Leo's Assisted Living II

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Mariana Agban conducted a follow up unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPA met with the Administrator and explained the reason for the visit. After further investigation LPA reviewed and obtained staff records. Records revealed that staff#2 (S2) doesn't have fingerprint and background clearance. Staff#2 (S2) started employment at this facility in June of 2022 and Staff#3 (S3) does have fingerprint and background clearance, but is not associated to this facility. According to S3 they started employment at this facility about two years ago. There were no transfer request forms in the personnel file. The Licensee/Administrator did not request a transfer with the department. This was previously cited on 07-27-2023. Deficiencies and civil penalty issued. Appeal rights given. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 20, 2023

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:Based on interviews and review of the personnel file one staff(S3) is not associated to the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Admnistrator agreed to transfer Staff 3(S3) and assosiate them to the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Oct 20, 2023

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 This requirement is not met as evidence by:Based on interviews and review of the personnel file one staff(S2) is not background cleared to the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator will remove S2 immedatley and will not allow them to return until they obtain background clearance and assosition to the facility. Administrator will sumbit all documents to LPA when complete.

Allegation investigated: Staff forced resident to assign licensee as resident's substitute payee. Staff does not ensure bathroom needs are being met. Staff does not allow resident to communicate with resident's family.

At 10:00am, Licensing Program Analysts (LPAs) Mariana Agban, and Huma Rahimi conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPAs granted access to the facility by staff. Administrator arrived shortly after and LPAs explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:10am, LPAs requested resident and staff roster. At 10:20am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. LPAs conducted file review and observed missing Physcian's report, incomplete Admission Agreement for R1. At approximately 10:30am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:40am – 12:10pm, LPA interviewed the Administrator, two (2) staff and four (4) residents and the Administrator. Unsubstantiated Allegation: Staff forced resident to assign licensee as resident's substitute payee. It was alleged that R1 was forced to assign the administrator as resident's substitute payee. Administrator denied the allegation. Administrator stated that R1 was responsible for their own finances. Administrator stated that for the 2 weeks R1 was in the facility R1 didn't provide any form of payment to the Administrator. Administrator contacted R1's family to become the POA of R1 to provide any sort of payment. Interview with 2 staff and 3 residents revealed that they didn't witness any resident being forced to assign licensee as resident's substitute payee. Allegation: Staff does not ensure bathroom needs are being met. It was alleged that R1's bathroom needs are not being met. Administrator denied the allegation. Interviews with 3 residents revealed that staff frequently assist residents with their bathroom needs. Residents stated that they have a call on button for immediate assistance as well as staff do rotation checks for each resident. Allegation: Staff does not allow resident to communicate with resident's family. It was alleged that R1 is being isolated and was prevented from contacting their family. Administrator denied the allegation. Administrator stated that R1 was homeless and didn't have family initially. Per Administrator, R1 didn't talk to their family for years and didn't know their contact information. Administrator stated R1 and R1's sister had many phone calls in regards the sister becoming the POA. Interview with 3 residents revealed that they are allowed to contact their families at any time. Based on inspection, observation and interviews there is no sufficient evidence to support the allegation. Therefore, all allegations are Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 18, 2023 · control 31-AS-20231009085600

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPAs met with the Administrator and explained the reason for the visit. During the visit, LPAs observed two (2) incidents for 2 residents that were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Moreover, Administrator informed LPAs that R1 was hospitalized on 10/03/2023. LPAs reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPAs informed the Administrator to submit the following two (2) incidents that occurred on: 10/03/2023 (one incident) 10/06/2023 (one incident) In addition, review of R1's record revealed that the facility file is incomplete/missing documents. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B,D · Plan of correction due date: Oct 25, 2023

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the five (5) incidents that occured on 10/3/23 and 10/6/23 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copies of 2 incidents, shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Oct 25, 2023

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Administrator will sumbit a written explanation on how to manage residents files for future addmissions.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Mariana Agban and Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20231009085600. LPAs met with the Administrator and explained the reason for the visit. During the visit it was observed that staff #2 (S2) and staff #3 (S3) were working in the facility without being associated with this facility. Record review revealed S2 and S3 do have fingerprint and background clearance, but is not associated to this facility. Employee records revealed S2 started employment at this facility in June of 2022. In addition, Staff #3 (S3) started employment at this facility about two years. Interviews with residents and staff corroborate S2 and S3 have worked in the facility and provided assistance to residents. Team requested and reviewed personnel files. There were no transfer request forms in the personnel file. The Licensee/Administrator did not request a transfer with the department. This was previously cited on 07-23-2023. A civil penalty will be issued. Due to time constrains LPA was unable to complete citations. The Administrator was informed that additional visit will follow to render the citations. Copy of this report provided, appeal form given. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 18, 2023

