Pearl of West Hills

Allegation investigated: Facility staff did not properly assist in feeding resident.

This is to amend the report that was delivered on 02/06/2023. Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA arrived at 1:30 PM. Upon entry, LPA met with the caregiver,Olga Knyazeva and explained the reason for the visit. Olga Knyazeva was degnated by the administrator, Irina Karbachinskiy, to sign and accept this report. --- Facility staff did not properly assist in feeding resident. It was alleged that staff are putting food into the resident’s mouth despite it running out of their mouth. To investigate this allegation, on 02/06/2023, LPA interviewed the Administrator at around 2:00 PM, requested pertinent documents at 2:45 PM and interviewed other parties at 3:15 PM. During interviews with the Administrator, they stated that Resident #1 (R1) has difficulty swallowing, needs prompts to swallow and at times forgets that there is food in their mouth. (Cont. on LIC 9099-C) Substantiated Administrator also stated that they do not feed R1 while they have food in their mouth and that staff do not have client specific training regarding feeding assistance and aspiration pneumonia or any recent training by an agency. During record reviews, LPA discovered that R1 needs feeding assistance due to health conditions. Record review also revealed that staff do not have client specific training regarding feeding assistance and aspiration pneumonia. During interview with other parties, they stated that R1 was being fed while food was running down the side of R1's mouth. Based on interviews and record review, there is sufficient corroborating information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 6, 2023 · control 31-AS-20230203150413

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(3)(B) · Plan of correction due date: Feb 7, 2023

Personnel Requirements - General (c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health & Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following: Importance and techniques of personal care services, including but not limited to,..feeding...This requirement is not met as evidenced by; Based on interviews & record review, staff do not have client specific training for feeding assistance & aspiration pneumonia which poses an immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Feb 6, 2023

Plan of correction: Administrator will ensure that all staff get client specific training for feeding assistance and aspiration pneumonia by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced required annual visit. LPA met with administrator and explained the reason for this visit. Upon entry LPA was properly screened using covid protocols. LPA had temperature checked and signed into facility log. LPA conducted a physical plant tour from 9:10-9:30am. Facility has four bedrooms and three bathrooms. Four bedrooms and two of the bathrooms are for resident use. One bathroom is designated for staff and visitors. LPA observed all resident bedrooms and bathrooms to be appropriately furnished. Carbon monoxide and smoke detector are combination and hard wired throughout the facility and were functioning properly. LPA observed the kitchen area for the ability to prepare and store food. LPA observed there to be a sufficient amount of perishable and non perishable food. Sharp objects were observed to be locked away and inaccessible. Medications are stored in a lock cabinet in the laundry area which is adjacent to the kitchen area. Common areas were observed to be properly furnished. LPA checked the backyard for clutter and debris. There is an additional non-attached dwelling unit on the property which is gated off from the facility. Administrator states she lives in the unit. Facility has two residents that are receiving hospice services at this time. LPA observed one resident to have full bed rails but is not receiving hospice services. Exit Interview conducted. Deficiency cited on LIC 809 D. Appeal Rights explained.the state’s words, verbatim · CDSS document, May 3, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Wendell Smith conducted a case management visit due to observations that were observed on a complaint visit on 3/2/22 . During the visit it was found that staff #1 (S1) that was working at the facility was not cleared or associated to work in the facility. S1 was left alone caring for the residents with no other staff working. LPA met with staff and explained the reason for this visit. LPA met with the licensee as LPA was leaving the visit and explained the reason for this visit.the state’s words, verbatim · CDSS document, Mar 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 4, 2022

(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 Departmentr This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not ensuring staff 1 (S1) obtained criminal record clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Licensee stated that S1 would not be at the facility until proper criminal record clearance is granted for S1.

