The Cottages of Lake Balboa 3

Allegation investigated: Staff mishandled a resident's medication while in care Staff did not address a resident's change in condition while in care

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit. On 01/28/2022, from 9:37 a.m. - 2 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, conducted Medication Audit, interviewed staff, residents and obtained pertinent documentation relevant to the investigation. On 06/09/2023, LPA interviewed residents and staff while on site for a separate investigation. On 10/27/2023 LPA interviewed Kaiser Home Health Nurse. Today LPA interviewed staff, residents and conducted a medication audit for residents in care. It was reported that staff mishandled a resident’s medication while in care, as it was alleged that R1 did not receive their medication Metorolol as it was not observed in R1's 7 day pill case. Interviews conducted and records reviewed revealed that facility was using a 7 day pill case for R1's medication. Unsubstantiated Continued from 9099 LPA's medication audits revealed R1 did have a 7 day pill case stored with their medication , but it was observed to be empty at that time. The Medication Administration Records (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews revealed that staff did not recall specific occurrences where medication errors occurred. LPA's Interview with (4) four residents in care revealed they did not express any concerns as it related to receiving their medications. LPA's interview with seven (7) staff revealed they could not recall a time when a resident did not receive a medication due to error. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff mishandled a resident’s medication while in care has been deemed Unsubstantiated at this time. It was reported that Staff did not address a resident’s change in condition while in care, as it was alleged that facility staff did not report to R1’s home health nurse that R1 has not had a bowel movement for several days. Interviews conducted and records review revealed that R1’s home health nurse would visit R1 approximately twice a week and each time the home health nurse visited they were regularly notified about changes of condition in R1 by Staff #1 (S1) and Staff #2 (S2). Updates were also provided to the home health nurse via phone calls, emails and resident records kept at the facility. LPA records review of resident records from September 2021 to January 2022 revealed bowel movements were recorded and updated regularly during that time. Interviews conducted with seven (7) staff further revealed that if they observed a change of condition in any resident, they would notify the Administrator and notate their observations in the resident’s file. All (7) staff also indicated that when any home health nurse conducted visits, they would always update the nurse about their patient. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff did not address a resident’s change in condition while in case has been deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 29-AS-20220121164812

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220121164812). LPA met with Justin Levi and explained the reason for the visit. The purpose of this visit is to issue a citation for deficiencies observed during the complaint investigation which were not related to the complaint. During today's visit, LPA conducted physical plant at approx 11:25am and observed medications for six (6) residents in care were pre-pored and out of their original containers for more than 24 hours. LPA observed the rest of resident medications to be securely stored in the Assistant Administrators office. LPA conducted medication audit. The Medication Administration Record (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Nov 3, 2023

87465(h)(5) Incidental Medical and Dental Care - Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on observations and interview, LPA the licensee did not comply with the section cited above as (6) residents had medications pre-poured and out of their original containers for more than 24 hours which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding to CCL via email by EOD 11/03/2023.

Allegation investigated: Staff is not assisting the resident with managed incontinence.

**This report supersedes report issued on 06/19/2023** Licensing Program Analyst (LPA) Brian Balisi, conducted an unannounced subsequent complaint visit to issue amended findings for the above listed complaint allegation. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit. On 11/02/2021 between 9:52am - 5:05pm, LPA Kelly Dulek conducted the initial complaint investigation. During that visit, LPA conducted physical plant, interviewed two (2) residents and three (3) staff, as well as reviewed pertinent documents relevant to the investigation. On 06/09/2023 at approximately 12:30pm, LPA conducted physical plant, interviewed four (4) staff, three (3) residents and their responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/19/2023 LPA conducted physical plant and interviewed two (2) staff. Unsubstantiated Continued from 9099 It was reported that staff is not assisting Resident # 1 (R1) with managed incontinence, as it was alleged that staff did not change R1 in a timely manner. Interviews and records review revealed that there were at least two (2) occasions when R1 was not changed in a timely manner. The facility administrator was notified by R1’s home health that R1 was observed to have wet sheets on 02/17/2020 and 02/18/2020. Interviews reflected that there was an evening where R1 in November 2021, where R1 was left in a soiled diaper for an extended period of time. Interviews also reflected that R1 preferred only certain caregivers assist and refused services until those caregivers were available. Moreover, it was revealed that R1 had an agreement that the caregiver’s of R1’s preference would assist with R1’s incontinent needs at 10:30am. R1 preferred staff to finish assisting other residents and complete their morning routine prior to assisting R1 due to liked staff to take their time assisting R1 which would last approximately 30 minutes to one (1) hour. Interviews conducted with other residents reflected that they had no concerns with incontinent care needs and staff routinely assisted residents every two (2) hours, or as needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued. Continued from 9099 It was reported that staff is not able to meet the needs of R1, as it was alleged that there was not enough staff scheduled to assist R1 during the NOC shift. Interviews conducted and records reviewed reflected that during the time the complaint was received facility staffing was as follows: two (2) staff during the morning shift, two (2) staff during the afternoon/evening shift and one (1) staff during the NOC shift. Records further reflected that during the time of the complaint, R1 required assistance by two (2) caregivers. Therefore, based on information gathered there is sufficient evidence to determine that the facility did not have sufficient staffing to meet resident care needs during the NOC shift. Therefore, the above allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 29-AS-20211101125640