Type of visit: Office

A second Informal Conference was conducted today at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss the licensee’s abandonment of the facility and possible solutions to resolve the issue while accounting for the health and safety of the current residents. Prior to the meeting, Licensee was given the chance to review the facility file. Present at today's meeting were the following: · Anna Gharibyan, Licensee - Levon Sayadayan - Khatchik Danielian, Administrator - Araksya Arzumanyan, caregiver - Naira Margaryan, Licensing Program Manager (LPM) - Nichelle Gillyard, Licensing Program Manager (LPM) · Nicholas Reed, Licensing Program Analyst (LPA) The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: The facility has been in operation since licensure on 08/26/2020. The Licensee has also operated Leo’s Assisted Living (197609916) since 03/05/2020. Since then, the facility has accrued more deficiencies: - 01/12/2023: LPA Reed completed multiple complaint investigations and issued Type B deficiencies under CCR 87307(a)(3)(A), 87411(c), 87411(d)(3), 87464(f)(3), 87506(c)(1), and 87555(b)(5). - Liability Insurance and Licensee Abandonment: · 05/31/2023 LPA Michael Cava contacted licensee Anna Gharibyan requesting proof of liability insurance. Licensee stated proof would be shown within 2 days. · 06/27/2023 LPM Nichelle Gillyard contacted licensee Anna Gharibyan requesting proof of liability insurance once again, as it had not yet been provided. · 07/05/2023 LPA Melissa Ruiz conducted a case management visit and issued a Type A deficiency under Health and Safety Code 1569.605 and a Type B deficiency under CCR 87411(d)(3) for staff being unable to communicate to residents in English. · 07/27/2023 LPA Antonia Alvizar and LPM Naira Margaryan visited the facility and reissued the Type A deficiency under Health and Safety Code 1569.605. · 08/04/2023 During an interview, Administrator Khatchik Danielian, facility staff Araksya Arzumanyan, and facility staff Narine Arakelyan stated licensee Anna Gharibyan has not been involved in facility affairs since selling the business in December 2021. The same information was verified by the Licensee Representative Levon Garibyan during phone conversation with LPM Margaryan on 08/15/2023. Levon stated the previous liability insurance policy had expired and the licensee forgot to renew the policy. Anna stated that although Khatchik is the administrator, Anna is still the licensee but does not have much time to be at the facility in person. LPM Margaryan reiterated the chronic non-compliance and repeat violations must be addressed by the licensee to show her presence in the facility. Levon stated he owns the property and is leasing the property to Khatchik. LPM Gillyard explained the regulation for Licensee Accountability and stated that until the new application for Oasis II Assisted Living (197610389), the current licensee is still responsible for all facility operations and plans of corrections. LPM Margaryan discussed the possibility of a Non-Compliance Conference (NCC), Technical Support Program (TSP), and quarterly visits. LPM Margaryan reviewed the outstanding deficiencies and plans of corrections which have not yet been cleared. LPMs Gillyard and Margaryan stressed the importance of staff training to ensure person centered care is afforded, and the extensive hospice care requirements for each resident. LPA Reed informed of the Regional Office email address for Plans of Corrections and hospice regulations. LPA Reed printed LIC 809-D pages with outstanding plans of corrections due, hospice regulations, and annual fee payment history.the state’s words, verbatim · CDSS document, Aug 23, 2023

Type of visit: POC

Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Naira Margargan met with facility staff, Narine Arakelyan at 8:15AM and LPM and LPA was greeted by staff and granted entrance. The purpose of the visit was explained. On 07/28/2023 a Plan of Correction was conducted due to facility not submitting Liability Insurance as it was requested. During visit other Title 22 Deficiencies were noted and citations were issued. Plan of Corrections for the issued citation were not submitted by POC due date and this visit was conducted to determine if plan of corrections were satisfied. At 8:28AM LPA requested a copy of the liability insurance. Staff was unable to locate the document, Khatchik Danielian (Administrator) was contacted and arrived at 9:15AM. Once again, LPA Alvizar explained that the purpose of this visit is to clear deficiency issued 07-05-2023 and 07-28-2023. At 10:00 AM LPA and Staff conducted a tour of the facility. At 10:45AM Khatchik provided appropriate documentation stating that Liability insurance was processed, and they are waiting for the final binder. The copy of Certificate of Liability Insurance will be received upon with the binder. At 11:00AM Khatchik provided appropriate documentation about Palliative Care, identifying the services they provided. The services included a wound care and staging of pressure injuries. Based on information received during this visit, the plan of correction is satisfied. During today’s visit LPA and LPM received all appropriated documents to clear the plan of corrections. In addition, during today’s visit LPA and LPM discussed Health and Safety Code regarding facility abandonment and other issues. The Administrator was informed that they may be called to the Woodland Hills South Licensing Office to Discuss the current facility status. No citations were issued during this visit. Exit interview was conducted and copy of report was issued.the state’s words, verbatim · CDSS document, Aug 4, 2023

Allegation investigated: Staff is not being rotated and repositioned resident resulting in multiple pressure injuries Staff are not maintaining a comfortable room temperature for residents

Licensing Program Manager (LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Antonia Alvizar conducted a complaint investigation visit to the facility. Upon arrival LPM and LPA was greeted by staff and granted LPM and LPA entrance. Staff contacted Designee Administrator, Sona Gevorkyan via phone and explained the purpose of this visit. At 10:07AM a few minutes later Sona assisted during this visit. Entranance interview conducted. LPM and LPA conducted physical plant tour at 10:15AM, requested copies of facility documents relevant to the investigations. At 10:45 AM LPM and LPA conducted file review. Between 11:37AM to 1:54PM interviewed three (3) staff and three (3) residents. At 3:26PM LPM obtained photos of R1’s file which include the following documents: Emergency information, Physician Report, Resident Appraisal, Hospice Records, Needs and Service Plan. Unsubstantiated Allegation: Staff is not rotating and repositioning resident resulting in multiple pressure injuries During interview R1 indicated that they are able to reposition every two (2) hours and is non-ambulatory per physician report dated 03-14-2023. R1 can communicate and ask for help when needed. R1 indicated that there is no problem with the care being provided at the facility. Staff interviews confirmed that R1 was rotating as needed and staff assisted R1 by placing pillows in areas to relieve pressure points. Interviews were conducted with Hospice agency who indicated that staff are educated on the care associate with the resident’s wounds. Based on interviews, there is an insufficient information to support the allegations. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation: Staff are not maintaining a comfortable room temperature for residents. The complainant concern is that the air conditioner was not on during a visit. At 10:15AM LPA/LPM conducted a tour of the facility and observed that the air conditioner was on and operational, and the temperature measured at 85 degrees Fahrenheit. The temperature fell within regulation. LPA also observed fans in rooms for additional cooling. Two out of 3 staff indicate there were no complaints of excessive heat and that the air conditioner was ever turned off. Three (3) out of three (3) residents interviewed stated that sometimes is a little warm but if they ask staff to turn on the Air Conditioner higher, they do. Based on observation and interviews there is an insufficient information to support the allegations. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 31-AS-20230724090132

