Mountain View Center

Allegation investigated: . Staff did not distribute resident's medication as prescribed. 2. Staff did not meet resident's incontinence needs. 3. Staff did not assist resident with showering.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation regarding the allegations listed above. LPA met with Administrator, Laura Hernandez, and explained the reason for the visit. The investigation consisted of the following: On 5/16/23, LPA Chan toured the facility and inspected six rooms. LPA also obtained copies of documents pertaining to Resident #1 (R1) and interviewed 2 Staff. Sufficient food supplies of 2-day perishable and a week of non-perishable were observed. There were no immediate health and safety concerns observed during that visit. On 9/21/23, LPA Chan conducted interviews with the Administrator, 3 Staff, and 4 Residents. (Continue on next page) Unsubstantiated Allegation - Staff did not distribute resident's medication as prescribed. It was alleged that the facility was administering medications that were discontinued to Resident #1 (R-1). LPA reviewed the physician’s order form provided to the facility by the hospice agency upon admission on 12/1/22. The medications listed on the facility's medication administration record (MAR) was also reviewed and it did not appear to have any discrepancies. The facility also had physician orders for any new medications that were prescribed after admission. Per interviews with staff, R-1 was overall compliant with the medications. Staff had initialed the MAR logs when resident took the medication and/or indicated the reason for not. R-1 had moved out of the facility on 12/28/22. Allegation - Staff did not meet resident's incontinence needs. LPA interviewed Staff and Residents. The administrator stated that staff check the resident’s diaper every 2 to 3 hours and change as needed. The caregiver will log down if there is a bowel movement. Staff indicated they would check the resident’s diaper a few times during their shifts and change when needed. They do not keep residents in soiled diapers. 3 out of the 4 residents interviewed stated that staff check their diapers and change them if needed. One is able to change it himself/herself but staff would also check on them. Allegation - Staff did not assist resident with showering. It was alleged that staff did not shower or wash R-1’s hair regularly which caused R-1 to smell bad. The administrator and staff interviewed stated the residents are showered daily. Those on hospice care receive showers through outside personnel, however, facility staff would also provide showers on the other days. Staff stated that R-1 was showered often when allowed, either by the hospice personnel or facility staff. LPA interviewed 4 residents who all stated they get showers frequently. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 21, 2023 · control 28-AS-20230512120959

