Brightstar Senior Care

Allegation investigated: Staff are not preventing resident(s) from being abused while in care. Staff are not ensuring that residents' care needs are being met while in care.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with staff, Zinaida Safaryan and Irina Grigoryan, and advised them of the complaint. LPA advised the office manager, Narine Aida and administrator, Ayedah Allahdad over the telephone. Today's investigation consisted of interviews with staff and residents and a physical plant inspection. Staff are not preventing resident(s) from being abused while in care: In regards to the allegation, it was reported that at least two (2) residents stated they're being abused. No residents were identified to who was being abused. There were also no witnesses identified to the allegation. During the course of the investigation, two (2) of two staff interviewed and they deny the allegation. According to both administrator and office manager, they are unaware of any abuse being made and haven't received any complaints from residents about being mistreated. LPA interviewed five (5) of five residents Unsubstantiated who do not corroborate with the allegation. LPA was able to speak with a witness, who comes to the facility everyday to visit one of the residents. Witness states they've never observed any abuse or mistreatment from staff during their visitations. The witness didn't express any concern regarding resident care, and is satisfied with the care and supervision provided to the resident in care. Based on the information obtained, there was insufficient evidence to prove that staff are not preventing residents from being abused. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are not ensuring that residents' care needs are being met while in care: In regards to the allegation, it was reported that a resident was found lying in bed and appeared to be neglected by staff. There is one staff member for multiple residents, who do not appear to be getting the care they need. During the day's investigation, LPA observed two (2) staff present and providing care and supervision for a total of five (5) residents. Interview with both staff deny the allegation of not ensuring the residents needs being met. Interviews with five (5) of five residents also deny allegation. Residents state their needs are being met, and had no complaints with the care and supervision provided by staff. Furthermore, LPA was able to interview one witness who comes to the facility everyday to visit one of the residents. Witness states they've never observed neglect or lack of supervision from staff during their visitations. Also the witness didn't express any concern regarding resident care, and is satisfied with the care and supervision provided to the residents in care. Based on the information obtained, there was insufficient evidence to prove that staff are not ensuring that residents' care needs are being met. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 15, 2023 · control 31-AS-20230907102318

Type of visit: Required - 1 Year

In conjunction with a complaint investigation, Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Zinaida Safaryan and facility designee, Irina Greforian. They were advised of the annual inspection. At 3:00pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. The carbon monoxide detector functions properly. The fire extinguisher is located in the kitchen. It was purchased on June 13, 2023 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. Bedrooms: The facility is a two story building. There is a total of six (6) bedrooms. Four (4) bedrooms designated for resident use are located on the downstairs level. Two bedrooms are for private use, and two bedrooms are shared. The second story has two bedrooms designated for staff. There is a child proof door that restricts access. The resident bedrooms were observed to be furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two and a half (2 1/2) bathrooms designated for residents' use. The two full bathrooms were properly supplied and had functional fixtures. The half bathroom, which only has a toilet and sink is located by the front entrance. Hot water temperature was measured at 108 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 and detergents is located in the garage. It is observed to be locked and inaccessible to the residents in care. Resident/Staff Records: Resident and staff records are maintained and locked on the second floor. Medications: Medications were reviewed for proper documentation. Medications are being maintained and stored locked in a closet at the front entrance. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted, and a Copy of the Report Issued.the state’s words, verbatim · CDSS document, Sep 15, 2023

Allegation investigated: Staff are unable to communicate with residents due to language barrier. Staff did not provide a safe environment for resident(s) in care.

