Concordia Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Emma Arutiunian, Aida Andriasyan, and Gagik Mkrtchyan. They were advised of the purpose for the visit. At approximately 9:45am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a two (2) story building, the second floor has three (3) bedrooms and designated for staff use only and will not be accessible for residents. Required postings were observed in the entry area. The smoke alarms and the carbon monoxide detectors are dual and installed throughout the facility. The facility has two fully charged fire extinguishers. One fire extinguisher is located in the hallway, and the other near the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were four (4) bedrooms designated for residents' use. All the bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are four (4) bathrooms in the facility. One (1) bathroom is designated for staff use only and the common bathroom has non-skid mat and appropriate grab bars installed. Hot water temperature was measured at 105 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area is located in the bedroom hallway. No cleaning supplies or laundry detergent present. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records. Medications: Medication and Medication Records were reviewed for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jul 22, 2023

Allegation investigated: Facility staff physically abused residents. Facility staff did not assist resident who was being threatened by another resident. Facility staff did not ensure that timely medical care was provided for residents. Facility staff did not ensure that residents were regularly observed for changes in functioning. Resident not accorded dignity in relationships with facility staff.

Licensing Program Analyst (LPA) Patrick Shanahan, arrived at the facility in response to the above mentioned allegations. The LPA was greeted by the facility administrator and was able to review a list of the residents living at the home. After the LPA was able to review resident files and interview the facility administrator it became clear that the resident in question had never lived at this location. Based on interviews conducted and a review of resident files, this allegation is deemed UNFOUNDED. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit Interview conducted and report issued. Unfoundedthe state’s words, verbatim · CDSS document, Dec 12, 2022 · control 31-AS-20221201164003

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: Required - 1 Year

At 11:45am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Aida Hambardzumyan, who granted access to the facility. Administrator arrived at 12:00pm and LPA explained the reason for the visit. LPA conducted a physical tour with the Administrator and observed the following: Infection control: LPA reviewed the facility mitigation plan (approved on 07/27/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids. Kitchen: At approximately, 12:05pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Medications: At approximately, 12:10pm LPA observed medications are centrally stored and locked in the cabinet, by the dining area and inaccessible to residents in care. Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational Continue on LIC809-C Bathrooms: At 12:25pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 117.0°F. LPA observed appropriate grab bar and showers had non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom. Common Areas: The facility maintains a comfortable temperature at 77°F. The living room and dining area appeared clean and were properly furnished. Laundry area is located near the kitchen. Facility has two (2) fire extinguishers (one in the kitchen and one by the laundry area) and both were last purchased on 03/10/22. Outside areas: At approximately, 12:45pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water. Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:00pm they were tested and observed to be operational. Administrative: Certificate of Liability Insurance, and LIC.500 will be emailed to LPA. No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.the state’s words, verbatim · CDSS document, Mar 23, 2022

Allegation investigated: Facility staff are not following COVID-19 guidelines. Facility staff are unable to understand or communicate in English. Facility does not provide a safe environment for residents in care.

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned complaints. LPA was greeted by facility staff and explained the reason for the visit. Allegation 1. Facility staff are not following COVID-19 guidelines LPA arrived at the facility and staff (S1) opened the door. S1 was observed at 9:30 AM to not be wearing a mask. LPA walked into the home and into the kitchen and observed S2 preparing breakfast for residents. S2 was also not wearing a mask. The LPA reminded the staff that they must wear a mask and follow COVID-19 protocol at the facility at all times. S2 then took the LPA's temperature at about 9:45 am and had the LPA sign in at the front of the facility. Based on LPA observation, this allegation is deemed to be substantiated at this time. Continues on LIC 9099- C Substantiated Allegation 2. Facility staff are unable to understand or communicate in English. At 9:45 AM, LPA attempted to interview S1 and S2. LPA asked if the staff could provide the LPA with a staff roster or a resident roster and both staff indicated that they could not speak English. At about 10:15 AM, the LPA was then able to speak with residents at the facility. The first resident (R1)) indicated that the residents like the staff and that for the most part they are able to get their requests across to the staff. At 10:30 AM, the LPA was able to interview the administrator. The administrator indicated that he knows that this is problematic and that he has been working to get a staff member who speaks English at the property 24 hours a day. Based on LPA observation and the administrator acknowledgement of the staff not being able to communicate effectively, this allegation is deemed substantiated. Allegation 3. Facility does not provide a safe environment for residents in care. At about 9:50 AM, LPA conducted a physical plant tour of the home. While touring the home, the LPA did not smell any signs of urine or other foul smells. There were no signs of immediate danger or any health and safety concerns. The LPA did observe that the staff were not following the COVID-19 protocols outlined in the facility mitigation plan that was submitted to Community Care Licensing (CCL). The LPA also observed that the staff were unable to communicate effectively in English to the residents, who all happen to be English speaking. Staff would also not be able to communicate effectively in the event of an emergency. Based on these observations and the administrators acknowledgement of these issues, this allegation is deemed substantiated. Exit interview conducted, deficiencies cited and report issued.the state’s words, verbatim · CDSS document, Dec 28, 2021 · control 31-AS-20211227095048