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 20, 2023

87411(a) Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... of adequate services. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the regulation cited above in that staffing was not sufficient in numbers to provide needed services to R1 who required 2 person assist which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2023

Plan of correction: Licensee has agreed review section cited and to write a Statement of Understanding and send to CCL via email by 10/20/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 12:30pm. Upon arrival LPA met with Administrator Justin Levi, and explained the reason for the visit. The LPA 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. The LPA began the inspection in the kitchen/food service area. LPA observed knives and sharp objects stored in a locked drawer to the right of the stove. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA inspected the common areas throughout the facility inside and out. All areas have been appropriately furnished. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room and living room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced Jan, 01, 2023. At approximately 12:30pm LPA inspected all six (6) resident bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Continued from 809 Surrounding Grounds (Outdoors): There was a shaded courtyard area with proper furniture for outdoor use to the left of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 1 and Cottages of Lake Balboa 2. Main Office is located in the rear of the facility. Records review began at 01:30 pm, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Medications review began at approximately 2:00pm The medications are centrally stored in the main office located at the rear of the property, inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record. Infection Control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has 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 each resident bedroom as a single isolation rooms if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Between 12:30pm - 01:30pm the LPA interviewed two (2) staff members and three (3) residents. LPA obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Sep 14, 2023

Allegation investigated: . Staff did not ensure residents received COVID-19 vaccine. 2. Staff are not wearing masks

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent complaint visit to conduct additional investigation and to deliver the findings of the above allegations. LPA Yee met with Justin Levi, Licensee and the reason for today's visit was explained. An initial unannounced complaint visit was conducted by LPA Brian Balisi on 5/24/22 from 1:30pm-2:30pm. LPA Balisi met with Angie Deleon, Resident Operations. During the initial visit LPA Balisi reviewed and obtained pertinent documents relevant to the complaint and conducted interviews with staff. Due to Covid-19 concerns in the facility, the visit was conducted in the facility office. The investigation was determined to need further investigation. Continued on LIC9099-C Unsubstantiated A subsequent unannounced complaint visit was conducted by LPA Christine Yee on 12/16/22 from 11:05am - 12:00pm to conduct further investigation of the above allegations. LPA Yee met Justin Levi, Licensee and the reason for the visit was explained. During the subsequent visit, LPA Yee obtained copies of vaccination cards for Resident #3 and #4 and conducted interview with Justin Levi, Licensee. Resident #1 was not available to be interviewed. Resident #2 through Resident #5 could not be interviewed due to dementia. The visit was terminated as needs further investigation due to insufficient information. On 1/5/23, LPA Yee was able to reach Resident #1 via telephone at 11:02am to conduct an interview regarding the above allegations. On today's visit LPA Yee conducted another interview with Justin Levi, Licensee at 09:25am to clarify information collected on the prior visits to the facility regarding Allegation #1- Staff did not ensure residents received COVID-19 vaccine. Per information obtained during the investigation, all facility residents had received both doses of the vaccine and the first booster shot when this complaint was received on 5/18/22. Resident #1 then requested the second booster, per Licensee in May 2022. However, there was some confusion as to the waiting period between boosters and if the other residents wanted the second booster since the pharmacy would not come to the facility for one resident. As the scheduling of the second booster shot was in the process of being addressed, the facility was impacted by Covid-19. Three residents, including Resident #1, received positive Covid-19 test results on May, 16 2022 and would not be eligible for the second booster for ninety days. This further delayed the eligibility to receive the second dose of the booster vaccine and not due to the facility's failure to ensure that Continued on LIC9099-C the residents received the second booster. Once Resident#1 became eligible, the second booster was administered on 8/18/22. In regards to Allegation #2 - Staff are not wearing masks: per interviews conducted with the Licensee and Angelie Deleon, Resident Operations, the staff are required to wear a mask while working inside the facility and assisting the residents. The choice of mask to be used would be determined by whether there are any positive cases at the home. Surgical masks are worn inside the facility, if there are no positive Covid-19 cases and N-95s are required if there are positive cases. The facility provides staff with Personal Protection Equipment(PPE). The complaint states the staff wear surgical mask but should be wearing N95 daily. The staff are not required to wear N95 masks at all times as alleged in the complaint. The facility's masking protocol is in line with the guidance provided in Provider Information Notice(PIN) #21-38-ASC dated August 19, 2021. Per tour of the facility conducted from 10:49am - 10:56am today, the 2 caregivers present on today's visit, were observed wearing surgical masks. Based on the information obtained from the investigation, it is determined that the above allegations are UNSUBSTANTIATED. Exit interview was conducted with Angelie Deleon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 17, 2023 · control 29-AS-20220518152247