Licensing Program Analysts (LPAs) Evelin Rios and Christopher Alemoh conducted a subsequent complaint visit to follow-up with the facility about the above allegations. LPAs were greeted by staff #1 (S1) and granted access. LPAs met with the house manger Narineh Ohanian and explained the purpose of the visit. Allegation: Staff are unable to communicate with residents due to language barrier. In regards to the allegation, it was reported that a staff spoke very limited English and was unable to understand instructions or requests for assistance. Interviews with staff #1 (S1) on 2/13/2023 indicated that they do speak limited English but it does not hinder them from taking care of the residents. According to S1 they can use google translate if need be. Interview with residents on 02/13/2023 and 08/14/2023 revealed S1 doesn't speak English very well but is able to assist when needed. Various resident interviews indicate if one staff doesn't understand they call on another staff that does. On 02/13/2023 LPA Rios observed S1 assisting residents with lunch and getting in and out of bed to use the bathroom. (Continued on LIC9099-C) Unsubstantiated Based on interviews and observation, 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. Allegation: Staff did not provide a safe environment for resident(s) in care. It was alleged a staff member was not able to follow the 911 instructions while being told by the operator how to perform CPR. Interviews with residents on 02/13/2023 and 08/14/2023 revealed that they believed staff were capable of assisting them during a medical emergency. Record review on 02/13/2023 and 08/14/2023 revealed Narineh Ohanian, S1 and staff #2 (S2), had and have current CPR and first-aid certification from an accredited organization. Unusual Incident/Injury Report (SIR) from 01/25/2023 about resident #1 (R1) reported R1 fainted. Interview with Narineh Ohanian revealed R1 has a health condition that was not disclosed to them by R1's responsible party and on the incident in question, according to Narineh she called 911 and was able to perform CPR until the ambulance arrived. Based on interviews and record review, 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. No deficiencies cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 14, 2023 · control 31-AS-20230208125524

Allegation investigated: Facility is denying residents visitation

Licensing Program Analysts (LPAs) Evilin Rios and Michael Cava conducted a subsequent complaint visit to the facility to obtain additional information pertaining to the above allegation. LPAs met with the administrator, Ayedeh Allahdadi, and advised her of the visit. Today's investigation consisted of record review, which was conducted at apprximately 1:30pm to 2:00pm. Based on the information obtained, the investigation to remain Unsubstantiated at this time. The administrator was advised and a copy of this report given. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 20, 2023 · control 31-AS-20230322162006

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

Allegation investigated: Staff did not respond to resident's requests for assistance in a timely manner.

Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted a subsequent complaint visit to follow-up with the facility about the above allegation. LPAs met with the administrator, Ayedah Allahdadi and explained the purpose of the visit. Allegation: Staff did not respond to resident's requests for assistance in a timely manner. In regards to the allegation, it was reported that staff did not respond to resident when they pushed their call button. Interviews with staff Narineh Ohanian on 2/13/2023 indicated that resident #1 (R1) would continuously push her call button and requested to know the time it was in the middle of the night. According to Narineh because staff knew it was R1 requesting to know the time at night they removed her call button. Interview with R1 and R1's roommate resident #2 (R2) revealed R1 would become disoriented at night and consistently request to know the time becasue R1did not know if it was morning, staff would no longer respond to R1's request. Based on interviews the allegation is deemed Substantiated at this time. Deficiencie issued. Exit interview conducted. Appeal rights and a copy of the report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 20, 2023 · control 31-AS-20230208125524

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 28, 2023

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Various interviews and observation revealed that staff did not responded to the call for assistance from R1. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jul 20, 2023

Plan of correction: Administrator is to submit to LPA a plan to ensure that Section 87468.2(a)(4) will be complied with at all times.

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.

Allegation investigated: Facility is denying residents visitation

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It was reported that since Resident 1 (R1) has moved into the facility, R1 wasn't allowed visitation by family and friends. LPA met with staff, Narineh Ohanian, and advised her of the complaint. The investigation consisted of interviews with residents and staff, record review, and a physical plant inspection to insure the health and safety of the residents in care. Interviews with four of four residents do not corroborate with the allegations of not being allowed visitors, stating they are allowed visitation. According to staff, residents have never been denied any visitation, so long as visitors come and visit during visitng hours. Regarding R1, staff stated it was their family's decision to limit visitation at this time, as R1 was recently diagnosed with a condition that causes them to become aggressive when they do have guests. Unsubstantiated During the visit, a phone call was made to R1's family, who is also the Power of Attorney (POA) for R1's health decisions. The family confirms that R1 was just diagnosed with a condition that causes them to become aggressive when having guests. R1's family, went into consultation with their primary physician, and the medical association specializing with this condition, and the family was advised that it would also be in the best health interest to limit or slow down R1 having visitors to smooth R1 into that transition and not cause R1 to become aggressive. The process is day to day, as R1's condition has been improving. Eventually, once fully adjusted, R1 will continue to have more visitors, but for now, based on the doctor's recommendation, it is to R1's best health interest to slow down with visits. Based on the information obtained, there was insufficient evidence to prove that the facility is denying residents visitation. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 28, 2023 · control 31-AS-20230322162006

Allegation investigated: Staff does not provide resident medications as prescribed. Staff did not provide resident with resident's medical records as requested. Staff did not accord resident privacy. Staff withheld resident' personal belongings.

Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted a complaint visit at the facility to investigate the above allegations. LPAs met with the administrator, Ayedah Allahdadi and staff, Narineh Ohanian, and advised them of the complaint. Today's investigation consisted of interviews with residents and staff that were held between 8:40am to 11:00am. At approximately 11:00am to 12:00pm, a physical plant inspection was made. Between 12:00pm and 1:00 pm, LPAs conducted a record revew. Staff does not provide resident medications as prescribed: In regards to the allegation, it was reported that Resident 1 (R1) was not given their medication consistently. Interview made with R1 could not confirm the allegation. R1 could not identify what medication and what time of the day, their medications were supposed to be taken. Interviews with the administrator and staff indicate that R1 received their medication as prescribed. LPAs also interviewed two of two residents. Both residents reveal that they've received their medications as prescribed by their doctor. Based on Unsubstantiated the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing R1 with their medication as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not provide resident with resident's medical records as requested/Staff withheld resident' personal belongings: In regards to the above allegations, it was reported that upon leaving the facility, R1 wasn't given their facility and medical records. It was also alleged that R1's personal belongings (checkbook, check card, wallet) were withheld upon departure. Interview made with R1 reveal that R1 may have lost some of their personal items when moving out of the facility. Interviews made with administrator and staff reveal that R1's personal belongings, medical records, and facility records were given to R1 upon leaving the facility. The administrator provided written documentation, with R1's signature, acknowledging that they have received their personal belongings when departing the facility on 10/31/22. Furthermore, on a previous complaint (see control #31-AS-20221020145038), there was also confirmation that facility provided R1 with their Admission Agreement per R1's request. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff withholding R1's medical records and personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not accord resident privacy: In regards to the allegation, it was reported that R1's incoming telephone calls and visitation are screened, allowing no privacy. Interview with R1 reveal that they have no close family and friends to visit them. R1 did state staff would sit near them when making phone calls. No witnesses, date and time provided by R1 to corroborate the allegation. LPAs interviewed two of two residents, who both indicated they are allowed to make and receive phone calls in private. Both residents also acknowledge they receive visitation rights with privacy. Based on the information obtained, there was insufficient evidence to prove staff do not provide residents with privacy. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 14, 2023 · control 31-AS-20230307095829

Allegation investigated: Resident’s are locked inside of facility. Facility outdoor passageway is not kept free of obstruction.

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned allegations. The LPA was greeted by facility staff and all Covid checks were preformed before allowing the LPA entrance. The administrator was notified of the LPA's visit and arrived a short while later. Allegation 1. Resident’s are locked inside of facility. The LPA was able to interview staff and residents regarding this allegation. Facility staff denied ever locking or restricting the residents movements while inside the facility. There were two residents residing at the home during the visit. The first resident (R1) was interviewed at the kitchen table and could not recall if the doors had been locked. R1 appeared to be forgetful and at times confused. The second resident (R2) was interviewed in R2's room. R2 stated that R2 had never tried to leave the facility unassisted and required a walker to move around. Continues on LIC 9099-C Substantiated A credible witness toured the home in November of 2022 and observed a staff member pull a pin out of a drilled hole on the facility front door frame, which allowed the door to remain closed even if the door was unlocked. During an inspection of the home, the LPA did observe the hole in the door frame and the front door. The LPA also observed that the back sliding door also had locks at the bottom of the sliding glass door that could prevent the doors from opening. Based on the LPA observations of the drilled holes in the front door, the locks on the back sliding door and the confirmation from the credible witness, this allegation is deemed SUBSTANTIATED at this time. Allegation 2. Facility outdoor passageway is not kept free of obstruction. LPA was able to tour the facility in order to investigate this allegation. While touring R1's room, the LPA observed a chair, clothing, shoes and other personal effects blocking the sliding glass door and preventing the the passageway to be free of obstruction. The facility staff reminded the resident not to block the passageway and staff assisted the resident in moving the personal items into the closet. Based on staff and LPA observation, this allegation is deemed SUBSTANTIATED at this time. Exit Interview conducted, deficiencies cited and appeal rights discussed.the state’s words, verbatim · CDSS document, Dec 13, 2022 · control 31-AS-20221207151234

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(5) · Plan of correction due date: Dec 14, 2022

