left heel eschar while residing at the board and care. The R1 was admitted to the hospital due to weakness, and was still in the hospital when the LPA conducted the visit to the facility. The LPA interviewed the complainant on 01/30/2023 from 3:31 p.m. to 3:52 p.m. Per the complainant, R1 presented an eschar on the left heel, and discoloration on the lower part of the legs, consequently the reason for the allegation. The complainant stated that after the allegation was submitted to Community Care Licensing Division(CCLD), they communicated with R1’s primary physician, who also practices out of the hospital where R1 is currently admitted. Per the physician’s statement, the discoloration on the lower part of the legs, and the eschar is due to R1’s poor blood flow to the legs. Furthermore, the complainant stated that the physician reported that even if R1 is repositioned every two hours, the discoloration will not go away, due to the fragile skin condition, and poor blood flow to the legs. The complainant added that although R1 has sacral redness, the redness is on the top layer of the skin, skin is not broken, and it is not a pressure wound. The complainant stated that R1 is doing well, ‘looks great’, and no further concerns were noted. LPA Urena interviewed the Administrator on 01/31/2023 at 11:30 a.m. The administrator stated that on 01/26/2023, staff noticed a change in R1’s demeanor; weak and not eating as usual. Consequently, the administrator contacted R1’s primary physician to inform them of the changes noticed by facility staff, and doctor recommended taking R1 to the hospital. R1 was taken to the hospital by facility staff due to R1 not feeling o.k., and experiencing weakness. The LPA conduced record review, and the record review revealed that the staff keeps progress notes on residents. Progress notes for R1 revealed that staff indicated the date that R1 was noted to have a change in condition, taken to hospital, and that staff communicated with R1’s primary physician. R1 was receiving home health services at facility up to 01/16/2023. Based on the information provided by a credible witness, and record review, the resident did not sustain an injury while in care. Therefore, this allegation is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted with the Administrator. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 31, 2023 · control 29-AS-20230130101515

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection visit at 10:00 a.m. This annual visit had an emphasis on infection control practices and procedures. The LPA spoke with the caregiver at arrival and introduced herself. Caregiver called the licensee representative via cell phone. The representative stated that they would arrive at the facility in 15 minutes. Representative , Ruzanna Sukiassyan arrived at the facility at 10:50 a.m. LPA Urena introduced herself, and explained the reason for the visit. The LPA, and the licensee representative toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition. The LPA observed a fire extinguisher in the kitchen area to be fully charged, and operational. The LPA observed sharp objects and toxins to be locked away, and inaccessible from residents. BEDROOMS: The LPA observed three residents’ bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. Bedrooms #1, #2 and #3 were occupied. RESTROOMS: Residents’ restrooms are clean, and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap, and paper towels. Continues on LIC 809C… COMMON SPACES: The common areas, walls, flooring and furniture were checked for cleanliness and were in good condition. Required postings were observed in the entryway. Exits had a functioning auditory device. OUTDOOR AREA: The facility has a pool, which is gated, and inaccessible. The LPA observed the backyard to be free of clutter and debris, and observed outdoor patio/furniture for residents’ use. No bodies of water were observed. The front outdoor area has a water fountain, and at the time of the visit, the water fountain did not have water flowing. INFECTION CONTROL: There is a central entry point for screening, and temperature checks. Signs were posted that promoted good hand hygiene, physical distancing, and cough/sneeze etiquette. The facility’s cleaning protocol is sufficient. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation, and vaccine requirements. The policies and procedures pertaining to infection control were adequate. LPA Urena discussed with the licensee representative the importance of infection control at the point of entrance, as well documentation of temperature checks for all staff, residents, and visitors. No deficiencies cited. Exit interview was conducted. The report was reviewed with the licensee representative, and signatures were obtained. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Nov 29, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 10:23 a.m. This annual visit had an emphasis on infection control practices and procedures. The LPA spoke with the caregiver at arrival and introduce herself. Caregiver called the administrator via cell phone. The administrator stated that she would arrive at the facility in 15 minutes. Administrator, Viktorya Hayrapateyan arrived at the facility at 10:50 a.m. LPA Urena introduced herself, and explained the reason for the visit. The LPA, and administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition. The LPA observed a fire extinguisher in the kitchen area to be fully charged and operational. The LPA observed sharp objects and toxins to be locked away and inaccessible from residents. BEDROOMS: The LPA observed four residents’ bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. Bedrooms #1, #4 were occupied, and bedrooms #2, # 3 were empty. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap and paper towels. Continues on LIC 808C COMMON SPACES: In the common areas, walls, flooring and furniture were checked for cleanliness and were in good condition. Required postings were observed in the entryway. Exits had a functioning auditory device. OUTDOOR AREA: The facility has a pool, which is gated and inaccessible. The LPA observed the backyard to be free of clutter and debris, and observed outdoor patio/furniture for residents’ use. Record Review: At approximately 11:45 a. m. The LPA conducted resident and staff file review. The LPA also checked medication storage and medication was stored in a locked cabinet. LPA Urena observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. LPA discussed with administrator the importance of infection control at the point of entrance, as well documentation of temperature checks for all staff, residents, and visitors. No deficiencies cited. Exit interview was conducted. The report was reviewed with the administrator, and signatures were obtained. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Jan 14, 2022