Allegation investigated: . Staff did not provide an admissions agreement to resident in care.

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent complaint visit to conduct additional interviews and to deliver the findings of the investigation and met with Justin Levi, Licensee. The reason for today's visit was explained. An initial unannounced complaint visit was conducted on 12/16/22 by LPA Yee from 8:10am - 11:00am. During the inital visit, LPA Yee collected the Admission Agreements for Resident #1, Resident #2 and conducted face to face interviews with Licensees, David Ebrami and Justin Levi and Resident #2. Resident #1 was not available for an interview. Continued on LIC9099-C Substantiated LPA Yee also made attempts to interview witnesses telephonically and was unsuccessful. LPA Yee determined that further investigation was needed. On 1/5/23, LPA Yee was able to reach Resident #1 to conduct a telephone interview. On today's visit, LPA Yee conducted another interview with Justin Levi at 9:25am to clarify information provided on previous interviews regarding the facility's practice of notification to the residents about increases to their daily rent. Per information obtained from the Licensee, the facility provides all residents with a copy of the Admission Agreement when they first move in. The facility does not issue a new Admission Agreement or create an addendum to the agreement when there is a change in the rental rate. When there is a rate increase, a letter is sent out or given to the resident 60 days before implementation of the new rate and the resident is then billed at the new rate. Per review of Resident #1's file, the copy of the Admission Agreement on file for Resident #1 was between Resident #1 and the previous owner and it was never updated when the facility was licensed on 9/13/2019. Resident #1 did not and does not have a valid Admission Agreement with the new entity identified as Cottages at Lake Balboa 3. Based on this information, Resident was never provided with a valid Admission Agreement, therefore Allegation #1 is substantiated. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted with Angelie De Leon and a copy of this report was provided and Appeals Rights were discussed. LPA Yee also made attempts to interview witnesses telephonically and was unsuccessful. LPA Yee determined that further investigation was needed. On 1/5/23, LPA Yee was able to reach Resident #1 to conduct a telephone interview. On today's visit, LPA Yee conducted another interview with Justin Levi at 9:25am to clarify information provided on previous interviews regarding the facility's practice of notification to the residents about increases to their daily rent. Per information obtained, the facility provides the residents and their responsible parties a letter of notification about the rent increases 60 days prior to implementation. Resident #1 was notified via letter dated 4/12/22 that the new daily rental rate would go into effect on 7/1/22. The facility does not generate a new Admission Agreement or complete an addendum to the admission agreement to reflect the increase in the daily rate. Instead the facility bills the resident at the new daily rate by the number of dates in the month. Per interviews conducted with the Licensees, the facility rate is a flat rate and is inclusive of all basic services and care, such as bathing, medication administration, diaper changes, laundry services and meals. Additional service rates are listed in the initial admission agreement signed with the previous ownership, such as the hourly rate charged for transportation for medical visits, cable services and third party services Based on the investigation, the allegation that Staff did not provide rate of services on admissions agreement to residents in care is Unsubstantiated. Exit interview was conducted with Angelie De Leon, Resident Operations since Justin Levi left during the visit and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 17, 2023 · control 29-AS-20221212110110