Allegation investigated: Facility does not have any planned activities Facility does not have enough staff

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with staff and explained the reason for this visit. LPA spoke with the administrator by telephone and explained the reason for the visit. Administrator stated they would come to the facility later due to being in the emergency room with another client. LPA toured the physical plant of the facility from 9:45-10:10am to ensure no immediate health and safety issues. It is alleged that the facility does not have any planned activities. LPA conducted interviews with residents from 10:15-10:45am regarding this allegation. LPA had previously conducted interviews with the Long Term Care Ombudsman (LTCO) and the administrator regarding this allegation. Information obtained through interviews reveal that there were no planned activities for the residents. Therefore this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Substantiated It is alleged that facility does not have enough staff to meet the needs of all the residents. LPA had previously conducted interviews with residents, staff, and LTCO prior to coming to this visit. LPA also had conducted a case management visit on 2/16/22 where interviews were conducted. Based on the information obtained through interviews this allegation is deemed Substantiated. Facility does not have enough staff to support the needs of all of their residents. Resident #1 (R1) is not able to leave the facility for a walk or go on outings due to lack of staff. Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.the state’s words, verbatim · CDSS document, Mar 2, 2022 · control 31-AS-20220301152954

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 4, 2022

Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews conducted facility did not have enough staff to meet all resident needs. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2022

Plan of correction: Administrator stated they have hired additional staff. A staff schedule will be sent to LPA to clear deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Mar 2, 2022

Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by: Based on interviews conducted residents did not have planned activities which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2022

Plan of correction: Corrected before visit. Activity calendar was given to LPA.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit. LPA was joined by Long Term Care Ombudsman (LTCO) Ginger Perini and Erin Pickerel during this visit. Upon entry to the facility LPA conducted a physical plant walk through to ensure no immediate health and safety issues. LTCO conducted interviews with residents in the facility while LPA conducted a walk through of the facility. During the course of the visit LPA observed that the administrator's administrator certificate had expired as of 8/8/2020. Facility was previously cited on 11/8/21 regarding the expired administrator's certificate. Administrator still has not renewed their administrator's certificate. During the course of the visit LPA and LTCO spoke with the administrator regarding the facilities policy on residents leaving the facility, Activities for residents in the facilities, and LTCO's role when visiting the facility. During the visit the administrator was given an LTCO Poster which was posted during the visit. Exit Interview conducted. Copy of report emailed to administrator.the state’s words, verbatim · CDSS document, Feb 16, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87406(g) · Plan of correction due date: Feb 18, 2022

87406 Administrator Certification Requirements (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by: Based on review of records and interview with licensee which revealed the Licensees Administrator Certificate expired 08/08/2020 and the Administrator has not taken the required classes to renew the required Administrator Certificate which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: Licensee/Administrator will notify the department when they will renew their certificate and who will be the designated administrator for the facility while she completes the renewal process.

Allegation investigated: Staff restricting resident from having phone calls Staff are mismanaging resident's medication

An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with ---- and informed her the purpose of the visit. Regarding the allegation of Staff restricting resident from having phone calls it was reported that families are able to speak with the residents only by calling the phone number of the Licensee Irina Karbachinskiy. It was also reported that the administrator would not allow resident 1 (R1) to have phone calls with family members in private. An initial 10 day complaint visit was conducted on 11/17/2021. During the visit interview was held with the licensee who confirmed that they no longer have a facility phone line and when anyone wants to speak with a resident they will call her on her cell phone. When asked licensee also stated that she was very particular with R1 and would be present during phone calls. During the 11/17/2021 LPA informed the administrator that per title 22 regulations all facilities are required to have telephone service on the premises at all times. LPA also informed the administrator that she is violating the residents personal rights by not allowing them to make and receive personal/confidential calls. Substantiated The licensee informed the LPA that she would disconnect the telephone line from the facility fax to ensure that they have telephone services at all times. On 12/3/2021 LPA spoke with the licensee regarding her pending plan of corrections. During that phone call LPA was informed that the licensee was continuing to use the phone number for the fax. on 12/6/2021 at 2:05 pm LPA called the facility phone number, which kept ringing. LPA called again at 2:07 pm at which time the fax line was connected. On 1/18/2022 at 3:30 pm LPA called the facility phone number which kept ringing until the fax line was connected. Based on the interviews conducted and attempted phone calls made to the facility the department has obtained sufficient information to determine that the facility Staff are restricting resident from having phone calls therefore the allegation is Substantiated. Regarding the allegation of Staff are mismanaging resident's medication it was reported that the licensee and staff are not ensuring residents medications are given as prescribed. An initial 10 day complaint visit was conducted on 11/17/2021 at which time LPA observed and documented as Licensee Irina Karbachinskiy counted medications for 2 residents. .Review of the medication records, and medication count revealed that Licensee and/or staff mismanaged 6 or R1's medications by not ensuring they were given according to the physicians order. Review of the medications revealed that licensee had extra medications for 5 of the 6 medications and the 6 th medication Divalproex had run out without being refilled or discontinued by the physician. Licensee and/or staff also mismanaged medications for R2 by not ensuring that 4 medications were given according to the physicians order therefore the allegation is Substantiated. Exit interview conducted, copy of report, citations, civil penalties and appeal rights issued and emailed to the licensee.the state’s words, verbatim · CDSS document, Jan 19, 2022 · control 31-AS-20211109140750