Type of visit: POC

Licensing Program Analyst(LPA) Antonia Alvizar and Licensing Program Manager (LPM) met with facility Designee Sona Gevoryan for a plan of correction visit. The purpose of the plan of correction visit is to clear deficiency issued 07-05-2023. Entrance interview conducted. At 10:20 am LPA requested a copy of the liability insurance. The facility Designee was unable to locate the document, Mr. Khatchik Danielian(Administrator) was contacted. LPM spoke with Khatchik Danielian and requested the liability insurance as the department as requested on a previous visit 07-05-2023. Mr. Danielian stated that a request for liability insurance has been made but does not have a current copy. As a result, the plan of correction is not met. Because the department did not clear the plan of correction within 10-days of it being due a new deficiency will be issued. In addition, it was discovered that facility designee Sona Gevoryan has not provided documentation to associate herself to the department therefore is not associated to the facility. She stated she just started today and will fax a copy into the department for association. In addition in the course of today, visit it was discovered that staff #2 is not associated to the facility. A citation and civil penalty will be issued. Other observations: LPM requested that the security straps on the cabinets be replace as there are issues with them sticking to the cabinet door and they can be easily ripped off making chemical, medications, etc. accessible. This visit was conducted in conjunction with today complaint 31-AS-20230724090132 visit, the following deficiencies where observed to be in violations however were not alleged on the complaint: Staff are providing wound care and staff are not appropriate skilled wound care professionals. Administrator has not documented all aspects of wound care in the resident #1 file. Deficiency and appeal rights issued. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 28, 2023

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on interview and review of licensing report summary facility Designee is not associated to the facility. No documentation to associate staff/designee has not been submitted. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: The facility designee has agreed to provide the LPA with copies of documentation to associate to the facility. Today LPM collected documentation for staff 1. Staff #2 documentation is needed. Submit transfer form and clear copy of ID.

From the deficiency page — Deficiency type: Type B · Section cited: CCR1569.605 · Plan of correction due date: Jul 28, 2023

§1569.605 Liability insurance; coverage requirements On and after July 1, 2015... This requirement is not met as evidence by: Based on records reviewed, and interview with the administrator facility does not have current liability insurance coverage.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87631(a)(1) · Plan of correction due date: Aug 3, 2023

Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1) When care is performed by or under the supervision of an appropriately skilled professional. This requirement is not met as evidence by: Based on interview staff are providing wound care and staff are not appropriate skilled wound care professionals. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator has agreed to have hospice document that staff has been trained on certain wound care issues. Need to obtain complete hospice care plan outling the stage of the wound. The resident reappraisal and needs and service needs to reflect the resident wounds and how staff can assist.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87631(a)(3)(B) · Plan of correction due date: Aug 3, 2023

Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound..(3)... pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. (B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement is not met as evidence by: Based on interviews and file review the facility is not documenting all aspects of care for R1 This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: Administrator has agreed to have hospice document that staff has been trained on certain wound care issues. Need to obtain complete hospice care plan outling the stage of the wound. The resident reappraisal and needs and service needs to reflect the resident wounds and how staff can assist.

Allegation investigated: Staff do not ensure facility is free of insects for residents in care Staff do not ensure bathing assistance is provided to residents Staff do not ensure resident is accorded clean bed linens

Licensing Program Manager Licensing Program Analyst (LPA) Antonia Alvizar conducted a subsequent visit to the facility to complete investigation initiated on 07/05/2023 by LPA Melissa Ruiz. Upon arrival LPA was greeted by staff (S1) and S1 granted LPA entrance. S1 contacted Administrator, Khatchik Danielian via phone and explained the purpose of this visit. At 10:50AM a Khatchik arrived and assisted during this visit. LPA conducted physical plant tour at 10:55AM, requested copies of facility documents relevant to the investigations. Between 11:45AM to 1:50PM interviewed two (2) staff and four (04) out of four (04) residents. At 2:15PM LPA received Emergency information, Physician Report, Resident Appraisal, Shower Schedule, Needs and Service Plan. Staff do not ensure facility is free of insects for residents in care It is alleged that resident had several bug bites on body but did not know what type of bites they were from. During physical plant tour LPA Alvizar inspected residents’ rooms and did not observe any signs of insects in faciltity and/or residents' bed. Unsubstantiated Staff interviews revealed that facility is free of insects, and they have not seen any insects in the facility. Four (4) out of four (4) residents stated that they have not experience any bug bites and facility does not have any bugs. Based on observation and interviews, there is an insufficient information to support the allegations. Therefore, the allegation is deemed Unsubstantiated at this time. Staff do not ensure bathing assistance is provided to residents It is alleged that resident has not been bathed in two (2) weeks due staff not showing up. Staff interviews revealed that resident are given showers as schedule however some resident refuse to shower because they feel sick. Four (4) out of four (4) residents stated that they receive showers and/or bed baths from facility staff and/or outside services as schedule. Based on observation, interviews, and record review there is an insufficient information to support the allegations. Therefore, the allegation is deemed Unsubstantiated at this time. Staff do not ensure resident is accorded clean bed linens It is alleged that the residents bed sheets are not washed on a regular basis and are dirty. During physical plant tour LPA Alvizar inspected laundry room, residents’ rooms and did not observe any dirty bed linens. Staff interviews revealed that dirty bed linens are cleaned daily. Four (4) out of four (4) residents stated that the facility keeps the bed linens clean and the washer machine is always operating cleaning all dirty linens and clothing. Based on observation and interviews, there is an insufficient information to support the allegations. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. No citations issued. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 10, 2023 · control 31-AS-20230703120422

Allegation investigated: Licensee does not ensure staff are able to communicate with residents in care.

