Golden Age Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required Annual inspection. Upon arrival, the LPA was greeted by staff, and explained the reason for the visit. The staff contacted the Administrator Siranush Alvadzhyan and they arrived shortly thereafter. The LPA and the Administrator toured the physical plant areas at 12:40 p.m. inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three residents’ rooms. There was a linen closet in the hallway with extra towels and linens. Washer and dryer were operational. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Hot water temperatures measured between 116.5 and 11.6.8 degrees Fahrenheit in the common and private restrooms. KITCHEN: Kitchen appliances were in operable condition. At 1:27 p.m. The facility has a sufficient supply of perishable and non-perishable food All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 112.8 degrees Fahrenheit at 1:35 p.m. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed required postings in the common area. One (1) fire extinguisher was observed to be fully charged and purchased on 04/20/2023. Continue on LIC 809C… BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility has one (1) shed in the backyard that is utilized for additional storage. RECORDS: Residents’ records review began at 3:00 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 4:00 p.m; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. The audit revealed that one out of three prescription medication bottles contained more pills than the actual number stated in the prescription bottle. Per the Administrator, the staff transferred pills from a current prescription bottle to a newly received prescription bottle, consequently, the number of pills in the bottles audited did not reflect the amount of pills per the new filled prescription. INFECTION CONTROL: 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 designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control. The LPAs obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Staff schedule The following deficiencies were observed (See LIC 809-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 was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 31, 2023

Allegation investigated: Facility restricted visitation Facility failed to notifiy residents' responsible party of change of condition Facility failed to treat resident with dignity and respect

Licensing Program Analyst (LPA) Elsie Campos conducted an unannounced subsequent complaint visit at the facility regarding the above allegations. The LPA met with Administrator Siranush Alvadzhyan and explained the reason for the visit. During the visit on 10/27/2022, the LPA conducted a facility tour at 10:00 a.m., interviewed staff at 10:05 a.m. and 10:25 a.m., reviewed and collected documents at 10:50 a.m. ad interviewed residents at 11:05 a.m., 11:15 a.m., 11:27 a.m. and 11:28 a.m. On 11/14/2022, the LPA returned to the facility to resolve the complaint allegations, requested additional information and conducted interview. On 5/17/2023 the LPA conducted a plant tour, interviewed residents and delivered the findings. **Continued on LIC 9099-C** Unsubstantiated PAGE 2 Regarding the allegation: Facility restricted visitation It was alleged that the facility restricted visitation by asking Responsible Parties (RP) not to visit. Interviews with staff, residents, and responsible parties of residents who reside at this location confirmed that at one time there were visitation restrictions due to COVID-19 however, facility did not impede from residents having visitation. Families were told that they can visit as they wish and that leaving a resident for a few days to acclimate without family visitation was not discouraged and left at the discretion of the family. The facility has set up a patio area for visitation outside the facility, meaning families could visit and see a resident in the patio if necessary. An interview with the complainant did not confirm claims that visitation was denied by the facility and that while the RP visited Resident #1 (R1) every day, they would often sit outside in the patio after dropping things off. The administrator confirmed that a conversation was had with the RP about allowing the resident to acclimate to the facility without visitation, but it was not required, nor did it imply that they were not to be visited by the RP. Residents communicated minimal concerns in having reasonable visits with visitors. Resident interviews revealed no difficulties in speaking to or seeing their family and had not experienced any limitations outside of local restrictions. Staff denied claims that anyone has been restricted visitation and visitors are allowed. Based on the information obtained, while this may or may not have happened there is insufficient evidence to support the claim that the ‘facility restricted visitation’. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility failed to notifiy residents' responsible party of change of condition It was alleged that the facility failed to inform the responsible party (RP) of Resident #1 (R1s) change in medical condition. It was reported that R1’s family was not informed of R1 having a change in condition within the first few days of admission. Interviews conducted with RP, revealed that R1 was at a skilled nursing facility prior to their admission to this facility as R1 had fallen at their personal home and suffered a head injury. Facility files reviewed revealed that R1 fell on 10/4/2022, to which staff took R1’s vitals, applied an ice pack and reported that they seemed okay. **Continued 9099-C** PAGE 3 The Administrator provided documentation confirming that R1s RP was informed of the changes. It was also discovered that R1’s RP had visited R1 at the facility on 10/5/2022 and at that time, R1 was sleeping but seemed strange, however still appeared okay. Additionally, R1’s family member had requested that facility staff monitor R1 and provide them with updates to which they did. On 10/6/2022 family visited R1 and noticed that R1 was not their usual self. However, staff indicated that R1 was only sleeping and was okay. Staff communicated that any changes to R1’s condition were communicated to the RP as they visited every day and were very active in R1’s care. Furthermore, interviews revealed that on 10/8/2022 R1 had a change in vitals and a decline in their condition at which time 911 was called and the RP was notified. The RP additionally requested R1 be sent to a religion specific hospital. Based on interviews and record review, while this may or may not have happened the Department does not have sufficient evidence to support the allegation of “facility failed to notify residents’ responsible party of change of condition”. Therefore, the allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility failed to treat resident with dignity and respect On the allegation of ‘facility failed to treat residents with dignity and respect’, the reporting party (RP)’s concern is that Resident #1 (R1) was screaming when touched or approached by staff and seemed terrified. To investigate the allegation the LPA’s conducted resident interviews and staff interviews. The residents’ interviews revealed that they feel respected and cared for here, and they are treated with dignity and respect. Resident interviews denied claims that they have ever been force fed, hurt or left unattended by staff. Residents’ interviews revealed that they have never witnessed staff treat residents inappropriately. Interviews with staff denied claims that residents have been has disrespected or failed to be treated with dignity and respect. Based on the information obtained through interviews, while this may or may not have happened there is insufficient evidence to support the allegation that ‘facility failed to treat residents with dignity and respect’. Therefore, this allegation is Unsubstantiated at this time. No deficiencies cited at this time. A copy of this report was issued.the state’s words, verbatim · CDSS document, May 17, 2023 · control 29-AS-20221019135455