87468.1 Personal Rights of Residents in all Facilities-(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (5) To leave or depart the facility at any time and not be locked in any room, building, or facility premises by day or night... This requirement was not met as evidenced by:LPA observation of holes drilled in the front door to lock it and locks installed on the sliding door, which poses an immidiate risk to the health and safety of residents in carethe state’s words, verbatim · CDSS document, Dec 13, 2022

Plan of correction: The administrator agrees to remove the locks on the sliding back doors and fix the holes in the front door. The administrator will then submit photos of the repair and a statement noting that she has read and understands this regulation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80087(c) · Plan of correction due date: Dec 14, 2022

80087(c) Buildings and Grounds. Outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement is not met as evidenced by; Based on inspection and observation, Licensee did not keep the R1's passageway free from obstruction, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Dec 13, 2022

Plan of correction: The administrator agrees to clear the obstruction from in front of the door, submit photos and put into writing her understanding of this regulation.

Allegation investigated: Resident did not receive a copy of their Admissions Agreement.

Licensing Program Analyst (LPA) Patrick Shanahan, arrived at the facility in response to the above mentioned allegation. The LPA was greeted by facility staff and the administrator was called and arrived a short while later. Allegation 1. Resident did not receive a copy of their Admissions Agreement. The LPA was able to interview staff and residents regarding this allegation. The facility staff and the facility administrator both confirmed that an admission agreement had been completed. Both the staff and the administrator also confirmed that one resident had requested a copy of the report, but due to a slow printer a copy was not provided to the resident. One out of the 4 residents interviewed also confirmed that an admission agreement was requested but was not provided. Based on interviews conducted with residents and admission from staff and the administrator, this allegation is deemed SUBSTANTIATED. Exit interview conducted, deficiency cited and report issued. Substantiatedthe state’s words, verbatim · CDSS document, Oct 25, 2022 · control 31-AS-20221020145038

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Oct 25, 2022

The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request. This requirement was not met as evidenced by, the administrator did not provide a copy of the admissions agreement to the resident when requested, which poses a potential risk to the residents in carethe state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Administrator provided a signed copy of the admissions agreement during the visit. Cleared during visit

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home in response to complaint number 31-AS-20221020145038. The LPA had his temperature taken before being allowed entry in the home. While touring the home, the LPA observed a bed in the living room that a resident had been sleeping in. The administrator was notified that this is not allowed. The administrator stated that the resident had requested the bed be placed in the living room because the couch was not comfortable. The LPA explained that this is not allowed. Exit interview conducted, deficiency cited and report issued.the state’s words, verbatim · CDSS document, Oct 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 85087(a)(3) · Plan of correction due date: Oct 26, 2022

Buildings and Grounds. No room used as a common area shall be used as a bedroom for any person This requirement was not met as evidenced by: The administrator did not prevent a resident from using the living room as a bedroom, which poses a potential risk to the residents in carethe state’s words, verbatim · CDSS document, Oct 25, 2022

Plan of correction: Administrator removed bed during visit. Cleared during visit

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by the facility administrator and the administrator's consultant. This visit was held in order to conduct a pre licensing inspection. This is a new application and there were no residents at the facility during the visit. The home is a six bed 3 bath, house. Four bedrooms and three bathrooms are located on the downstairs level. The upstairs level will be for staff only and there was a child proof door that restricts access to the upstairs. On the first level, there are two private rooms and two shared rooms. The facility was inspected for fire safety and all smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA toured the home inside and out and no issues were observed. Component III Conducted. Pre-licensing Inspection tool review all eleven inspection domains, no deficiencies were observed. This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. You are to inform your LPA once you receive your first resident. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Aug 5, 2022

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Ayedeh Allahdadi(Applicant/Administrator) Interview Method: Telephone interview with CAB During COMP II, Applicant/Administrator confirmed the understanding of the California Code Title 22 Regulations. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Applicant and Administrator qualifications 3. Staffing requirements & Training 4. Program policies -restricted/prohibited health conditions; abuse reporting, incident reporting to CCLD; food service management; emergency procedures; activities programs 5. Grievances, Complaints, Community resources 6. Application document review and technical assistance- Criminal record clearance; Health screening; Fire clearance; First aid/CPR certificate; Administrator certificate; Financial verification; Compliance history; Control of propertythe state’s words, verbatim · CDSS document, Jul 29, 2022