On 7/5/2023, Licensing Program Analyst arrived at the facility to conduct an initial 10-day complaint investigation. Allegation: Licensee does not ensure staff are able to communicate with residents in care. Upon LPAs arrival, LPA was greeted by staff (S1) and S1 was unable to thoroughly speak or communicate in English. S1 was the only staff at the facility during this visit, responsible for providing care and supervision to three out of four residents in care. Later on, another staff arrived at the facility (S2) who can communicate in English. Based on LPAs observation and interviews, the allegation above is deemed SUBSTANTIATED. Deficiencies issued per CA Code of Regulations, Title 22. Report signed and delivered. Substantiatedthe state’s words, verbatim · CDSS document, Jul 5, 2023 · control 31-AS-20230703120422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Jul 12, 2023

Personnel Requirements - General 87411(d)(3).. experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance.. Skill and knowledge required to provide necessary resident care and supervision,... This requirement is not met as evidenced by: Based on LPA interview with staff, the administrator did not have staff available to communicate with residents and emergency personnel effectively which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit updated LIC500 to reflect all staff.

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 7/5/23, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility. The purpose of this report is to address the Licensee/Administrator's unwillingness to provide the Woodland Hills Regional Office (RO) with proof of liability insurance coverage. The RO has attempted to contact the Licensee/Administrator multiple times on 5/25/2023, 5/31/2023, and 6/27/2023. As of today's date, no proof of Liability Insurance has been faxed to the RO. The Licensee/Administrator has submitted a letter stating that the facility is under a "CHOW" application, therefore, there is no need to obtain liability insurance for a couple of days. LPA reviewed the letter and the CHOW application was submitted on 12/9/2022. LPA Ruiz explained to the new Licensee under the name "Oasis II Assisted Living" that although the facility is under a "CHOW" application, facility still needs to maintain liability insurance coverage, because there is no prediction or set time line for when the CHOW will be completed and as of today's date, it has been over 6 months that facility did not have coverage. Additionally, LPA explained that any and all reports or citations, are still under the responsibility of the current licensee/administrator under Leo's Assisted Living II because the CHOW has not been completed. Deficiencies issued per CA Code of Regulations, Title 22. Report signed and delivered.the state’s words, verbatim · CDSS document, Jul 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Jul 7, 2023

§1569.605 Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidence by: Based on records reviewed, facility does not have current liability insurance coverage.the state’s words, verbatim · CDSS document, Jul 5, 2023

Plan of correction: Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will need to be submitted as POC.

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required Infection Control visit at this facility. LPA met with administrator Katchik Danielian and explained the purpose of this visit. A tour of the physical plant was conducted at 3:45 PM and the following was observed: The facility has one main entrance being used, the main door has required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) are posted on the door. The PPE screening station is located immediately upon entrance and had a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. Visitors are required to wear mask. The facility has an approved mitigation plan on file. The facility is a single storey building and has three (3) bedrooms and two (2) bathrooms. Fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 75°F. The dual smoke and carbon monoxide alarms are hardwired and interconnected and observed to be operational. Fire extinguisher is located at the dining area and observed to be full and current. (continued on LIC 809-C) (continued from LIC 809) Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry room is located in the bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at 113.7°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet. Medications: LPA observed that the medication are kept in the filing cabinet inside the office and was observed to be locked and inaccessible to residents. There was a complete first aid kit located on top of the medication cabinet. Garage: There is no garage at the facility only drive ways. The Backyard had a covered shaded area for clients with outdoor furniture. There is no body of water at the facility. Staff and residents records were reviewed and appeared to be complete and updated. Exit interview conducted. Copy of this report issuedthe state’s words, verbatim · CDSS document, Jan 13, 2023

Allegation investigated: Staff is unable to properly communicate with residents due to language barrier. Facility has inadequate food service. Staff were unable to provide Paramedics with resident's records.

At 9:30 a.m. on 01/12/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA interviewed residents, staff, and Administrator at 9:45 a.m. on 12/08/2022. LPA conducted a records review at 12:15 p.m. on 12/08/2022. LPA reviewed photographs at 9:35 a.m. on 11/08/2022 and at 5:30 p.m. on 12/07/2022 Regarding the allegation “Staff is unable to properly communicate with residents due to language barrier”, it was alleged Staff #1 (S1) and Staff #2 (S2) did not speak English fluently enough to communicate with residents. From interviews, residents had difficulty communicating with S1 and S2. Residents have used a translator app and written translations from Armenian to English. When interviewed, S1 stated they are taking English lessons, and S2 did not speak sufficient English. The administrator noted that since being hired on 12/05/2022, employees have been hired who effectively communicate with residents, though conditions were different prior. Based on interviews and record review, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. Substantiated Regarding the allegation “Facility has inadequate food service”, it was alleged the food served did not meet residents’ nutritional requirements. A similar allegation was investigated on 11/08/2022 and 11/09/2022 in complaint # 31-AS-20221108101558. From interviews, residents were unsatisfied with the food served. The Administrator noted that food quality has improved since their recent hiring. From observations, food served on 12/08/2022 appeared to improve in quality and variety from photos observed on 12/07/2022 and 11/08/2022. Based on observations and interviews, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. Regarding the allegation “Staff were unable to provide Paramedics with resident's records”, it was alleged that paramedics could not access the records of Resident #1 (R1) after they called 9-1-1. From interviews, staff do not recall the encounter with paramedics and R1. R1 claimed they had to communicate with paramedics and provide information since the facility was not able to. Based on interviews, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. Exit interview conducted. Copy of report provided. Appeal rights discussed.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 31-AS-20221202164248