Allegation investigated: Resident sustained pressure injury while in care

Licensing Program Analyst (LPA) Salia Walker arrived unannounced to deliver the findings for the above allegations. The LPA met with Administrator Siranush Alvadzhyan, and explained the reason for the visit. On 10/01/2021, the Department received a complaint of neglect/lack of care and supervision, resulting in Resident #1 (R1) sustaining pressure injurie(s) while in care. During the initial visit conducted on 10/04/2021, LPA Salia Walker conducted a physical plant tour at 8:59 a.m. The LPA also conducted interviews with the facility residents, the administrator, staff, and reviewed and obtained copies of documents pertinent to the investigation. The LPA determined further investigation was needed at that time. Continue on LIC9099C.. Substantiated Regarding the allegation, ‘Resident sustained pressure injury while in care,’ it is alleged that R1 sustained pressure injurie(s) while in care. According to the complainant, on 9/6/2021, R1 was seen by a Home Health Medical Team (HHMT) and had a small opened wound. Then on 9/21/2021, the HHMT saw R1, and the images showed an “unstageable” pressure injury (most severe). During the investigation, the LPA attempted to contact R1 to obtain additional information. However, all contact numbers provided were no longer in service. The investigation revealed that R1 was admitted to this facility on 9/10/2021. A review of the initial Physician’s Report, dated 9/9/2021, indicated that R1 did not have a history of skin breakdown. The reporting party was able to interview R1, who informed them that there were only two little ladies working the facility, who were physically unable to move or reposition R1. On 9/28/2021, R1 went to the Hospital for a Radiology appointment. During the appointment, R1 reported having a painful pressure injury on R1’s sacrum. The nurse then requested that Radiology send R1 to the Emergency Room (ER) to get care “for stage 4 pressure ulcer.” Record review revealed that upon admission to the ER, R1 was assessed by a wound care RN, in which the nurse documented “Type of Wound: pressure injury. Location: Sacro coccyx. Stage: Unstageable. Measurements(cm): 11x11 x0.1 cm (uneven edges) ...” Records review revealed that R1 was discharged from the hospital on 10/13/2021 with palliative care to a Skilled Nurse Facility (SNF). Record review revealed that R1’s home health admission date was 9/13/2021. An interview with the administrator revealed that R1 was only at the facility for 19 days; R1 went to a radiology appointment and was then transferred to a SNF. According to the administrator, they were unaware of the severity of R1’s skin integrity. The administrator stated that the discharging hospital did not notify the facility of any wound upon placement. The administrator stated the facility staff reported to the administrator (date unknown) that R1 had an open wound on their ‘buttocks’ area. The administrator also stated that they “never saw the wound on R1.” However, it is the administrator’s responsibility to observe and monitor any wounds/pressure injuries for any changes. According to the administrator, the facility then called the discharging hospital and requested that they send a wound specialist. Additionally, the administrator stated that the Home Health nurse would call and provide an update on R1’s progress. Allegedly, however, the Home Health nurse did not disclose R1’s wound stages. Continue on LIC9099C.. However, it is the administrator’s responsibility to follow-up and ask those questions from the home health nurse. The administrator disclosed that the Home Health nurse advised via telephone, prior to the appointment on 9/28/21, that R1 was going to check themselves “into the ER to have the wound checked.” The LPA made numerous attempts to speak with the HH nurse to ask whether or not the nurse informed the facility staff of the wound stage; however, the nurse did not return the call. Staff interviews revealed that staff were able to move/reposition R1. Although the staff stated that R1 ‘was heavy,’ staff ‘always repositioned’ R1. Staff confirmed that R1 was a two-person assist, and repositioning would be conducted ‘often’ as they were ‘always in pain’; and, R1’s diapers had to be changed. Staff interviews further revealed that staff discovered the pressure injury on R1’s ‘bottom,’ and advised the Administrator (date unknown). Staff #1 (S1) stated that they discovered the ‘wound on his lower back,’ the first day R1 came to the facility (09/10/21). S1 also stated that there was an individual that accompanied R1 to the facility, who took photos, then ‘made calls.’ S1 stated that after that individual made the calls, nurses from home health began to visit R1 for wound care. The discharge documents did not note any wound on R1 upon discharge. The administrator stated she had no knowledge of R1 having a pressure injury upon admission to the facility; or, of the stage of the pressure injury. The facility staff failed to ensure that R1 was regularly observed for any changes; and, that appropriate assistance was provided when the observation revealed unmet needs. The staff also failed to document R1’s medical changes and notify the appropriate parties. R1’s Reappraisal was not updated to reflect the change of condition that R1’s pressure injury was worsening. Therefore, the licensee representative did not have a level of care meeting to discuss the change of condition with the resident, staff, and the home health agency. In addition, as a result, the licensee representative was retaining a resident with a prohibited health condition and failed to request an exception to retain that individual with a prohibited health condition. Based on the investigation, there is sufficient evidence to support the claim that due to neglect and lack of care and supervision, R1 sustained a pressure injury while in care. Therefore, this allegation is deemed Substantiated at this time. Continue on LIC9099C.. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was issue, along with appeal rights. Regarding the allegation, ‘Facility staff are unable to meet resident's care needs,’ it is alleged that R1 was only at the facility for a month, and they could not handle R1, but accepted R1 from a hospital placement. It is also alleged the facility staff could not move or reposition R1 during the duration of stay. During the investigation, LPA Walker conducted interviews with the administrator, and facility staff. The LPA also attempted to contact R1 to obtain additional information. However, all contact numbers provided were no longer in service. Interviews with the administrator revealed that facility staff reposition residents that require repositioning ‘as needed.’ The Administrator stated that Resident #1 (R1) was repositioned approximately every hour. Interviews with the administrator also revealed that all facility staff are trained in repositioning. Interviews with facility staff revealed tthat staff were able to move/reposition R1. Although the staff stated that R1 ‘was heavy,’ staff ‘always repositioned’ R1. Staff confirmed that R1 was a two-person assist, and repositioning would be conducted ‘often’ as they were ‘always in pain’; and, R1’s diapers had to be changed. Based on conducted interviews and a record review, R1 was placed on Home Health to receive wound treatment upon staff reporting to the administrator that R1 had an open wound. Therefore, there is insufficient evidence to support the allegation ‘Facility staff are unable to meet resident's care needs.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted and a copy of the report was emailed.the state’s words, verbatim · CDSS document, May 27, 2022 · control 29-AS-20211001095530

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Jun 1, 2022

87615(a)(1) Prohibited Health Condition: Persons who require health series for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly. (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee did not fail to comply with the section cited above. The Licensee retained a resident with a prohibited health condition between 9/21/21 and 9/28/21, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jun 1, 2022