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(a) · Plan of correction due date: Feb 24, 2023

Admission Agreement: (a)The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement was not met as evidenced by: The facility failed to complete an Admission Agreement for Resident #1.the state’s words, verbatim · CDSS document, Feb 17, 2023

Plan of correction: The Licensee will review all residents file to ensure that there is a completed Admission Agreement in their file. Licensee will submit a written statement indicating that all resident files have been reviewed and all files contain a completed Admission Agreement by 2/24/23

Type of visit: Required - 1 Year

At 11:00 a.m., Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff Laura Gomez Caregiver. LPA spoke with Administrator Justin Levi over the phone who stated that caregiver Laura Gomez can sign for the report in his absence. This annual had a specific emphasis on infection control practices and procedures. At approximately 11:30am, LPA 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. Fire extinguishers were observed fully charged and last serviced in December of 2021. LPA observed the kitchen/dining area. Knives are stored in a locked drawer to the right of the stove. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications were observed stored in a locked cabinet to the left of the fridge. First aid kit was observed on the wall outside of the entry way of kitchen. Restrooms were observed relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured between 115 - 120 degrees Fahrenheit. LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 11:38am, LPA observed residents resting in their bedrooms. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Laundry area located in the rear of the facility was observed inaccessible to residents at this time. Continued on 809-C Continued from 809 Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use to the right of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 1 and Cottages of Lake Balboa 2. Main Office is located in the rear of the facility. The LPA spoke with Laura regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 isolate each resident in their private room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Exit interview conducted, report issued and sent via email.the state’s words, verbatim · CDSS document, Sep 13, 2022

Allegation investigated: Facility Resident #1 (R1) fell and sustained a fractured tibia as a result of facility lack of supervision

Licensing Program Analyst (LPA) conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with caregiver Benjie Binuya and explained the reason for the visit. Mr. Binuya contacted Angelie De Leon Resident Operation. Reason for visit was explained and allegation finding disccused. On 07/15/2021, the Department receivehochiad a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that facility Resident 1 (R1) fell and sustained a fractured tibia as a result of facility lack of supervision. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Jose Santana. On 07/16/2021, from 11:40am to 1:00pm, Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced initial 10-day complaint visit to the facility. LPA Smith met with Administrators David Ebrami and Justin Levi and explained the reason for the visit. The LPA conducted a tour of the physical plant, conducted a file review at 12:20pm and obtained copies of pertinent documentation. (continue to LIC9099c) Unsubstantiated The Administrators were notified that the complaint was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Jose Santana. The LPA determined further investigation was required. On 07/20/2021, Investigator Santana conducted interviews with the reporting party and with R1’s representative; on 07/30/2021, a follow-up interview with R1’s representative; on 08/02/2021, with Witness #1 (W1); on 08/06/2021, with R1 and Staff #2 (S2); on 08/13/2021, with facility Administrator Nicholas Saenz, Licensee and Staff #1 (S1); on 08/18/2021, with Witness #2 (W2); and on 09/02/2021, a follow-up interview with S1. On 07/21/2021, Investigator Santana contacted the Los Angeles Police Department (LAPD) West Valley Station. The LAPD did not investigate the allegation as it did not receive an APS cross referral. On 10/19/2021, Long Term Care Ombudsman Program (LTCOP) Region II was contacted and advised that the complaint allegation was not investigated because they did not obtain the required consent to do so. Investigator Santana reviewed copies of facility records and medical records related to R1. The admission agreement indicated R1 was admitted to the facility on 04/11/2019. The physician report, dated 08/20/2020, listed the primary diagnoses as chronic respiratory failure, hypoxia, asthma, and COPD. R1’s secondary diagnoses included osteoarthritis and osteoporosis. R1 was noted as requiring continuous bed care, was able to communicate needs and follow instructions, required use of oxygen, had mild cognitive impairment but was not typically confused. Additionally, the Investigator reviewed the Unusual Incident Reports for 07/08/2021 and 07/10/2021, caregiver notes, Emergency Medical Services (EMS) records, Valley Presbyterian Hospital, and Kaiser Permanente Panorama City records. The facility and hospital records indicate that when the facility noticed R1 was difficult to rouse on the morning of 07/08/2021, the facility sent R1 to the hospital because it recognized a change of condition. R1 was treated for Acute-on-chronic hypoxemic respiratory failure and was discharged with oral antibiotics. On 07/10/2021, prior to R1’s hospital discharge, the last hospital entry on R1’s condition, at 3:55pm, noted R1 was awake, alert, stable and in no acute distress. The ambulance transported R1 back to the facility at 6:17pm. The Emergency Medical Technician (EMT) noted R1 was alert and oriented times four with a chief complaint of general weakness; the EMT also noted R1’s baseline was normally alert and oriented times one or two. (continue to LIC9099c) R1 was calm and communicative during transport, but R1’s level of consciousness decreased to alert and oriented times zero in transit; R1 was otherwise in no distress. R1 arrived at the facility at 7:08pm and EMTs transferred R1 to bed via sheet transfer and left the bedrails raised and departed at 7:23pm. S1, the sole caregiver who accepted R1 at the facility, stated to Investigator Santana that despite EMT assessment, R1 was confused, R1 was as alert as usual but stated being tired. However, it was later discovered from S1’s 911 call at 8:04pm that S1 told the operator that R1 told S1, fifteen (15) minutes prior, that R1 was confused and “did not know what was happening”. S1 failed to inform the facility Administrator of R1’s condition upon return from the hospital. After S1 left R1 in bed to attend to another resident, R1 fell while attempting to stand and fractured right tibia. Investigator Santana asked the Licensee, Justin Levi, if R1’s confusion on facility return would have warranted a reassessment, and he informed the investigator that the facility’s entire care operation is designed to care for residents who are as confused as R1 was on return from the hospital. The level of supervision S1 would have had to provide R1 given R1’s increased confusion would have been no different from the standard level of supervision, so a reassessment would not have changed R1’s level of care. The allegation that R1 sustained injury as a result of facility Neglect/Lack of Supervision is therefore deemed Unsubstantiated at this time. Exit interview conducted, appeal rights and a copy of this report issued.the state’s words, verbatim · CDSS document, Mar 26, 2022 · control 29-AS-20210715134128