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Feb 10, 2023

87411 Personnel Requirements - General (d) All personnel shall... have related experience in the job assigned to them. (3) Skill and knowledge required to provide necessary resident care... including the ability to communicate with residents. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above in 2 out of 2 employees which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee has hired staff who can adequately communicate with residents. Deficiency is cleared as of 01/12/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(3) · Plan of correction due date: Feb 10, 2023

87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above in 3 out of 5 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee will conduct a training with all staff on food service requirements and submit to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Feb 10, 2023

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above in 1 out of 5 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Administrator showed LPA resident files which are ready for emergency responders. Staff have been trained. Licensee to submit written statement confirming that staff are capable of accessing emergency files for emergency personnel.

Allegation investigated: Facility did not provide resident with a copy of their Admission Agreement Staff took residents cell phone after calling 9-1-1

At 9:30 a.m. on 01/12/2023 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. No immediate health or safety concerns were observed. LPA Reed interviewed staff, family, and residents at 11:30 a.m. on 11/08/2022 and at 10:00 a.m. on 11/09/2022. LPA conducted record reviews at 12:45 p.m. on 11/08/2022 and at 9:35 a.m. on 11/09/2022. LPA toured the physical plant at 11:15 a.m. on 11/08/2022 and at 9:30 a.m. on 11/09/2022. Regarding the allegation “Facility did not provide resident with a copy of their Admission Agreement”, it was alleged Resident #1 (R1) did not receive a copy of their admission agreement. From interviews, the Administrator stated R1 received a copy, which R1 denied. Other residents interviewed did have copies of their admissions agreements. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Unsubstantiated Regarding the allegation “Staff took residents cell phone after calling 9-1-1”, it was alleged S1 took R1’s cell phone after calling 9-1-1. From interviews, S1 said they never took R1’s phone. R1’s roommate Resident #2 (R2) did not witness the event occur. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility food is not nutritious”, it was alleged that meals served have not sufficient in quantity or quality. From interviews, residents noted the food served was not consistently nutritious and often lacking fruits or vegetables. Staff and residents noted Staff #2 (S2) was designated to shop for the facility. S2 had not been to work in over 3 days. From photo review, several meals served were lacking fruits and vegetables. R1 also showed LPA receipts from takeout ordered due to poor food quality. From observations, LPA saw a refrigerator full of fresh fruits and vegetables. Based on interviews, phot review, and observations, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. Regarding the allegation “Medications accessible to residents”, it was alleged S1 left medications unlocked. From physical plant tour on 11/08/2022, LPA observed medications unlocked and accessible. S1 immediately locked the medications afterwards. Based on observations, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. The deficiency was cited during a case management visit on 11/08/2022. Regarding the allegation “Resident bed in disrepair”, it was alleged the brakes on R1’s bed were inoperable. From interviews, some residents noted their beds to be uncomfortable. From observations, the brakes on R1’s bed were not functional. Based on observations and interviews the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D. Exit interview conducted. Copy of report provided. Appeal rights discussed.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 31-AS-20221108101558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Feb 10, 2023

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in 2 out of 2 employees which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee has hired 2 additional staff with sufficient qualifications. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Feb 10, 2023

87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural... backgrounds and food habits of residents. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in 3 out of 5 residents which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee will conduct a food requirement training for all staff and submit by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A) · Plan of correction due date: Feb 10, 2023

87307 Personal Accommodations and Services (a)...The following provisions shall apply: (3) ...the licensee shall assure: (A) A bed... shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above in 3 out of 5 residents which posed a potential risk to the Health, Safety, or Personal Rights to persons in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee will inspect all resident beds and ensure that resident are comfortable with their sleeping arrangements. Confirmation will be provided to LPA by POC due date.

Allegation investigated: Staff member is physically abusing resident in care.

At 11:10 a.m. on 01/12/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Administrator and disclosed the reason for the visit. Regarding the allegation above, it was alleged Resident #1 (R1) was physically abused by staff at the facility. LPA interviewed a resident at 11:12 a.m., staff at 11:45 a.m., and family at 12:15 p.m. on 01/12/2023. LPA conducted a record review at 11:55 a.m. on 01/12/2023 and a a file review at 8:00 a.m. on 01/12/2023. From interviews, Resident #2 (R2) reported no abuse had occurred to them. Staff #1 (S1) stated that R1 hit them while S1 was providing assistance. S1 blocked further hits with their hand, and Staff #2 (S2) witnessed the interaction. R1’s family member stated R1 may have dreamt the encounter and noted R1’s tough attitude. From file review, another unsubstantiated allegation of abuse towards R1 came from a different licensed facility on 12/29/2022 as part of complaint investigation #31-AS-20221229154813. Based on record review, file review, and interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided. Appeal rights discussed. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 12, 2023 · control 31-AS-20230110153807

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.