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes… and that appropriate assistance is provided when such observation reveals unmet needs… documented and brought to the attention of the.. physician… This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to communicate R1’s worsening pressure injury/wound with R1’s physician which attributed to R1’s stage 4 pressure injuries while in care, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD. Immediate civil penalty of $500 is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(c) · Plan of correction due date: Jun 3, 2022

87463(c) Reappraisals(c): The licensee shall arrange a meeting with… a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition… This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above as the facility failed to have a level of care meeting to discuss R1’s change of condition when R1’s pressure injury worsened, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(3) · Plan of correction due date: Jun 3, 2022

Reappraisals (a)The pre-admission appraisal shall be updated...as frequently as necessary to note significant changes… (3) Any illness, injury…or change in the health care needs... Prohibited Health Conditions. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above as the facility failed to update R1’s appraisal with change of condition when R1’s pressure injury worsened, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2022

Plan of correction: Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition to CCLD.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPA was greeted by staff, and the LPA explained the reason for the visit. The LPA toured the physical plant areas inside and outside, with staff at 2:23 p.m., to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. Between 2:28 p.m. and 2:31 p.m., hot water temperatures measured between 113.2 and 113.8 degrees Fahrenheit in the common and private restrooms. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 118.5 degrees Fahrenheit at 2:34 p.m. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in dining room area. One (1) fire extinguisher was observed to be fully charged and purchased on 5/27/21. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility has one (1) shed in the backyard that utilized for additional storage. Continue on LIC 809C.. INFECTION CONTROL: During today’s visit, the LPA spoke with staff regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control. No deficiencies cited at this time. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 5, 2022

Allegation investigated: Resident's had questionable withdrawals from an account while in care. Resident's personal belongings went missing while in care.

On 03/02/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent complaint visit to deliver the findings regarding the above allegations. The LPA met with the Administrator Siranush Alvadzhyan at 1:20 p.m., and explained the reason for the visit. On 08/18/2021, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day day complaint investigation regarding the above allegations. LPA Urena arrived unannounced at the facility at 1:45 pm. LPA Urena spoke initially with caregiver Ruzanna Tonoyan. The caregiver contacted Administrator and the LPA waited for Administrator, Siranush Alvadzhyanto, to arrive and explained the reason for the visit. At 2:30 pm, LPA Urena conducted a physical plant tour and requested copies of staffs' schedule, Admission Agreement and resident documentation relevant to the investigation. The LPA reviewed staff and resident files, as well. The LPA interviewed residents and staff from 2:00 p.m. to 4:00 p.m. Unsubstantiated Resident had questionable withdrawals from an account while in care. It is alleged that there were questionable withdrawals made by the facility from the Resident’s #1 (R1’s) account outside of what was paid for their short time stay at the facility. To investigate this concern, LPA Urena conducted interviews. The LPA interviewed S1, who stated that R1 was admitted to the facility on approximately 07/18/2021 and left the facility on 07/21/2021. S1 further stated that while R1 resided at the board and care facility, R1 only paid a fraction of the total monthly fee. LPA Urena asked S1 how much R1 paid for the four days R1 stayed at the facility? S1 stated that R1 paid $50.00 dollars a day, and R1 paid in cash. When LPA Urena asked S1 to provide copy of the receipt/s for the fees charged to R1, S1 stated that they did not have copies, because R1 did not request one; therefore, S1 did not make any receipts. When LPA Urena interviewed R1, LPA Urena asked them about the questionable charges made with the debit bank card, but R1 could not remember the charges. When the LPA asked R1 specifically about giving permission to anyone to use their bank card and providing them with the PIN number, R1 stated that they were not sure, and did not remember. The LPA also conducted a record review on 08/24/2021 at 1:47 p.m. The LPA reviewed a bank statement submitted by the complainant; and although the bank statements provided by the complainant do show withdrawals made from the bank, the withdrawals do not identify the entity making the withdrawals, only the type of purchases made. The bank confirmed that $1300 was withdrawn from the bank account and that R1 did not make the withdrawals. The bank credited the resident’s bank account for the unauthorized charges and canceled the card. Additionally, none of the charges documented on the bank statement show charges made by the board and care facility. The Los Angeles Police Department is investigating the withdrawals. The facility record review revealed that an Admission Agreement (LIC 604A) for R1 was never created prior to the admission of R1 to the facility. Per S1, “R1 arrived in the middle of the night, and didn’t have time to create one, and then R1 left within a couple of days”. Consequently, there is no record on file which documents the fee charged for the month of board and care services. Based on the investigation, although the resident did have unauthorized withdrawals from their bank account while in care, there is insufficient evidence to support that a facility staff made the unauthorized withdrawal at this time. The allegation is deemed Unsubstantiated at this time. Resident’s personal belongings went missing while in care. It is alleged that the R1’s personal belongings went missing while R1 was in care and staying at the board and care facility. It is alleged that the missing personal belongings are medication, clothing, bank ATM card, and a Cal Fresh card. To investigate this concern, LPA Urena interviewed S1, R1, and RP. The LPA also conducted record review. The LPA interviewed S1 about the personal belongings and S1 stated that the resident was admitted to the facility approximately on 07/18/2021. S1 stated “R1 didn’t really didn't have many have belongings, only a sitting walker and a couple of bags of clothing. R1 didn’t have any meds”. The S1 stated that “when R1 left, R1 called transportation, got her stuff and left”. The record review revealed that Client/Resident Personal Property and Valuables (LIC 621) form was not completed by the facility staff at the time when R1 was admitted to the board and care facility. LPA Urena interviewed R1 and asked them about the missing personal belongings. R1 stated, "Nobody stole my belongings, only shoes." When LPA Urena asked R1 who stole their shoes, R1 could not say. Based on the investigation, there is insufficient evidence to support the allegation that the Resident’s personal belongings went missing while in care. The allegation is deemed Unsubstantiated at this time. No deficiencies were cited at this time. Exit interview conducted with administrator Siranush Alvadzhyan . Signatures were obtained. A copy of report was issued via email.the state’s words, verbatim · CDSS document, Mar 2, 2022 · control 29-AS-20210813133851

