Land of Peace 2

Type of visit: Required - 1 Year

At 10:00 a.m. on 11/07/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out at 10:15 a.m. No immediate health or safety hazards were noted at the time of the visit. The facility was last visited on 05/03/2022 for an annual inspection. It is a single story building with 7 bedrooms, 5 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory and 1 bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for 6. At the main entrance, LPA observed postings for confidential complaint contacts, Ombudsman contact information, resident rights, resident councils, neighborhood policy, house rules, facility sketch with evacuation routes clearly labelled, emergency disaster plan, admission agreement, administrator certificate, and the facility license. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. The interior was recently painted. Two (02) residents were observed watching television in the living room. A piano, reading material, and activities were available in the living room as well. Sufficient amounts of fresh linens and hygiene supplies were stored in the hallway cabinets. The facility has 7 bedrooms. 1 bedroom is designated for staff. The staff room was locked and free from hazards. All 6 resident bedrooms are private. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #6 had a resident using oxygen. Appropriate signage was posted on the bedroom door and at the exterior of the facility. The facility has 5 bathrooms. 4 bathrooms were private and 1 was a shared bathroom. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet, commode, and shower, and a non-skid mat in the shower. At approximately 10:45 a.m. LPA measured the water temperature in the shared bathroom to be 115.7 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food in refrigerators in the kitchen and the garage. The stove hood clean was free from debris. Appliances were in good condition. Sharps were locked in a drawer below the counter. Medications were locked above the counter. LPA observed a washing machine and a dryer in good condition in the laundry area. Detergents were locked near the appliances. The administrator stated the dryer was serviced yesterday, 11/06/2023. LPA observed a resident sitting in a covered patio area with furniture in good condition. A ramp led out to the street. It was free of hazards and had secure handrails. A gardening area was available in the rear of the facility. A gas grill was also present. All emergency exit paths were free from obstructions. The exit gate was unlocked. All auditory alarms were on and functioning. At approximately 11:00 a.m., the dual-purpose smoke and carbon monoxide detector were tested and operational. When tested, three (03) out of three (03) detectors were heard and the fire door in the living room released from its magnetic suspension. At approximately 12:30 p.m. a fully charged fire extinguisher was observed in the laundry area. A receipt from 05/03/2022 was attached. The facility vehicle was parked in the driveway. Seat belts, windows, and ignition were operational and in good condition. LPA observed cleaning supplies stored in the locked garage. Perishable and non-perishable food were stored separately. LPA conducted resident and staff interviews between 11:30 a.m. and 12:15 p.m., a medication review with staff at 12:30 p.m., and reviewed staff and resident files at 3:30 p.m. During today's inspection, the facility is in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 7, 2023

Allegation investigated: Residents in care sustained multiple pressure injuries

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to deliver the findings for the above allegation. LPA met with Administrator Sona Muradyan and explained the reason for the visit. On 11/15/21 a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigations Branch (IB) but did not meet the criteria for full investigation. On 11/15/21 at 1:00 PM, then LPA Jackson initiated the complaint visit. LPA conducted physical plant tour, interviewed staff and residents and obtained copies of the facility records relevant to the investigation. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that residents in care sustained multiple pressure injuries, it was alleged that Residents #1 and #2 (R1 and R2) had multiple bed sores with broken skin on their bottoms. LPA’s record review on 10/29/22 at 11:00 AM revealed that R1 was admitted at the facility on 07/29/2020 and was on hospice care since 12/30/2020. Further review also revealed that R1 had no pressure wound during the time in question (11/10/21) but has a traumatic wound on right forearm that the hospice agency was taking care of. LPA’s record review also revealed that R2 was admitted at the facility on 01/29/21 and had stage three (3) pressure sores that were being taken care of by the home health agency wound care nurse since R1 was admitted at the facility. Further review also revealed that the home health agency nurse/staff was visiting R1 seven (7) days a week and cleaned R1’s wound three (3) to four (4) times a day. LPA’s interview with staff on 10/29/22 between 10:30 AM to 1:00 PM revealed that residents who were incontinent were being checked regularly. An interview with three (3) aware residents confirmed that staff checked them and change their diapers regularly. Based on the information gathered during the course of the investigation, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 31-AS-20211115151602

Allegation investigated: Staff did not meet the incontinence needs of resident(s) in care.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPA met with administrator Sona Muradyan and explained the reason for the visit. LPA conducted physical plant tour at 9:22 AM, requested copies of facility documents at 10:00 AM and interviewed residents and staff between 10:30 AM to 1:00 PM. Regarding the allegation that staff did not meet the incontinence needs of resident(s) in care. It was alleged that on the morning of 11/10/21, two (2) of the residents were "covered with urine and feces from head to toe". LPA's record review today at around 1:00 PM revealed that the staff are changing the diapers of incontinent residents regularly and as needed. LPA's interview with staff today at 11:00 AM today also revealed that during the period in question, staff did not witness any resident being soiled at anytime the staff was on duty at the facility. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with the administrators between 10:30 AM to 11:00 AM also revealed that they did not receive any report of any resident being soiled especially during the time period in question. LPA's interview with three (3) aware residents between 10:30 AM to 1:00 PM revealed that the staff regularly changed their diapers and as needed. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Oct 29, 2022 · control 31-AS-20211115151602

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.