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(14 · Plan of correction due date: Jan 21, 2022

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) 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 interview the licensee did not comply with the cited sections by allowing R1 to have personal/confidential phone calls with family which posed an immediate personal rightsviolation to R1.the state’s words, verbatim · CDSS document, Jan 19, 2022

Plan of correction: Licensee will review the cited regulation 87468.1. Licensee will submit a written statement that they have reviewed the regulation and indicate what steps will be taken to ensure the residents personal rights are not violated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87311 · Plan of correction due date: Jan 21, 2022

All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement was not met as evidenced by: Based on interview and attempted telephone calls to the facility the licensee did not comply with the cited section by not ensuring that a telephone service is available on the premises at all times which poses an immediate personal rights violation to R1.the state’s words, verbatim · CDSS document, Jan 19, 2022

Plan of correction: Licensee will notify the department in writing what steps have been taken to correct this deficiency, Licensee and administrator will also submit a written statement that telephone services will be made available at the facility at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jan 21, 2022

(5) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on medication count the licensee did not comply with the section cited by not assisting R1 and R2 with self administered medications as prescribed which posed/poses an immediate health and safety and personal right risk to residents in care.the state’s words, verbatim · CDSS document, Jan 19, 2022

Plan of correction: Licensee and all staff attended vendorized medication training on 12/19/2021. Licensee will submit a written statement notifying the department what steps will be taken to ensure residents are assisted with medications as prescribed.

Allegation investigated: Staff hits residents.

On this day Licening Program Analyst (LPA) Eleza Jackson conducted a facility tour to ensure no immediate health and safety issues were present. LPA Jackson did not observe any immediate health and safety issues. LPA Jackson met with the facility administrator upon her arrival at approximately 1430hrs and explained the reason for this visit. It is alleged that the facility administrator hits residents in the facility. LPA Jackson was unable to locate former resident(s). Based on the inability to locate former resident(s) this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to administrator with signature. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 23, 2021 · control 31-AS-20211210153243

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff slapped a resident Staff does not allow resident to keep personal items in their drawer spaces Staff did not make medications inaccessible to residents Staff did not report incidents as required