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20210715134128). LPA met with Benjie Binuya - Caregiver. Angelie De Leon - Resident Operation was contacted by phone and LPA explained the purpose of this report is to issue citation for deficiencies observed during the course of the complaint investigation. During the complaint investigation of complaint #29-AS-20210715134128, Investigator Santana observed the following deficiencies: 1) Per review of the Licensing Information System (LIS) report, Staff #1 (S1) appears to be an uncleared adult. There was no record of anyone with this name among the facility’s personnel history. An immediate civil penalty is issued today for $500. 2) Resident #1 (R1) has half bedrails on bed, but it is unclear whether they are used solely for assistance with mobility, since they are engaged even when R1 sleeps. 3) Investigator Santana compared R1’s Appraisal Needs and Services Plan dated 05/10/2020 with the Plan dated 06/01/2021. It is evident the information from the former Plan was copied and applied to the latter Plan, rendering the 06/01/2021 Plan less than accurate. For example, the T7 compression fracture for which R1 was hospitalized sometime prior to 05/10/2020 would no longer be considered “recent” to 06/01/2021. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Immediate civil penalty $500 issued, exit interview conducted, copy of report and appeal rights issued via email to Licensee and Angelie De Leon - Resident Operation.the state’s words, verbatim · CDSS document, Mar 26, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Mar 28, 2022

Criminal Record Clearance:(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) 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 or (f) Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Mar 26, 2022

Plan of correction: Licensee will not allow S1 to work at facility until criminal record clearance obtained. Submit plan of correction to CCL by 3/28/2022. Based on records review, the licensee did not comply with the section cited above. S1 was not listed on the LIS, timecards and interviews indicated S1 worked at the facility without a criminal record clearance, which posed an immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(A) · Plan of correction due date: Apr 1, 2022

Postural Supports:(A)A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Based on observation by Investigator Santana, the licensee did not comply with the section cited above. Half bed rails are engaged on R1’s bed at night, which posed a potiential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2022

Plan of correction: Licensee may submit copy of doctor's order for the half bed rails and indicate they will be used solely for the purpose of assistance with mobility or provide proof of coorection to regulation cited by other means after discussing with case LPA before due date. Submit correction by 4/1/2022 to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Apr 1, 2022

Reappraisals:(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. R1 Needs and Services Plan dated 06/01/2021 did not contain accurate, current information, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2022

Plan of correction: Licensee to submit copy of R1’s current, accurate Needs and Services Plan, signed and dated by both licensee and R1 or R1’s representative. Submit to CCL by 4/1/2022.