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Elizabeth Irra and Kimberly Ramirez conducted the required annual inspection. LPA met with Laura Hernandez (Administrator) and discussed the purpose of today’s visit. This facility is licensed to serve (40) non-ambulatory residents, of which, (10) may be bedridden and (20) may be on hospice. Per Administrator, there are (2) bedridden residents and there are (7) residents under hospice care at this time. This facility consists of (2) single story buildings. The front building consists of a reception area, administrative offices, employees lounge, conference room, and commercial-size kitchen. The back building includes a medication room, resident rooms, living room, dining room, bathrooms, and indoor/outdoor areas. Residents bedrooms have the required furniture. Most of the resident bedrooms have a “jack and jill” bathroom. Bathrooms were clean and operational. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (40) non-ambulatory residents, of which, (10) may be bedridden and (20) may be on hospice. Staff were unable to provide proof of liability insurance coverage (citation issued). Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed (both tested and operable). Fire extinguishers are located throughout the premises (service date of 02/01/23). Signal system was tested and operable. The water temperature measured as follows: 106.3* in the bathroom between room #2 and room #3, 106.5* in the bathroom between room #4 and room #5, 112.0” in bathrooms between rooms #12, #13, #14 and #15. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Bathrooms had non-skid surfaces and grab bars. **Refer to LIC 9099C for the continuation of this report.** Physical Plant & Environment Safety (cont). During facility tour, LPAs observed debris on the side of the back building that are accessible to residents, visitors and staff (citation issued). The following items were observed: (1) unsecured tall ladder, (2) large air conditioning units, (6) metal-like framing items, a shed inside the packaging, (1) roll of insulation, (1) plywood, (1) wooden pallet, (2) trays, (1) Geri Chair and (6) wheelchairs (of which 1 appears to be disassembled). Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: Activity schedule is posted. There is an activity director for this facility. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items.. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining area has adequate seating. Posted menu observed. Refer to LIC 9099C for continuation of this report. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and//or original containers. The facility uses the Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician. The facility provides incidental medical services. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Deficiencies cited. Refer to LIC 9099D. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Laura Hernandezthe state’s words, verbatim · CDSS document, Sep 1, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jose Villalobos conducted a case management visit. LPA met with Staff Daisy Fitter and the purpose of the visit was discussed. The purpose of the case management is to deliver and receive signature for an amended 9099-D page for complaint control # 28-AS-20201124163559. No further investigation was conducted by LPA Villalobos and no other deficiencies are cited on today visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cynthia Chan initiated a case management visit to issue deficiencies observed during a complaint investigation #28-AS-20230512120959. LPA met with Staff, Elvira Cortez, and explained the purpose. During the tour on 5/16/23, LPA observed strawberry yogurt bars in a tray uncovered and a gallon of juice without the top left inside the refrigerator, located in the second building dining room. In addition, the signal system in the residents' rooms are not operable. Staff stated a new signal system was purchased and is waiting on installation. LPA observed the shipment of the signal system was dated 1/20/23 and the box of call systems are left in the owner's office. Staff stated that they are consistently conducting round checks every 2 hours and residents are given a bell to signal staff in the meantime. The deficiencies are issued on the LIC809D form. A civil penalty for a repeated violation is also issued. The report along with appeal rights were given to staff Cortez.the state’s words, verbatim · CDSS document, May 16, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(28) · Plan of correction due date: May 23, 2023

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on LPA observation, food items were not properly covered which poses an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2023

Plan of correction: The licensee shall ensure all foods are protected against contamination. An in-service training shall be conducted with all staff and log shall be submitted to LPA by 5/23/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(i)(1)(B) · Plan of correction due date: May 23, 2023

87303 Maintenance and Operation (i) Facilities shall have signal systems... (1)All facilities licensed for 16 or more and all residential facilities having separate floors...shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location... This requirement is not met as evidenced by: Based on observation and interview, the facility did not have a working signal system for residents to alert staff which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2023

Plan of correction: The licensee shall ensure the signal system is operable. The written plan shall indicate how the deficiency will be corrected and estimated date in which the signal system will be installed. This plan is due by 5/23/23. **A civil penalty is being assessed for a repeated violation.

Allegation investigated: Resident sustained unexplained injuries while in care. Resident was not provided proper eviction notice. Staff did not notify authorized representative about injuries. Resident room is not properly cleaned resulting in room is malodorous. Resident not provided adequate sleeping conditions.

Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegations and for the purpose of rendering the findings. LPA met with Staff #1 Yvonne Montaya who allowed entry into the facility and was later met by Administrator Laura Hernandez who assisted with the visit. The investigation consisted of the following: On 1/5/2023, LPA interviewed S1 and S2 and obtained copy of resident and staff roster and Resident#1 (R1)'s Identification and Emergency Information, Hospice physician order form, hospice training log, discharge medication, notification of initiation of hospice services, Individual Service Plan (ISP), Hospital Record from Pomona Valley Hospital, Progress Notes, physician report dated on 11/30/22 and Functional Capacity Assessment and Admission Agreement. On today's date, LPA interviewed additional three staff (S3-S5) and administrator, and four clients (R2-R5) and one resident's family via telephone. (See LIC 9099C for continuation) Unsubstantiated The investigation revealed of the following: Allegation#1 "Resident sustained unexplained injuries while in care." LPA interviewed staff and reported when R1 first admitted to the facility. R1 already came with a lot of skin tears on his arms and staples on his forehead. The administrator also stated that R1 likes to jump out from the hospital bed rail and wheelchair when R1 feels agitated which may caused some skin tears on his hands or arm. Hospice also reported when R1 felt agitated. R1 may bite or scratch himself which caused the skin tears but R1's skin condition was resolved. Allegation#2 "Resident was not provided proper eviction notice. " LPA interviewed administrator and reported facility never planned to evict R1. The facility never provided any eviction notice to resident or family members. It was the agreement between R1's family and hospice agency and family decided to send R1 back home and live with the family. Allegation#3 " Staff did not notify authorized representative about injuries." LPA interviewed four residents and all denied the allegation. They all reported anything happened to them, the staff or facility would notify their family members or authorized representatives immediately. They never delayed reporting. The resident's family also reported facility is on top of notifying family members. The administrator also stated that if resident fell and was unable to move or in any serious condition, they usually would call 911 immediately and then they would notify hospice and family or authorized representatives at the same time. Allegation#4 "Resident room is not properly cleaned resulting in room is malodorous. " LPA interviewed four residents and all reported their room are clean, nice and with no smell. LPA interviewed staff and reported sometimes residents may have accident on their bed and it definitely smelled bad but they would change the bedsheet right away and open up the window for the fresh air. Staff also clean residents' room every day. LPA also toured residents' rooms and they are all in sanitary and free of odor. Allegation#5 "Resident not provided adequate sleeping conditions." LPA interviewed four residents and all reported they all sleep in their own bed and have a good sleeping environment and conditions. LPA interviewed staff and reported all residents sleep in their bed. The administrator stated R1 had a full hospital bed rail since day one through the hospice agency. (See LIC 9099C for continuation) On the first week, R1 was very agitated, R1 always wanted to jump out of the bed rail and screamed in the middle of the night. Therefore, staff tried to placed R1 in different area including the sofa in the living room or the wheelchair to get R1 comfortable but nothing works. Staff would place R1 back to the bed in his room and stay with R1. Administrator reported R1 always sleep on the bed and R1 never slept in a booster type chair. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegations are found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report and Appeal Right was provided to Administrator (Laura Hernandez).the state’s words, verbatim · CDSS document, Feb 14, 2023 · control 28-AS-20221229092451

Allegation investigated: Resident fell while in care. Resident sustained bruises while in care. Staff tied resident to the bed. Staff not meeting resident's hygiene needs.

***This report supersedes the report LIC9099 dated 12/29/22.*** Licensing Program Analyst (LPA) Kruz Long conducted a subsequent complaint investigation at the facility. Upon arrival, LPA met with Laura Hernandez (Administrator) and explained the purpose of the visit. During today's visit, LPA requested proof or documentation indicating the facility notified the authorized representative for Resident #1 of a fall incident which occurred on 09/08/20. Facility was not able to provide proof or documentation. During the initial visit conducted on 12/17/20, LPA interviewed Staff #1 and requested a copy of the Staff/Resident roster. Continue to LIC9099C..... Unsubstantiated ***This report supersedes the report LIC9099C dated 12/29/22.*** During a subsequent visit dated 12/29/22, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library. In regards to the allegation: Facility has a scabies outbreak. Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the time frame of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated. In regards to the allegation: Staff did not notify resident's authorized representative of incidents. Interviews with Staff indicate the authorized representative is notified if there is an incident with the Residents. Based on allegation details, R#1 had an un-witnessed fall on 09/08/20. Hospice notes indicate the hospice agency notified the authorized representative of the incident but there are no records that indicate the facility notified R#1's authorized representative. Based on the department's record review, evidence and interviews, in the investigation revealed: The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Laura Hernandez and a copy of this report and appeal rights provided. ***This report supersedes the report LIC9099C dated 12/29/22.*** During a subsequent visit dated 12/29/22, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library. In regards to the allegation: Resident fell while in care. Interviews with 6 of 6 Staff indicated they do not recall whether R1 had a fall while residing in the facility. Records indicate R1 had an un-witnessed fall on 09/08/20 while under Hospice care. Per Hospice notes, R1 denied pain and plan of care to continue. In regards to the allegation: Resident sustained bruises while in care. Review of R1's medical records indicate R1 has a medical condition resulting in progressive movement which caused R1 to be susceptible to bruising. Interviews with Staff and review of the Individual Services Plan indicate preventable measure were put in place to prevent R1 from bruising due to the medical condition. In regards to the allegation: Staff tied resident to the bed. Interviews with 5 of 5 Staff indicate they have never tied a Resident to the bed. Interviews with 4 of 4 Residents indicated they have never been tied to a bed. In regards to the allegation: Staff not meeting resident's hygiene needs. Interviews with indicated Residents are meeting the Resident's hygiene needs. Interviews with 4 of 4 Residents indicate their hygiene needs are being met. Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Laura Hernandez and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 6, 2023 · control 28-AS-20201210143607