On this day Licensing Program Analyst (LPA) Eleza Jackson conducted a facility tour to ensure no immediate health and safety issues were present. LPA Jackson did not observe any immediate health and safety issues. LPA Jackson met with the facility administrator upon her arrival at approximately 1430hrs and explained the reason for this visit. On 10/21/21 Eleza Jackson and Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA's met with the facility administrator and explained the reason for this visit. Upon entry to the facility a physical plant tour was conducted from approximately 9:50am-10:10am to ensure no immediate health and safety issues were present. LPA's did not observe any immediate health and safety issues. It is alleged that the facility administrator hits residents in the facility. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am and it was determined that staff nor administrator has hit residents. A subsequent telephonic interview was conducted with R1 on 11/02/2021; at approximately 12:56pm and the interview supported the previous interview findings. Based on information obtained through subsequent interviews and interviews conducted at the visit; this allegation is deemed Unsubstantiated at this time. Unsubstantiated Staff does not allow resident to keep personal items in their drawer spaces It is alleged that the facility administrator and staff does not allow resident to keep personal items in their drawer spaces. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am and observed resident belongings stored in drawers. Based on information obtained through interviews and observations during the visit this allegation is deemed Unsubstantiated at this time. Staff did not make medications inaccessible to residents It is alleged that the facility administrator and staff did not make medications inaccessible to residents. Upon entry to the facility a physical plant tour was conducted from approximately 9:50am-10:10am. LPAs observed medications labeled, locked, and inaccessible to residents. Based on observations during the visit this allegation is deemed Unsubstantiated at this time. Staff did not report incidents as required It is alleged that the staff did not report incidents as required. There were no incidents reported at the visit. Based on information obtained through interviews and observations during the visit this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report emailed to administrator with signature.the state’s words, verbatim · CDSS document, Dec 23, 2021 · control 31-AS-20211013144148

Allegation investigated: STAFF DID NOT SEEK MEDICAL ATTENTION IN A TIMELY MANNER

On this day Licening Program Analyst (LPA) Eleza Jackson conducted a facility tour to ensure no immediate health and safety issues were present. LPA Jackson did not observe any immediate health and safety issues. LPA Jackson met with the facility administrator upon her arrival at approximately 1430hrs and explained the reason for this visit. It is alleged that the facility administrator did not seek medical attention in a timely manner for Resident 1 (R1) in the facility. LPA conducted interviews with resident(s), administrator, and facility staff on 12/01/21 from approximately 10:20-11:20am. Interviews revealed that the Facility Administrator admitted to waiting over 20 days to send R1 to hospital for medical attention. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Substantiatedthe state’s words, verbatim · CDSS document, Dec 23, 2021 · control 31-AS-20211129160812

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 24, 2022

Incidental Medical... A plan for incidental medical...shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted with administrator and R1 that revealed that the administrator did not receive medical attention in a timely manner which posed an Incidental Medical...violation to resident(s) in care.the state’s words, verbatim · CDSS document, Dec 23, 2021

Plan of correction: Administrator will submit a written step by step guide to ensure that facility clients medical needs are met and that residents do not experience neglect.

Type of visit: POC

An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to follow up on the Case Management Deficiencies visit and a subsequent complaint visit Complaint Control # 31-AS-20210416135138 which were conducted on 11/5/2021. Upon arrival LPA met with staff Olga Nikolaevna, Licensee/administrator Irina Karbachinskiy arrived to the facility approximately 3:20 pm. During the 11/5/2021 Case Management Deficiencies visit the licensee was issued a citation for the deficiency of not having a certified administrator working at the facility. The plan of correction due date for the citation was 11/8/2021. As of today's visit a plan of correction has not been submitted to the Department. The licensee was also cited for the same deficiency on 4/20/2021 and did not submit the plan of correction. For the subsequent complaint visit the licensee was cited for: 87465 (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. The plan of correction was for the licensee to schedule vendorized medication training for all staff and submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency on or before 11/8/2021. 87465 (C3)(D3) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date & time the PRN medication was taken, the dosage taken, & the resident's response. The plan of correction was for the licensee to schedule vendorized medication training by 11/8/2021 87465 (c)(2) (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. The plan of correction was for the licensee to schedule vendorized medication training for all staff and submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency on or before 11/8/2021. As of today's visit Licensee has failed to submit the plan of corrections for all deficiencies documented in this report, which were cited on 11/5/2021. The licensing reports issued on 11/5/2021 gave notice that failure to correct the violations within a specified length of time would result in civil penalties. Because the licensee failed to make the corrections by the specified dates a civil penalty in the amount of $100 dollars per violation per day will be assessed until the plan of correction is submitted. Exit interview conducted, copy of report, citations and civil penalties emailed to the administrator.the state’s words, verbatim · CDSS document, Nov 17, 2021