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

Allegation investigated: Facility staff are financially abusing resident.

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit on this day to deliver the complaint investigation findings for the above listed allegation. At 9:00 a.m., the LPA met with Harut Manukyan , the facility caregiver. LPA spoke with Lusine over the phone and she stated Harut can sign in her place. On 02/22/2021, between 12:38pm and 2:00pm, LPA Balisi conducted an initial 10-day virtual visit, at which time, copies of pertinent documents from Resident 1’s (R1) facility file was requested; and, a virtual tour of the physical plant was conducted. Based on the nature of the allegation, the complaint was referred to Community Care Licensing Department’s Audit Division and General Auditor, Lisa Ni conducted the investigation. On 2/26/2021, Auditor Ni conducted interviews with Pacific Western Bank Rosemead Branch staff and family members of R1. Auditor Ni also obtained and reviewed R1’s facility documents, and Pacific Western Bank Rosemead Branch’s surveillance video footage from 2/9/2021 between 12:34:55pm to 13:12:27pm. (continued on 9099-C) Substantiated It was reported, that since 02/1/2021, checks were made out to “CASH” in R1’s name, in the amounts of $6,400, $6,000, $4,000 and $2,020. It was also reported that Staff 1 (S1), accompanied R1 to the bank and identified themselves as R1’s Power of Attorney (POA). Information gathered and reviewed during the course of the investigation revealed that in early February 2021, R1’s family members received a call from Pacific Western Bank Rosemead Branch informing R1’s family that there were several suspicious checks in R1’s name made out to cash and to other entities. There were (5) written checks totaling in the amount of $22,400: $4,000 made out to S1 $6,250 made out to cash $6,400 made out to cash $3,550 made out to Golden Century $2,200 made out to Silver Hospice Care Inc. The auditor’s interview with Pacific Western Bank Rosemead Branch banking staff revealed they had known R1 for about one year and that the signature on the checks were not consistent in comparison with R1’s signature depicted on the bank signature card. The banking staff stated when R1 was living by themselves, the monthly expense payments were usually utility bills and insurance. Payments were normally in the range of $50 to $100. The banking staff further revealed that on 2/1/2021, after multiple attempts to contact R1 and noticing multiple red flags, R1’s account was frozen to ensure no checks were cleared. It was further revealed that on 02/08/2021, the Pacific Western Bank Rosemead Branch received a phone call from someone pretending to be R1. The branch staff knew it was not R1 because of the different type of voice. The branch staff also knew R1 was having memory loss and/or mental illness. The individual who called in seemed to be very coherent. Later, the branch staff found out that this individual was a worker from the facility where R1 was residing. This individual wanted to find out why R1’s checks were being returned and if the bank could provide the process for adding a POA (Power of Attorney) to R1’s accounts. The branch staff did not give information to this individual because the branch staff knew this individual was not R1. On the same day, S1 called Pacific Western Bank Glendale Branch asking for the same information. The Glendale Branch did not give the information either and referred S1 to the Pacific Western Bank Rosemead Branch Continued on 9099-C On 02/09/2021, S1 brought R1 to the Pacific Western Bank Rosemead Branch. The branch manager spoke with R1 first, away from S1, to have a private conversation. R1 seemed to be very confused. R1 said they were in a car accident a week prior, and then R1 said they were in jail. R1 wanted the branch manager’s help to get them out. R1 was calling Villa Catherine Senior Care Facility a jail. R1 did not know who S1 was, and why they were at the branch. R1 was unable to verify all the checks that were returned by bank. After speaking with R1, the branch manager spoke with S1. S1 informed the branch manager that S1 was a long-time friend of the facility and just wanted to get paid for the care that R1 has been receiving. S1 provided the branch manager with R1’s hospital documents and documents showing that R1 was assigned to Villa Catherine Senior Care Facility. In addition, S1 informed the branch manager that S1 had a Power of Attorney (POA) over R1. The branch manager asked if S1 could provide a copy of the POA documents by email. S1 replied yes. S1 also informed the branch manager that R1 has a family member who was a witness to the power of attorney. However, up to current, S1 never sent the branch a copy of the alleged POA documents. The auditor’s review of the video surveillance on 2/9/2021, revealed an unknown individual and S1 brought R1 to the Pacific Western Bank Rosemead Branch bank. The branch staff had a private conversation with R1 first at 12:36:54pm. Then, the branch staff had another private conversation with S1 at around 13:12:27pm. During the course of the auditor’s investigation, R1’s monthly bank statement, Pacific Western Bank Rosemead Branch surveillance cameras, R1’s family members statement and the bank manager’s statement were received and reviewed. It was determined that the licensee’s relative/friend, S1, stole R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account. Due to the unusual checks that were written and the unfamiliar signature, which did not match with the bank records, the bank froze R1’s account immediately. The forged checks were not cleared and there was no financial loss in R1’s bank account. However, based on information obtained through the Auditor’s investigation, the allegation that Facility staff are financially abusing resident is deemed SUBSTANTIATED at this time. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit Interview conducted/ Citations issued/ Civil Penalties issued/ Appeal Rights Discussed / A Copy of Report Issued.the state’s words, verbatim · CDSS document, Aug 26, 2021 · control 29-AS-20210210152037