Type of visit: POC

At 9:30 a.m. on 01/12/2023 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced Proof of Correction (POC) visit. LPA met with the Administrator and disclosed the reason for the visit. At 11:14 a.m. on 12/29/2022 the Administrator notified LPA that all deficiencies were cleared. LPA conducted a file review today at 10:00 a.m. and observed complete files for current staff and residents. LPA cleared deficiencies from 09/28/2022 and 10/27/2022.the state’s words, verbatim · CDSS document, Jan 12, 2023

Type of visit: Office

An Informal Conference was conducted today at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss recent deficiencies and provide guidance to ensure future compliance. Prior to the meeting, Licensee was given the chance to review the facility file. Present at today's meeting were the following: · Anna Gharibyan – Licensee - Khatchik Danielian - Administrator - Cassandra Harris, Licensing Program Manager (LPM) · Nicholas Reed, Licensing Program Analyst (LPA) The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: The facility has been in operation since licensure on 08/26/2020. Component II was waived due to the applicant/Administrator on file Sargis Ayvanyan having experience in a licensed facility in good standing (Tarzana Senior Living, Inc. – 197609918). The Licensee has also operated Leo’s Assisted Living (197609916) since 03/05/2020. · On 07/14/2021 LPA Patrick Shanahan conducted an annual inspection with Licensee’s husband Leo Sayadyan. On 08/30/2022 LPA Nicholas Reed conducted an annual inspection with Licensee’s husband Leo Sayadyan. LPA Reed later checked the Guardian system and discovered Leo Sayadyan was not associated to the facility. Leo also did not have a criminal background check on file, nor was he listed on the facility’s LIC 500. · On 09/28/2022 LPA Reed conducted an unannounced complaint visit. LPA discovered that the staff present, Egda Pastora Castro, did not have a criminal background clearance. Egda signed the report as “Sofia Hernandez”. When asked who the boss was, Egda provided LPA with the phone number for Anna Hakobyan. Anna was issued a permanent exclusion from CDSS-CCLD activities on 09/30/2021. The investigation resulted in a deficiency for lack of resident records. The deficiency has yet to be corrected, and daily civil penalties for a failure to correct the deficiency have accrued since 10/28/2022 in the amount of $100/day. · On 09/29/2022 LPA Reed conducted an unannounced case management visit to address staff without criminal background clearances. The LIC 500 was not current. From an interview, Egda Pastora Castro stated she had worked at the facility for four days. Therefore, LPA issued a civil penalty in the amount of $100/day for four days of working without a criminal background clearance. Egda’s criminal background clearance was transferred on 10/01/2022. · On 10/27/2022 LPA Reed conducted an announced case management visit. LPA notified Administrator Armine Arakelian of the visit with the intention to meet Administrator and correct deficiencies. The Administrator did not arrive as expected. LPA observed staff Eydi Garcia in the facility. A criminal background clearance was submitted for Eydi on 10/01/2022 but was still “In Process”. Eydi was not cleared to be in the facility. Administrator Armine was not present for 4 out of 4 facility visits by LPA Reed, so LPA issued a deficiency for Administrator qualifications. LPA also issued a deficiency for the lack of personnel files. The deficiency has yet to be corrected, and daily civil penalties for a failure to correct the deficiency have accrued since 11/26/2022 in the amount of $100/day. · On 11/08/2022 LPA Reed conducted an unannounced case management visit and observed medication accessible and removed from its original container. The deficiency was cited. · On 11/09/2022 LPA Reed conducted an unannounced case management visit to address staff’s inability to communicate with residents in English. The deficiency was cited and corrected on 12/08/2022. · On 12/08/2022 LPA Reed conducted an unannounced POC visit to address the deficiencies from 09/29/2022 and 10/27/2022. The deficiencies were not corrected and have not been corrected to this day. Resident records and staff files are still incomplete. o LPA Reed has never met with Armine Arakelian in person in 7 out of 7 facility visits. o Resident records and personnel files are incomplete. o No deaths or hospice admissions have been reported. o The facility’s first resident was never reported. Anna noted that she had a family emergency in October, and Administrator Armine had COVID. Therefore, the two had limited participation in facility operations during October and November 2022. Anna noted Armine's estimated date of termination was 10/10/2022, at which point Dinah Pasco served as facility Administrator. Dinah was the Administrator until 12/05/2022 when Khatchik took over. Administrator Khatchik stated a resident was admitted to hospice yesterday. LPA Reed informed the Administrator of reporting requirements for the resident's hospice admission. Licensee, Administrator, and LPA reviewed Health and Safety Code 1569.682 regarding facility closure. Administrator Khatchik noted the license application was submitted to his consultant Sergey on 12/16/2022. LPM reviewed background information for the licensee, former administrators, and current administrator. All parties discussed the change of ownerships at Oasis Senior Living (#197610233) and Leo's Assisted Living #2. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 21, 2022