Type of visit: Case Management - Deficiencies

On 03/02/2022, at 1:35 p.m., Licensing Program Analyst (LPA) Sandra Urena, conducted an unannounced Case Management-Deficiency visit to address the deficiencies noted during complaint control # 29-AS-20210813133851, conducted on 08/18/2021. LPA Urena spoke with administrator Siranush Alvadzhyan, and explained the reason for the visit. At 2:30 pm on 08/18/2021, the LPA conducted residents’ file review, and the LPA found that the facility failed to ensure that a resident’s file for Resident #1 (R1) was completed prior to the time of admission. LPA interviewed Staff # 1(S1), and S1 stated that Resident R1 arrived in the middle of the night, and didn’t have time to create a resident’s file. The R1 resided at the facility from 07/18/2021 to 07/21/2021. The licensee did not create a file for R1 with all the required documents prior to admission, and during R1’ s stay at the facility. The following documents were missing: · Resident Appraisal RCFE (LIC 603A) .· Appraisal Need and Services Plan, when applicable (LIC 625). · Physician’s Report for RCFE (LIC 602A) Residential Care for the Elderly, · Medical Assessment Section 87569 and General Requirements for Allowable Health Conditions, · (Section 87702.1). · Identification and Emergency Information (LIC 601). · Current admission agreement with authorized signatures, Admission Agreement Guide for RCFE · (LIC 604A). · Evidence of receipt of personal rights information by resident and/or authorized representative Personal Rights (LIC 613C). · Reports of safeguards for resident cash resources including supporting receipts of expenditures. · Record of Client’s/Resident’s Safeguarded Cash Resources (LIC 405) and record of each resident’s personal property and/or valuables entrusted to facility, Client/Resident Personal Property and Valuables (LIC 621). Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Deficiencies were issued today. Exit interview was conducted. Today's report was reviewed and signed by Siranush Alvadzhyan. Citations and and Appeal Rights were reviewed and provided. A copy of the report was issued via email.the state’s words, verbatim · CDSS document, Mar 2, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(d) · Plan of correction due date: Mar 4, 2022

87506-Residents Records a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidence by Base on the records review, the facility failed to ensure that a resident’s file for R1 was created prior to the time of admission to the facility, and while R1 resided in the facility, which poses a health and safety, personal risk to persons in care.the state’s words, verbatim · CDSS document, Mar 2, 2022