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Aug 27, 2021

Enumerated rights; severability(a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from neglect, financial exploitation... physical, or sexual abuse. This requirement is not met as evidenced by: Based on Auditing department’s interviews and record review licensee did not comply as licensee’s friend/relative stole R1’s checkbook, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account, which poses an immediate health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2021

Plan of correction: Licensee agreed to review enumerated rights and provide LPA a written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(3) · Plan of correction due date: Aug 31, 2021

87405(3) Administrator Qualifications and Duties – Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by: Based on Auditors interviews and record review, the licensee’s relative/ friend was able to access R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account, which potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2021

Plan of correction: Licensee agreed to review section cited and provide documentation of scheduled training for Administrator and staff. Licensee will send documentation via email by POC date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20210210152037). LPA met withvHarut Manukyan caregiver. LPA spoke with Lusine over the phone and she stated Harut can sign in her place. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. On 02/22/2021, between 12:38pm and 2:00pm, LPA Balisi conducted an initial 10-day virtual visit, at which time, copies of pertinent documents from Resident 1’s (R1) facility file was requested; and, a virtual tour of the physical plant was conducted. Based on the nature of the allegation, the complaint was referred to Community Care Licensing Department’s Audit Division and General Auditor, Lisa Ni conducted the investigation. On 2/26/2021, Auditor Ni conducted interviews with Pacific Western Bank Rosemead Branch staff and family members of R1. Auditor Ni also obtained and reviewed R1’s facility documents, and Pacific Western Bank Rosemead Branch’s surveillance video footage from 2/9/2021 between 12:34:55pm to 13:12:27pm. It was reported, that since 02/1/2021, checks were made out to “CASH” in R1’s name, in the amounts of $6,400, $6,000, $4,000 and $2,020. It was also reported that Staff 1 (S1), accompanied R1 to the bank and identified themselves as R1’s Power of Attorney (POA). Information gathered and reviewed during the course of the investigation revealed that in early February 2021, R1’s family members received a call from Pacific Western Bank Rosemead Branch informing R1’s family that there were several suspicious checks in R1’s name made out to cash and to other entities. There were (5) written checks totaling in the amount of $22,400: Continued on 809-C $4,000 made out to S1 $6,250 made out to cash $6,400 made out to cash $3,550 made out to Golden Century $2,200 made out to Silver Hospice Care Inc. The auditor’s interview with Pacific Western Bank Rosemead Branch banking staff revealed they had known R1 for about one year and that the signature on the checks were not consistent in comparison with R1’s signature depicted on the bank signature card. The banking staff stated when R1 was living by themselves, the monthly expense payments were usually utility bills and insurance. Payments were normally in the range of $50 to $100. The banking staff further revealed that on 2/1/2021, after multiple attempts to contact R1 and noticing multiple red flags, R1’s account was frozen to ensure no checks were cleared. It was further revealed that on 02/08/2021, the Pacific Western Bank Rosemead Branch received a phone call from someone pretending to be R1. The branch staff knew it was not R1 because of the different type of voice. The branch staff also knew R1 was having memory loss and/or mental illness. The individual who called in seemed to be very coherent. Later, the branch staff found out that this individual was a worker from the facility where R1 was residing. This individual wanted to find out why R1’s checks were being returned and if the bank could provide the process for adding a POA (Power of Attorney) to R1’s accounts. The branch staff did not give information to this individual because the branch staff knew this individual was not R1. On the same day, S1 called Pacific Western Bank Glendale Branch asking for the same information. The Glendale Branch did not give the information either and referred S1 to the Pacific Western