Allegation investigated: Facility staff are not attending to resident's hygeine needs Facility staff are failing to reposition the resident

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit. Initial visit regarding these allegations was conducted on 11/26/2019. Facility staff are not attending to resident's hygeine needs It is alleged that the facility staff failed to change resident #1 (R1) bed sheets consistently, bathe R1 consistenly or change R1's catheter bag. Interviews were previously conducted with R1, facility staff, Long term care ombudsman (LTCO), and R1's home health nurse. Information from interviews revealed that R1 did not have their sheets changed or was R1 bathed consistently. Based on the information obtained through interviews this allegation is deemed Substantiated. Substantiated Facility staff are failing to reposition R1 Regarding the allegation above interviews were previously conducted with R1, facility staff, and R1's home health provider. Information from interviews revealed that facility staff was not repositioning R1 as they needed to. Based on the information obtained through interviews this allegation is deemed Substantiated. After this complaint was generated other complaints were completed and deficiencies were cited and addressed that are the same that would be cited under this complaint. See complaint control number 29-AS-20200728111220. Due to those citations already being issued and addressed after this complaint no additional citations are warranted. Exit Interview conducted.the state’s words, verbatim · CDSS document, Mar 4, 2022 · control 31-AS-20191125101741

Allegation investigated: Staff failed to provide comfortable accommodations for resident while in care Staff failed to ensure resident needs are properly met

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA arrived at the facility at 9:52 AM and met with Justin Levi, the Licensee. Entrance interview conducted. During an initial virtual complaint inspection on 03/20/2020, LPA Dulek conducted telephone an interview with the administrator at 12:00 PM. The LPA also requested copies of documents pertinent to the investigation be emailed to LPA. During a subsequent complaint inspection on 06/10/2021, LPA interviewed Administrator at 12:05PM, conducted staff interviews from 12:27 to 1:10 PM, and interviewed Resident #1 (R1) at 1:13 PM. LPA conducted additional resident and staff interviews on 11/02/2021 and reviewed documents on 12/01/2021. The following was then determined: Interviews revealed that R1 frequently refuses care. R1 is particular about the staff caring for R1 and has REPORT CONTINUED ON LIC 9099-C Substantiated specific care instructions R1 prefers. Record review showed R1 is a two-person assist for most personal care needs. During part of R1’s residency at the facility, R1 did have home health care, however, the home health plan indicated services were provided at a duration of 1 time per week for a 3-week period. Home health was responsible for R1’s skincare, including educating care staff how to keep skin clean and dry and Home Health was responsible for R1’s urinary device care. Facility staff were at the time and continue to be responsible for meeting R1’s personal care needs, including changing sheets/bedding, clothing, incontinence care and all other ADLs for which R1 requires assistance. Record review revealed that during the time period of February 2020, R1 had a diaper change indicated 12 out of 29 total days, sheet changed 13 out of 29 total days and wound care provided 7 out of 29 total days. Therefore, based on interviews and record review, the allegation that “staff failed to ensure resident needs are properly met” is deemed SUBSTANTIATED at this time. Additionally, based on interviews and record review, the allegation that “staff failed to provide comfortable accommodations for resident while in care” 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 809-D): Exit interview conducted, todays reports, and appeal rights were reviewed and emailed to the Licensee/Administrator.the state’s words, verbatim · CDSS document, Dec 3, 2021 · control 31-AS-20200311165246

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: Dec 3, 2021

87464 Basic Services (f) Basic services shall at a minimum include: (2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure R1's sheets were regularly changed, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2021

Plan of correction: Licensee conducted a staff training on 11/17 and 11/18/2021 including basic services training. POC met at this time.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Dec 3, 2021

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...dressing...bathing and assistance with taking prescribed medications, as specified in Section 87608... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure R1's skin remained clean and dry, and incontinece needs were met, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Dec 3, 2021

Plan of correction: Licensee conducted a staff training on 11/17 and 11/18/2021 including basic services training. POC met at this time.