Allegation investigated: Staff hit resident Staff caused injury to resident

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. In regard to the allegation it was reported that facility staff injured Resident 1 (R1) by hitting R1 in the eye resulting in severe bruising. These allegations were investigated by Lorraine Patterson, Investigator with Community Care Licensing Division’s Investigations Branch. On 04/26/2021 Investigator Patterson conducted interviews with various individuals including the Licensee/Administrator Irina Karbachinsky, Resident 2 (R2), facility volunteer. Additionally, on 4/26/2021 Investigator attempted to interview Resident 1 (R1) but was unable to do so. On 5/20/2021 Investigator Patterson conducted interview with R1’s responsible party and hospice staff. The investigator attempted to interview the complainant but was unable to do so. Unsubstantiated On 5/27/2021 Investigator conducted review of the Los Angeles Police Department (LAPD) Incident report which documented that the police were called to the facility for a welfare check. During the call officers spoke with licensee/administrator, hospice nurse, and R1’s responsible party. The LAPD report documented “The Reason and Cause of Injury as: Accident, Fall. The Extent of Injury: Minor” Information obtained during the course of the investigation revealed the following: On 3/27/2021 R1 was very agitated at the facility. Due to the agitation resident was running around the facility and ran into the facilities closed sliding door hitting his/her face. After the incident Administrator contacted the hospice agency. Hospice nurse visited R1 and completed an assessment. Administrator also contacted R1’s responsible party/family to notify them of the incident. Based on the lack of witnesses and evidence to corroborate the allegations Investigator Patterson has determined the allegations to be Unsubstantiated at this time. Facility increased resident's rate without proper notice: In regard to the allegation it was reported that the licensee/administrator increased Resident 1 (R1’s) fees several times after admission to the facility without providing proper notice. During the initial 10-day complaint visit which was conducted on 4/20/2021 LPA conducted interview with the administrator Irina Karbachinsky. When interviewed the Administrator denied raising R1’s monthly fees. On 10/17/2021 LPA conducted interview with R1’s responsible party/family who also denied that the R1’s fees were increased from the initial agreed upon rate. Based on the information obtained from the interviews conducted the allegation is Unsubstantiated at this time. Exit interview conducted and copy of report emailed to the administrator IRINA_KARBACHINSKIY@HOTMAIL.COM On 10/17/2021 LPA conducted review of the submitted CSMDR, hospice medication list for March and April 2021. Records reviewed revealed that R1 does not have a prescription for Geodon, and the medication is not listed/documented in facility, hospital, hospice records or any of the submitted/reviewed records. Additionally, LPA conducted medication count utilizing the photos taken of the medications in bubble packs on 4/20/2021. LPA also used the information provided by the licensee such as the start dates, hospitalization dates and the order dates listed on the hospice records. Medication count revealed the following: R1’s medications were not assisted with as prescribed. R1 was given additional doses of various medications. (7 extra pills of temazepam, 4 extra pills of melatonin, 25 (21 and 4) extra pills of Quetiapine/Seroquel from 2 different prescriptions. During the 4/20/2021 visit the administrator did not provide the medication Lorazepam/Ativan for LPA to review. The medication was also not listed in the March 2021 CSMDR. Medication documentation reviewed also revealed inconsistencies with the hospice medication list, licensees CSMDR and the medication orders on the bubble packs. Based on the medications counted and records reviewed the allegation is Substantiated. Exit interview conducted, copy of report citations and appeal rights emailed to the administrator IRINA_KARBACHINSKIY@HOTMAIL.COMthe state’s words, verbatim · CDSS document, Nov 5, 2021 · control 31-AS-20210416135138

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(C3)(D3) · Plan of correction due date: Nov 8, 2021