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Dec 29, 2021

Personal Rights of Residents in All Facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on LPA observation, the administrator did not ensure that the COVID-19 protocal was followed properly, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 28, 2021

Plan of correction: The administrator agrees to hold an inservice on the facilities mitigation plan and submit a sign in sheet and teaching materials to the LPA by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Dec 31, 2021

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 interviews with staff and the administrators acknowledgment, 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, Dec 28, 2021

Plan of correction: The administrator has been actively looking for English speaking staff. Administrator agrees to put in writing his plan for hiring English Speaking staff and submit the plan by the POC date.

Allegation investigated: Facility did not issue resident a refund

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegation. LPA was greeted by facility staff and the administrator was called. LPA began touring the home at about 11:10 AM. No health and safety issues were observed during the visit and the home is following their approved mitigation plan. Allegation 1 - Facility did not issue resident a refund LPA was able to interview the administrator at about 11:35 AM regarding this allegation. At 11:45 AM the administrator stated that he knew what this was regarding and went to his car. The administrator provided an envelope with the resident in question's address written on it. The administrator then opened the letter and confirmed that he had written the payment, but due to his family members becoming ill, he never had the chance to mail the letter. A review of the residents rental agreement was conducted at 12:00pm. Continues on LIC 9099-C Substantiated According the the signed rental agreement, "Fees paid in advance will be refunded within 15 days of removal of a deceased residents belongings." The resident in question passed away on 7/10/21 and all personal belongings were moved out by 7/13/21. The administrator did not deny the timeline and confirmed that the refund was written but a family member became ill and the administrator forgot to issue the payment. Based on interviews and a review of the admission agreement, this allegation is deemed SUBSTANTIATED at this time. Exit interview conducted, deficiencies cited and report issued.the state’s words, verbatim · CDSS document, Nov 8, 2021 · control 31-AS-20211103164432

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Nov 8, 2021

Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees ... within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on record review & interview, licensee did not issue a refund within 15 days of R1's personal property being removed which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: Administrator put the payment in the mail during LPA's visit. This was cleared during the visit.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to an Incident Report received in the CCL office on 10/18/2021. Upon entry, the LPA's temperature was taken and covid 19 questions were asked. The administrator was called and came to the facility at around 10:15 AM. The LPA explained to the staff that the LPA was at the facility in regard to an elopement of a resident (R1) that was reported to the community care office. Staff indicated that R1 had got up late at night and had opened the sliding door in R1's room and had walked away from the facility. At 10:00 AM, LPA tested all doors and sliding doors to ensure that the alarms were functioning properly. Rooms 1 and 2 were observed to have sliding doors and the alarm did not go off when the LPA tested them. At 10:45 AM, the administrator showed the LPA that the sliding doors need to be completely closed for the alarm to set. Once the administrator opened and closed the door, the alarms did work. The LPA explained that the door alarms need to be functional, regardless of how the door is closed and that their can't be some type of trick to set the alarm. At the time of the elopement, there were two staff at the facility. Both staff denied hearing the alarm go off and realized R1 was not in the room while conducting hourly checks. The police were immediately informed and so were R1's responsible party and the administrator. R1 was located a short while later and returned to the facility. No further information gained. Exit interview conducted, deficiencies cited and report issued.the state’s words, verbatim · CDSS document, Oct 25, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Oct 31, 2021

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on LPA observation, the administrator did not have an auditory device that would work every time resulting in an AWOL of R1, which is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2021

Plan of correction: The administrator adjusted the sliding doors to reset the alarms during the visit. The administrator also stated that he will have all doors hard wired so that staff will know exactly which door is opening. A reciept will be sent to LPA as POC.