Allegation investigated: Staff did not follow physician's orders.

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegation listed above with the purpose of delivering findings for the above allegation. LPA arrived at the facility at 9:52 AM and met with Justin Levi, a facility Administrator. Entrance interview conducted. During an initial virtual complaint inspection on 08/07/2020, LPA Dulek conducted a telephone interview with the administrator and a video call at 3:15PM which consisted of a of a physical plant tour to ensure health and safety of the residents and testing the call button system, which was functional at the time of the visit. The LPA also requested copies pertinent documents. During a subsequent complaint visit on 06/10/2021, LPA interviewed Administrator at 12:05PM, conducted staff interviews from 12:27 to 1:10 PM, and interviewed Resident #1 (R1) at 1:13 PM. LPA requested documents pertinent to the investigation be emailed. During a subsequent complaint visit on 11/02/2021, LPA interviewed Administrator at 10:27 AM, conducted resident interviews from 11:45 AM to 12:40 PM, staff interviews at 10:54 AM and 12:43 PM, REPORT CONTINUED ON LIC 9099-C Unsubstantiated toured the facility with Administrator at 11:33 AM, and reviewed pertinent resident file information. During the course of the investigation, LPA reviewed R1’s medical record and facility file information. The following was then determined: Interviews and record review revealed R1 schedules all their own medical appointments, arranges their own transportation, and is responsible for communicating with their own physician. Licensee interview revealed R1 has copies of their medical documentation and does not release information to the facility regularly. LPA requested copies of doctor’s orders during initial visit as well as both subsequent visits. Both R1 and Licensee were unable to provide copies of physician’s orders. LPA reviewed R1’s medical records obtained by CCL during the course of the investigation; review did not reveal orders for stretching which were referred to in the complaint. There was a statement by a nurse indicating “doctor ordered physical therapy” on 05/20/2019. No copy of the doctor's orders were contained in R1's medical record and no further information was provided. Based on interview and record review, although the allegation may be vaild, at this time there is insufficient evidence to prove the allegation occurred, therefore the allegation that “staff did not follow physician's orders” is deemed UNSUBSTANTIATED at this time. Exit interview was conducted with Justin Levi. Report was provided via email.the state’s words, verbatim · CDSS document, Dec 3, 2021 · control 29-AS-20200728111220

Allegation investigated: Resident was not accorded dignity in their relationships with staff. Facility staff do not respond to resident's request for assistance in a timely manner Facility did not provide basic personal care services to resident