If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date & time the PRN medication was taken, the dosage taken, & the resident's response. This requirement was not met as evidenced by: Based on records review and interview the licensee did not comply with the cited sections by not documenting when PRN medications were administered to R1. Which posed anthe state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: immediate health, safety and personal rights risk to R1. Licensee/Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 11/19/2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 8, 2021

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff shall be permitted to assist the resident with self-administration, provided the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on medication review the licensee did not comply with the cited sections by not giving medications per the physicians directions which posed an immediate health, safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Licensee/Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 11/19/2021 Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Nov 8, 2021

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement was not met as evidenced by: Based on hospital records review the licensee did not comply with the section cited above by not having a signed written order from a physician for the medication Geodon given to resident 1 which posed an immediate health, safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Licensee/Administrator will schedule vendorized medication training for all staff. Training will need to be scheduled within 24 hours and completed by 11/19/2021 Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to prevent the reoccurrence of the cited deficiency.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Virtual Case Management Deficiencies visit due to deficiencies observed during the investigation of complaint control 31-AS-20210416135138 on 4/20/2021. Upon entrance to the facility LPA was greeted by 2 staff. At 3:35 pm LPA spoke with the licensee who stated that she would come to the facility shortly. Administrator arrived approximately 4:05 pm. LPA held a discussion Ms. Karbachinskiy regarding the status of her administrator certificate. Per Licensee she has not completed all the required classes and has not hired a certified administrator to oversee the facility. Prior to this visit LPA conducted a review of the licensing information system and obtained the names of all staff who are associated with the facility. Upon review of the records LPA observed that the 2 staff working at the facility are not associated with the facility. At 4:14 pm LPA called the Woodland Hills Regional office and clarified that staff 1 (S1) has criminal record clearance, however staff 2 (S2) does not have criminal record clearance. A discussion was held with the administrator regarding criminal record clearance requirements. Exit interview conducted, copy of report, citations, civil penalties and appeal rights issued.the state’s words, verbatim · CDSS document, Nov 5, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 5, 2021

(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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not transferring criminal record clearance for staff 1 (S1) to this facility prior to employment which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Licensee Irina Karbachinskiy provided transfer of criminal record clearance and photo ID to the LPA during the visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Nov 5, 2021

(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 Departmentr This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above by not ensuring staff 2 (S2) obtained criminal record clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: Licensee Irina Karbachinskiy requested for staff member to leave the facility. Licensee provided LPA a signed written statement that the staff # 2 will not return to the facility until criminal record clearance is obtained.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87406(g) · Plan of correction due date: Nov 8, 2021

87406 Administrator Certification Requirements (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by: Based on review of records and interview with licensee which revealed the Licensees Administrator Certificate expired 08/08/2020 and the Administrator has not taken the required classes to renew the required Administrator Certificate which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2021

Plan of correction: This deficiency was cited on 4/20/2021. As of todays visit Licensee Irina Karbachinskiy confirmed that she has not completed all of the required classes to renew her certificate. Licensee/Administrator will notify the department when they will renew their certificate and who will be the designated administrator for the facility while she completes the renewal process.

Allegation investigated: Staff yell at residents Staff does not allow resident's to leave the facility Staff confiscated resident's clothing Facility does not have planned activities Staff are not following COVID protocol