Type of visit: Case Management - Deficiencies

At 2:45 p.m. on 12/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with the Administrator and disclosed the reason for the visit. On 09/28/2022 LPA investigated complaint #31-AS-20220923175322 and substantiated the allegation of resident records not maintained at the facility. A Proof of Correction due date was set for 10/28/2022. At 12:15 p.m. on 12/08/2022 LPA reviewed resident records at the facility as part of complaint investigation #31-AS-20221202164248. LPA observed the following deficiency: The facility did not maintain records for Resident #1 (R1), Resident #2 (R2), nor Resident #3 (R3). Due to the failure to correct the deficiency cited on 09/29/2022, a civil penalty of $100 per day is hereby assessed for the period of 10/29/2022 – 12/08/2022 in the amount of $2,900 (29 days x $100/day). Daily civil penalties will continue to accrue until the deficiency is corrected. The civil penalty is issued on the attached LIC 421FC page. At 4:00 p.m. on 10/27/2022 LPA conducted a case management visit. LPA requested to view staff records. No staff records were available for audit. A deficiency was issued with a Plan of Correction date of 11/25/2022. At 12:15 p.m. on 12/08/2022 LPA requested staff records. The Administrator noted the facility did not maintain staff records for previous or current staff. Staff records were not available for audit. Due to the failure to correct the deficiency cited on 10/27/2022, a civil penalty of $100 per day is hereby assessed for the period of 11/26/2022 – 12/08/2022 in the amount of $1,300 (13 days x $100/day). Daily civil penalties will continue to accrue until the deficiency is corrected. The civil penalty is issued on the attached LIC 421FC page. Additionally, Staff #1 (S1) and Staff #2 (S2) did not maintain criminal background clearances and were not associated to the facility. The Administrator noted S1 began employment on 11/21/2022 and S2 began on 12/07/2022. An additional civil penalty is assessed due to a repeated violation of the same regulation within 12 months. The deficiency are cited on the attached LIC 809-D page. Civil penalties are issued on the attached LIC 421BG page and LIC 421FC page Exit interview conducted. Copy of report, appeal rights, and citation(s) issued.the state’s words, verbatim · CDSS document, Dec 8, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 8, 2022

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... 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) This requirement is not met as evidenced by: Based on file review, the licensee did not comply with the section cited above in 2 out of 3 employees which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2022

Plan of correction: Licensee will request for a criminal background clearance transfer to the facility and provide LIC 508, LIC 9182, and identification of all staff needing a transfer.

Type of visit: Case Management - Deficiencies

At 11:15 a.m. on 11/09/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. As part of complaint investigation # 31-AS-20221108101558, LPA interviewed residents on 11/08/2022 from 12:05 p.m. to 12:45 p.m. and on 11/09/2022 at 10:40 a.m. LPA interviewed Staff #1 (S1) on 11/08/2022 at 11:30 a.m. 3 out of 3 residents reported difficulty communicating with Staff #1 (S1). Resident #1 (R1) reported that they can not really understand S1. Resident #2 (R2) reported that S1 uses a translation app at times, but it is an inefficient method of communication. Staff #2 (S2) is bilingual and translates for residents and S1, but S1 reported S2 has not been at the facility for approximately 4 days. During today's inspection, the facility is not in compliance with Title 22 regulations. Deficiency is cited on the attached LIC 809-D page. Exit interview conducted. Copy of report provided. Appeal rights discussed.the state’s words, verbatim · CDSS document, Nov 9, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 9, 2022

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above in 1 out of 2 employees which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: Licensee will hire and retain at least one staff who is able to communicate effectively to residents. Licensee to submit LIC 500 with staff work hours and schedule.

Type of visit: POC

At approximately 9:20 a.m. on 11/09/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced Plan of Correction visit. LPA met with staff and disclosed the reason for the visit. On 09/28/2022 LPA investigated complaint #31-AS-20220923175322 and substantiated the allegation of resident records not maintained at the facility. A Proof of Correction due date was set for 10/28/2022. LPA called Administrator Armine Arkelian and Licensee Anna Gharibyan to remind them of the POC due date. LPA called Administrator Armine Arkelian on 11/08/2022 to remind that the Proof of Correction was not received in time. On 11/09/2022 at 9:35 a.m. LPA reviewed resident records at the facility as part of complaint investigation #31-AS-20221108101558. LPA observed the following deficiencies: Resident #1 (R1) had an Admission Agreement with missing signatures and no date, no LIC 602A Physician’s Report, an incomplete LIC 603 with no date, an incomplete LIC 621 with missing signatures and no date, and an incomplete LIC 625 Needs and Service Plan with missing signatures and no date. Resident #2 (R2) had an Admission Agreement with no signature and no date, an incomplete LIC 603, and an incomplete LIC 625 Needs and Service Plan. Resident #3 (R3) had no LIC 602A Physician’s Report, an incomplete LIC 603 with missing signatures and no date, and an incomplete LIC 625 Needs and Service Plan. Due to the failure to correct the deficiency cited on 09/29/2022, a civil penalty of $100 per day is hereby assessed for the period of 10/29/2022 – 11/09/2022 in the amount of $1,200 (12 days x $100/day). Daily civil penalties will continue to accrue until the deficiency is corrected. The civil penalty is issued on the attached LIC 421FC page. Exit interview conducted. Copy of report provided. Appeal rights discussed.the state’s words, verbatim · CDSS document, Nov 9, 2022

Type of visit: Case Management - Deficiencies

At 11:15 a.m. on 11/08/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, initial complaint visit of complaint #31-AS-20221108101558 . LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility at 11:25 a.m. and observed medication accessible. The medication was also removed form its original container and organized in a separate pill container. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the deficiency was cited (refer to LIC 809-D). Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 8, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Dec 9, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) ...medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above in 1 out of 3 residents which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 8, 2022

Plan of correction: Licensee will conduct an in-service training on the cited section for all staff handling medication and submit proof by the POC due date.