Bank Rosemead Branch. On 02/09/2021, S1 brought R1 to the Pacific Western Bank Rosemead Branch. The branch manager spoke with R1 first, away from S1, to have a private conversation. R1 seemed to be very confused. R1 said they were in a car accident a week prior, and then R1 said they were in jail. R1 wanted the branch manager’s help to get them out. R1 was calling Villa Catherine Senior Care Facility a jail. R1 did not know who S1 was, and why they were at the branch. R1 was unable to verify all the checks that were returned by bank. After speaking with R1, the branch manager spoke with S1. S1 informed the branch manager that S1 was a long-time friend of the facility and just wanted to get paid for the care that R1 has been receiving. S1 provided the branch manager with R1’s hospital documents and documents showing that R1 was assigned to Villa Catherine Senior Care Facility. In addition, S1 informed the branch manager that S1 had a Power of Attorney (POA) over R1. The branch manager asked if S1 could provide a copy of the POA documents by email. S1 replied yes. S1 also informed the branch manager that R1 has a family member who was a witness to the power of attorney. However, up to current, S1 never sent the branch a copy of the alleged POA documents. The auditor’s review of the video surveillance on 2/9/2021, revealed an unknown individual and S1 brought R1 to the Pacific Western Bank Rosemead Branch bank. The branch staff had a private conversation with R1 first at 12:36:54pm. Then, the branch staff had another private conversation with S1 at around 13:12:27pm. During the course of the auditor’s investigation, R1’s monthly bank statement, Pacific Western Bank Rosemead Branch surveillance cameras, R1’s family members statement and the bank manager’s statement were received and reviewed. It was determined that the licensee’s relative/friend, S1, stole R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account. Due to the unusual checks that were written and the unfamiliar signature, which did not match with the bank records, the bank froze R1’s account immediately. The forged checks were not cleared and there was no financial loss in R1’s bank account. However, based on information obtained through the Auditor’s investigation, Pursuant to Title 22, California Code of Regulations, the following deficiencies will be cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report has been issued.the state’s words, verbatim · CDSS document, Aug 26, 2021

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87506(c)(1) · Plan of correction due date: Sep 3, 2021

87506 (c)(1) Resident Records - The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents...make available confidential information only upon the resident’s written consent or that of his designated representative. This requirement was not met as evidenced by: Based on Auditors, record review, the licensee did not ensure that resident financial records were kept confidential. This poses a potential risk to the personal rights and safety of R1.the state’s words, verbatim · CDSS document, Aug 26, 2021

Plan of correction: Licensee agreed to review 87506(c)(1) and provide LPA a written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC87468.1(14) · Plan of correction due date: Sep 3, 2021

87468.1(14) – Personal Rights of Resident - To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidenced by: Based on Auditor’s interviews, the licensee did not provide access to a telephone for R1. This poses a potential risk to the to the personal rights and safety of R1.the state’s words, verbatim · CDSS document, Aug 26, 2021

Plan of correction: Licensee agreed to review 87468.1(14) and provide LPA a written statement on how they will prevent a repeat violation. Licensee will send statement to LPA via email by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87405(3) · Plan of correction due date: Sep 3, 2021

87405(3) Administrator – Qualifications and Duties – Ability to maintain or supervise the maintenance of financial and other records. This requirement was not met as evidenced by: Based on Auditors interviews and record review, the licensee’s relative/ friend was able to access R1’s check book, forged R1’s signature, pretended to have POA over R1 and attempted to misappropriate the money from R1’s bank account, which potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2021

Plan of correction: Licensee agreed to review section cited and provide documentation of scheduled training for Administrator and staff. Licensee will send documentation by POC date.