Licensing Program Analyst(s) Eleza Jackson and Wendell Smith conducted an unnannounced complaint visit to investigate the allegations above. LPA's met with the facility administrator and explained the reason for this visit. Upon entry to the facility a physical plant tour was conducted from approximately 9:50am-10:10am to ensure no immediate health and safety issues were present. LPA's did not observe any immediate health and safety issues. Staff yell at residents It is alleged that the facility administrator have yelled at residents in the facility. LPA's conducted interviews with residents, administrator, and facility staff from approximately 10:20-11:20am. Interviews revealed that on occassion the facility administrator had yelled at resident # 1(R1) when R1 was smoking in their room and in the kitchen area. Administrator admitted to this happening and facility residents stated they overheard a staff yelling at a resident but could not state which staff was doing the yelling. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Substantiated Staff does not allow resident's to leave the facility It is alleged that residents are not allowed to leave the facility without permission. Interviews were conducted with residents and staff from approximately 10:20-11:20am. Interviews revealed that residents didn't feel they were able to leave the facility without permission from staff or unless they were supervised by staff. Interviews revealed that some residents do not require supervision to be outside of the facility independently. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Staff confiscated resident's clothing It is alleged that the administrator confiscated R1's clothing so they could not leave the facility. Interviews were conducted with the administrator regarding this allegation. Administrator stated that anytime R1 would wear clothes they would leave the facility and that due to R1's health condition their safety was in jeopardy. R1 was kept in a hospital gown or diaper while in the facility which was witnessed by visitors to the facility. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Facility does not have planned activities It is alleged that the facility does not have planned activities. LPA's conducted interviews with residents and facility staff from approximately 10:20-11:20am. Interviews with residents and the administrator reveal that the facility does not have planned activities for the residents. There are some board games or television for residents to partake in but nothing planned. Based on the information obtained through interviews this allegation is deemed Substantiated. Staff are not following COVID protocol It is alleged that the staff are not checking all visitors temperatures when they visit the facility to check for signs of covid. LPA's conducted interviews with facility staff regarding this allegation. Facility staff admitted to on a few occasions on not checking a visitors temperature when they came to the facility to check on residents. During today's visit LPA's temperatures were checked before starting the visit. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. All deficiencies cited on LIC 9099 D. Appeal Rights explained, Exit Interview conducted. Staff are not able to communicate with residents It is alleged that facility has staff that are not able to communicate with residents. LPA's conducted interviews with residents and staff from approximately 10:20-11:20am. Interviews revealed that staff #2(S2) does not speak English well but S2 always works with another staff who is able to communicate in English. Information from interviews reveal that on each shift there is a staff that is able to communicate in English. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Facility does not have a poster displaying information on the appropriate reporting agency It is alleged that the facility was provided a Long Term Care Ombudsman poster on 9/20/21 but that it has not been posted in the facility. During the physical plant tour done today LPA's observed the Long Term Care Ombudsman poster to be posted by the entry to the facility. Interview with the administrator revealed that it had been posted as soon as it was provided by the Long Term Care Ombudsman. Based on information obtained through observation this allegation is deemed Unsubstantiated at this time. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 31-AS-20211013144148

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 25, 2021

Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews conducted it was revealed that R1 was yelled at by the facility administrator which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Administrator shall submit written statement that no residents will be yelled at and will be talked to appropriately. Copy of written statement will be due by poc due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Oct 25, 2021

Personal Rights of Residents in All Facilities-To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Based on interviews conducted residents were not able to leave the facility at anytime. This poses a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Administrator shall have a meeting with all residents and explain those that are able to leave the facility without supervision shall be able to without permission. Staff will have a sign in sheet to which residents will sign that meeting too place and copy will be sent to LPA by poc due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Oct 25, 2021

Personal Rights of Residents in All Facilities-To wear their own clothes; to keep and use their own personal possessions. This requirement was not met as evidenced by: Based on interviews conducted it was observed and admitted to by the administrator that R1 was not able to wear or have access to their own clothes which is a violation of residents personal rights.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Administrator will send statement that all residents will be able to wear whatever clothes they choose to and will have access to all of their clothing without interference from facility staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Oct 25, 2021

Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by: Based on interviews conducted facility does not have any planned activities for residents.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Administator shall come up with an activity calendar with input from the residents of various activities that residents will be offered and can participate in. Copy of activity calendar will be sent to LPA by poc due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Oct 22, 2021

Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews conducted staff were not checking all visitors temperatures upon entry to the facility which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: Administrator shall have in-service with facility staff on the importance of checking all visitors temperatures. Copy of in-service sign in sheet shall be sent to LPA.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.