Type of visit: Case Management - Deficiencies

At 4:00 p.m. on 10/27/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced case management visit to address deficiencies. LPA met with staff and disclosed the reason for the visit. LPA notified the Administrator of the meeting on 10/26/2022 at 11:13 a.m. LPA called the Administrator on 10/27/2022 at 2:27 p.m. and 3:20 p.m. and left voicemails. At 4:15 p.m. LPA requested to review facility personnel records. The records were not available for audit. LPA observed S1 and S2 working at the facility during the visit. During today's inspection, the facility is not in compliance with Title 22 regulations. For failure to submit plan of corrections, a civil penalty in the amount of $2,100.00 ($100 per day X 21 days) is hereby assessed on 10/27/2022. Civil penalties are ongoing in the amount of $100 per day, per employee until the deficiency is cleared. Exit interview conducted. Copy of report, appeal rights, and citations issued.the state’s words, verbatim · CDSS document, Oct 27, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 25, 2022

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator...The administrator shall be on the premises a sufficient number of hours to permit adequate attention to the management ... of the facility. This requirement is not met as evidenced by: Based on observations the licensee did not comply with the section cited above in 1 administrator which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee will provide the LIC 500 with the administrator and their hours by the POC due date. The Administrator will be available during the scheduled hours to ensure the facility is managed properly.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(g) · Plan of correction due date: Nov 25, 2022

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Based on observations the licensee did not comply with the section cited above for 2 out of 8 employees which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee will ensure all personnel files are maintained at the facility and available for audit by the POC due date.

Type of visit: Case Management - Other

At approximately 11:00 a.m. on 10/26/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. LPA toured the facility and did not observe any immediate health or safety concerns. At 11:13 a.m. LPA interviewed the Administrator. At approximately 11:30 a.m. LPA interviewed staff and reviewed resident records. At approximately 11:45 a.m. LPA interviewed Resident #1 (R1). Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 26, 2022

Type of visit: Case Management - Deficiencies

At 12:35 p.m. on 09/29/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out. During a complaint investigation on 09/28/2022, LPA Reed conducted a file review at approximately 5:00 p.m. LPA observed 1 staff present was not associated to the facility in the Guardian system. The assistant Administrator confirmed over the phone that all staff had background clearances but needed to be associated. LPA conducted another file review on 09/29/2022 at 12:30 p.m. The staff present were still not associated to the facility in the Guardian system. Deficiency is cited on the attached LIC 809-D page. Exit interview conducted. Copy of report, appeal rights, and citation issued.the state’s words, verbatim · CDSS document, Sep 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 6, 2022

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review... 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) This requirement is not met as evidenced by: Based on file review, the licensee did not comply with the section cited above in 1 out of 1 employees which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2022

Plan of correction: Licensee will request for a criminal background clearance transfer to the facility and provide LIC 508, LIC 9182, and identification of all staff needing a transfer.

Allegation investigated: Resident records were not maintained at the facility

At approximately 3:45 p.m. on 09/28/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out. No immediate health and safety concerns were observed. LPA interviewed Staff (#1) and Staff #2 (S2) at approximately 4:15 p.m. LPA interviewed Resident #1 (R1) at 4:30 p.m. LPA conducted a record review at 4:45 p.m. Regarding the allegation above, it was alleged facility staff did not provide records to paramedics. From interviews, S1 confirmed that the resident files were not provided to paramedics. R1 stated paramedics looked at discharge paperwork but no licensing forms. S2 stated that the forms were locked in the facility, but S1 did not have the key to access them. Based on interview, the allegation is deemed SUBSTANTIATED at this time. Deficiency is cited on LIC 9099-D page. Substantiated Administrator/Designee unqualified to manage facility Regarding the allegation above, it was alleged S1 was unable to communicate with paramedics in English. From interviews, S1 stated they spoke with a Spanish-speaking paramedic during the encounter. S2 stated they spoke with paramedics over the phone in English. During today’s visit, LPA observed R1 and S1 communicate successfully in Spanish. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Resident's bed is in disrepair. Regarding the allegation above, it was alleged the remote control was broken on R1’s bed. At approximately 4:30 p.m. LPA inspected R1’s bed and observed it was unplugged. The remote and bed functioned properly after plugging it in. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANIATED at this time. Exit interview conducted. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 28, 2022 · control 31-AS-20220923175322

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 28, 2022

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 residents which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2022

Plan of correction: Licensee will provide a key for staff and designees to access the files. Licensee will also submit copies of resident records for all current residents by the POC due date.

Type of visit: Required - 1 Year

At 11:50 a.m. on 08/30/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. The facility was last visited on 07/14/2021 for an annual visit. It is a single story building with 3 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 1 may be bedridden in Bedroom #1. Approved hospice waivers for six. Due to staffing needs, the facility has not yet admitted any residents. A screening station near the front entrance contained digital thermometer and visitor log. The visitor log tracked temperature, symptoms, and vaccination status. The 3 shared bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The emergency exit in Bedroom #1 was free of obstructions. The facility has 2 bathrooms. The resident bathroom contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Kitchen appliances were functional and sanitary. Sharps and cleaning solutions were locked. A washer and dryer were in good condition. Detergent was locked above the appliances. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. At 12:10 p.m. LPA tested the dual functioning smoke and carbon monoxide detector to be operational. At 12:19 p.m. LPA observed a fully charged fire extinguisher in the dining room. A covered patio contained furniture in good condition. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report issued.the state’s words, verbatim · CDSS document, Aug 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Patrick Shanahan conducted an Annual Required visit and inspection of the facility. This was an infection control visit and mitigation plan review. LPA met with Leo Sayadyan, the licensees husband. A tour of the physical plant was conducted. All smoke alarms were tested and function properly. The fire extinguisher was green and appeared functional. The carbon monoxide detector was tested and functions properly. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of non-perishable food at the facility; properly stored. Knives and detergents were stored in locked drawers and cabinets. The medications are stored in a locked cabinet in the office. Bedrooms: There were three bedrooms designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There were two bathrooms designated for residents' use. Both bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 112.2 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. There were no residents at the time of the visit. No health and safety concerns observed during todays visit. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jul 14, 2021