Type of visit: Required - 1 Year

At 1:45 p.m. on 05/03/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. The facility was last visited on 04/21/2022 for a Case Management visit. It is a single story building with 7 bedrooms, 5 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory and 1 bedridden in Bedroom #6. The facility serves residents with dementia. Approved hospice waivers for 6. Entry: At the main entrance hung a sign stating “No Smoking – Oxygen in use”. Once inside, LPA observed postings for confidential complaints, Ombudsman contact information, resident rights, resident councils, neighborhood policy, administrator certificate, and the facility license. Screening: LPA was screened for infectious disease upon entry. The screening station contained digital thermometer, hand sanitizer, and visitor log. LPA suggested adding two columns to track visitor symptoms and proof of vaccination. Bedrooms: The facility has 7 bedrooms. 1 bedroom is designated for staff. It was locked and free from hazards. All 6 resident bedrooms are private. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Bathrooms: The facility has 5 bathrooms. 4 bathrooms were private and 1 was a shared bathroom. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 3:28 p.m. LPA measured the water temperature in the shared bathroom to be 105.7 degrees Fahrenheit. Kitchen: LPA observed an adequate supply of perishable and non-perishable food in refrigerators in the garage. The stove hood clean was free from debris. Appliances were in good condition. Sharps were locked in a drawer. Medications were locked above the counter. Laundry: LPA observed a washing machine and a dryer in good condition. Detergents were locked near the appliances. Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 2:30 p.m. LPA measured the room temperature to be 78.8 degrees Fahrenheit. Safety: All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. Emergency Disaster Plan was posted at the front. Evacuation routes were posted throughout. Auditory alarms were turned on and functioning. At approximately 2:15, smoke and carbon monoxide detectors were tested and operational. At approximately 2:30 p.m. LPA observed a fully charged fire extinguisher in the laundry area. A receipt from 05/13/2021 was attached. Outdoor areas: LPA observed a covered patio area with furniture in good condition. A ramp led out to the street. It was free of hazards and had secure handrails. Vehicle: The facility vehicel was parked in the driveway. It was operational and in good condition. Garage: LPA observed cleaning supplies stored in the locked garage. Non-perishable food was stored separately. During today's inspection, the facility is in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 3, 2022

Type of visit: Case Management - Incident

At approximately 10:15 a.m. on 04/21/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later Administrator and disclosed the reason for the visit. On 04/18/2022, the facility submitted an incident report regarding Resident #1 (R1). It was reported that at 2:55 a.m. on 04/17/2022, West Hills Hospital notified the facility that R1 was seen unsupervised outside of the facility. R1 was held at the hospital for observation until 04/18. At the time of the incident, facility staff was tending to other residents and did not any hear auditory devices. A power outage occurred on 04/15/22 which may have caused the alarms to malfunction. At 10:25 a.m. staff and LPA tested auditory devices. LPA heard 5 out of 5 auditory alarms on and functioning at the front door, laundry room, family room, hall door, and Bedroom 7 door where R1 stayed. Staff held a conversation with R1. R1 was safe and in good health. At approximately 10:35 a.m. Administrator confirmed that the facility currently serves residents with Dementia. Administrator also attributed the AWOL to the power outage on 04/15. During today's inspection, the facility is in compliance with Title 22 regulations. Deficiency issued for auditory devices turned off on 04/17 on the attached LIC 809-D page. Exit interview conducted. Copy of report provided. Appeal rights provided. Citation issued.the state’s words, verbatim · CDSS document, Apr 21, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(j) · Plan of correction due date: May 20, 2022

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not ensure 1 out of 5 auditory devices was functioning properly on 04/17/2022 which poses a potential Health, Safety, and Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: 5 out of 5 auditory devices were detected on and functioning during visit. Licensee will check auditory devices after power outages in the future. Licensee will submit a 5 day log checking device functionality to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pitz conducted an unannounced infection control visit on this day. LPA was greeted upon entry and screened for COVID-19 symptoms. LPA toured the facility with administrator Sona Muradyan and confirmed that they do have an approved mitigation plan on file. LPA utilized the infection control domain of the RCFE inspection tool to verify that the facility was in compliance with various aspects of the mitigation plan, including but not limited to: screening visitors, having ample handwashing/ sanitizing supplies on site, having adequate PPE on site, having signs posted throughout the facility to remind residents and staff of various Covid precautions. LPA did not note any concerns at the time of visit. Report reviewed, signed and delivered. Exit interview conducted, no deficiencies cited.the state’s words, verbatim · CDSS document, Jun 30, 2021