Plan of correction: Licensee agrees to review Regulation 87506 (a)-(d) to ensure that no resident is admitted, and resides at the facility without a full file Resident Record. A self certification letter attesting to reviewing the regulation should be submitted to the licensing office by 03/04/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies inspection visit at the facility today due to deficiencies observed during the initial visit of complaint control #29-AS-20211001095530. At 9:03 a.m., the LPA observed one (1) lighter on the outdoor seating area, accessible to residents in care. Lighter was secured at the time of observation. At 9:04 a.m., the LPA observed an outdoor shed, containing Detergent, Soap, Hot Shot Bug Killer, Comet, Easy Off, Ant & Roach Killer, Pinesol floor cleaner, and Round Up spray, among other chemicals, was unlocked and accessible to residents in care. Staff secured it at the time of observation. At 2:44 p.m., the Administrator did not provide the LPA the required documentation for one (1) out of six (6) resident files Hospice care plan. At 2:44 p.m., the Administrator also did not provide the LPA the required documentation for one (1) out of six (6) resident files Home Health care plan. Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty assessed for repeat violation. Exit interview conducted, today's reports and appeal rights were issued.the state’s words, verbatim · CDSS document, Oct 4, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1)(2) · Plan of correction due date: Oct 4, 2021

87705 Care of Persons with Dementia:(f)The following shall be stored inaccessible to residents with dementia:(1) Knives, matches.. (2) Over-the-counter medication.. toxic substances such as.. cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the LPA observed one (1) lighter on the outdoor patio seating and an unlocked outdoor shed containing cleaning supplies and disinfectants, which poses an immediate health and safety rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2021

Plan of correction: During today's visit, lighter and outdoor shed was locked and secured. The Licensee has agreed to do the following: 1. Provide training on section 87705(f)(1),(2) to staff, and submit proof of training to CCL by 10/11/2021. Civil penalty assessed for repeat violation on 05/27/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d)(1)(I) · Plan of correction due date: Oct 4, 2021

Resident Records:(d)All resident records shall..(1)Licensing representatives shall not remove..records..(I)Any other records containing.. health-related information..(e)Original records.. shall be retained for a minimum of three (3) years.. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as one (1) out of six (6) resident files did not contain the resident Home Health care plan, which poses a potential health, and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2021

Plan of correction: The Licensee agreed to do the following: 1. Submit required Home Health records to CCLD by 10/07/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b) · Plan of correction due date: Oct 4, 2021

87633(b) Hospice Care of Terminally Ill Residents: (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as one (1) out of six (6) resident files did not contain the resident Hospice care plan, which poses a potential health, and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2021

Plan of correction: The Licensee agreed to do the following: 1. Submit required Hospice records to CCLD by 10/07/2021.

Allegation investigated: Staff unable to communicate with resident due to language barrier. Resident toileting needs are not being met.

Licensing Program Analyst (LPAs) Brian Balisi conducted a subsequent complaint visit to deliver final findings for the allegations listed above. LPA met with Ruzanna Tonoyan and explained the reason for the visit. LPA spoke with the Administrator who stated Ruzanna is able to sign for the report. During the course of the investigation, LPA conducted a physical plant tour virtually on 12/24/2020 as well as interviewed Administrator. On 6/11/21 LPA conducted interviews with facility staff and gathered and reviewed facility documentation pertinent to the allegation. On 6/18/2021, LPA conducted interviews with the administrator and residents. It was alleged, that staff are unable to communicate with resident due to language barrier, LPAs interview with residents revealed most feel they do not have any concerns with communicating with staff at the facility. LPAs interviews with staff revealed they were able to communicate regarding facility business, resident care needs and questions related to emergency response. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that staff are unable to communicate with resident due to language barrier. Therefore, the above allegation is UNSUBSTANTIATED at this time Unsubstantiated continued from 9099 It was alleged that Resident toileting needs are not being met, LPAs interview with residents revealed that most do not have any concerns with staff assisting them with their toileting needs. During the course of the investigation LPA observed Resident 1 (R1) request Staff 1 (S1) to use the bathroom. S1 went into the bedroom and assisted R1 into the bathroom and waited by the door until R1 requested S1 to return them to their room. Based on the information gathered during this and previous visits, the department does not have sufficient evidence to determine that resident toileting needs are not being met. Therefore the above allegation is UNSUBSTANTIATED at this time. Exit interview conducted. Report issued and sent via Email.the state’s words, verbatim · CDSS document, Aug 6, 2021 · control 29-AS-20201216081630