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 9:52 AM and met with Justin Levi, the Licensee. Entrance interview conducted. During today's visit, LPA interviewed Licensee at 10:27 AM, conducted resident interviews from 11:45 AM to 12:40 PM, staff interviews at 10:54 AM and 12:43 PM, toured the facility with Licensee at 11:33 AM, and reviewed pertinent resident file information. During a virtual initial complaint inspection on 08/07/2020, LPA Dulek conducted a telephone interview with the Licensee and a video call at 3:15PM which consisted of a of a physical plant tour to ensure health and safety of the residents and testing the call button system, which was functional at the time of the visit. During a subsequent complaint visit on 06/10/2021, LPA interviewed Licensee at 12:05PM, conducted staff interviews from 12:27 to 1:10 PM, interviewed Resident #1 at 1:13 PM, and received copies of documents pertinent to the investigation. The following was then determined: REPORT CONTINUED ON LIC 9099-C Substantiated LPA Dulek reviewed a copy of R1's signed Admissions Agreement dated 05/12/2019, including section #9 on Rate Change. This section states that "the cost of providing services by facility to resident is subject to modification upon sixty (60) days notice from facility to resident and/or his/her responsible party, if any..." LPA was also provided a copy of a letter dated 07/27/2020 indicating there will be a rate increase effective October 2020, which provided the resident the required 60 days notice. Interviews revealed the letter was issued to the resident with greater than 60 days notice. Based on interviews and record review, at this time there is insufficient evidence to support the allegation, therefore, the allegation that "admission agreement did not include information on rate changes" is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was provided via email. Regarding the allegation "Resident was not accorded dignity in their relationships with staff:" Interviews revealed that Resident #1 (R1) has care needs that differ from those of the other residents. R1 is non-ambulatory and is particular about how R1's care needs are met. R1 will let facility staff know when R1 is unhappy with the care being provided. According to R1's family member, they understand that R1 can be difficult and is not always kind to the caregivers. Facility staff interviews revealed that R1 yells at them regularly and only wants certain caregivers assisting with R1. R1's needs and service appraisal indicates R1 is "incredibly nasty to caregivers - potential for caregivers to quit." Interviews revealed that facility staff try to be patient with R1 when R1 yells at them, however sometimes caregivers lose their patience with R1. Interviews revealed that staff have raised their voice with R1. Therefore, based on interviews and record review, the allegation that "Resident was not accorded dignity in their relationships with staff" is deemed SUBSTANTIATED at this time. Regarding the allegation "Facility staff do not respond to resident's request for assistance in a timely manner:" LPA reviewed text message documentation provided by R1 indicating there are times when R1 waits for assistance for hours prior to staff entering R1's room to assist them. Interviews revealed that R1 calls for assistance frequently throughout the day and night time. During the night, there is one care staff scheduled for the home and R1 does require 2-person assistance, so when R1 has care needs at night, care staff are unable to respond timely. R1's call pendant wasn't working for some time and R1 was required to call out for assistance. Often times R1 has to call on their cell phone in order to get a caregiver to come assist them. Interviews revealed that residents feel it takes too long for care staff to respond. Therefore, based on interviews and record review, the allegation that "Facility staff do not respond to resident's request for assistance in a timely manner" is deemed SUBSTANTIATED at this time. Regarding the allegation "Facility did not provide basic personal care services to resident:" LPA reviewed R1's needs and service appraisal and physician's report, both of which indicate R1 can feed thyself, but requires assistance with all other ADLs. During the subsequent complaint inspection on 06/10/2021, LPA observed R1's hair to be oily and very tangled/matted in the back. R1 indicated that their hair Report Continued on LIC 9099-C had not been washed in over 6 months. Staff interviews revealed that R1 frequently refuses when facility staff offer to provide care. LPA reviewed documentation for May 2021 indicating the resident refused care 23 days and was out of the facility for 2 days. The remaining 6 days, there is no documentation of refusal. No documentation provided indicated that the physician was notified when R1 refused care or that additional measures were taken to ensure R1's personal care needs were met in spite of the resident's refusal. Therefore, based on observation and interview, the allegation that "facility did not provide basic care services to the resident" 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 809-D): Exit interview conducted, todays reports, and appeal rights were reviewed and emailed to the Licensee/Administrator.the state’s words, verbatim · CDSS document, Nov 2, 2021 · control 29-AS-20200728111220

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 3, 2021

87464 Basic Services (f) 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...in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on observation and interviews, R1's hair had not been washed or brushed regularly, which poses an immediate health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2021

Plan of correction: Administrator agreed to immediately ensure staff are regularly offering to wash R1's hair and ensure all residents' personal care needs are met. Additional training to be provided to staff on working with R1. Administrator will provide CCL with a detailed plan on how the facility will handle care refusal including who will be notified and when care needs are refused by 11/10/2021.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 16, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on observation and interviews, facility staff have raised their voice with R1 and do not respond timely to R1's requests for assistance, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2021

Plan of correction: Licensee agreed to train all staff on section 87468.1. Training to be held and a copy of the roster including information on trainer, attendees, topics covered, date and duration of training to be sent to CCL by POC due date.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At 10:56 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA explained the reason for the visit to Administrator JUSTIN LEVI. This annual had a specific emphasis on infection control practices and procedures. Between 10:56 a.m.- 11:30 a.m., LPA 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. OUTDOOR SPACE: At 10:56 a.m., LPA observed the front patio, which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction. KITCHEN: At 10:57 a.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:00 a.m., LPA observed staff preparing food in the kitchen. At 11:08 a.m., hot water measured at 105.2-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:10 a.m., hot water measured at 117.8-degree Fahrenheit. Continued on LIC 809-C. Continued from LIC 809. COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and last serviced on 12/29/2020. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day 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 has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate. Between 10:50 a.m. - 11:30 a.m., LPA conducted Infection Control mitigation module with Administrator. No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.the state’s words, verbatim · CDSS document, Sep 9, 2021