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

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 complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.the state’s words, verbatim · CDSS document, Feb 6, 2023

Plan of correction: Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 20, 2023

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: There are no records that indicate the facility notified R#1's authorized representative that R#1 had an un-witnessed fall on 09/08/20.the state’s words, verbatim · CDSS document, Feb 6, 2023

Plan of correction: Licensee shall review section 87211 and provide a signed statement to the department by the POC date indicating the Licensee understands and will report to the department and Resident's authorized representatives of similar incidents which may occur in the future.

Allegation investigated: Staff illegally evicted resident

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Laura Hernandez and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Administrator Laura Hernandez, Staff 1-4, Resident 2-4 (R2-4), R1's FM, and Witness 1. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information, Physician's Report for Residential Care Facilities for the Elderly (RCFE), Resident Appraisal, Functonal Capability Assessment, CA Assisted Living Waiver Program Individual Service Plan, Progess Notes and Unusual Incident/ Injury Reports dated 9/23/22, 10/6/22, 1/11/23, 1/16/23 and 1/20/23. (See LIC9099C for continuation) Substantiated Investigation revealed the following: Regarding allegation, Staff illegally evicted resident, it is alleged that facility administrator texted R1's FM and stated that due to R1's history of eloping, R1 could not return to the facility. R1 has not been served an eviction notice. Interview conducted with facility administrator revealed that administrator did notify R1FM that R1 could not return to the facility due to aggressive behavior towards staff and also their continuous attempts to leave the facility unassisted. Administrator also stated that they told hospital staff that they could not take R1 back. Interview with R1 FM revealed that they received a text message from administrator informing them that R1 could not return to the facility due to incidents that they are aware of involving R1. LPA reviewed R1's progress note dated 1/26/23 which stated that R1 could not be taken back due to physical and verbal abuse. LPA also reviewed a text message sent from facility administrator to R1FM indicating that they could not take R1 back due to for previous incidents. LPA reviewed R1's file and did not observe an eviction notice. Based on interviews conducted with facility staff, R1FM and review of records, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on attached LIC9099D. Exit interview was conducted with Facility Staff Elvira Cortez.. A copy of the report and appeal rights were Investigation revealed the following: Regarding allegation of, Staff did not provide adequate supervision resulting in preventing resident from eloping, is alleged that R1 has eloped from the facility on various occasions, one in October 2022 and another on January 20,2023. Is is also alleged that R1 got out of the facility and took a taxi to their doctor's office by themselves and later returned to the facility. Interview conducted with administrator revealed that the incident that occurred in October 2022 was addressed on 10/6/22 by LPA Irra and facility is appealing the citation. She also stated that on R1 never took a taxi by themselves and denies that ever occurring. She stated that on January 20, 2023, R1 did not elope from the facility. She stated that she accompanied R1 to the bank and she was with R1 during the whole outing. She stated that during the outing, R1 refused to return to the facility and proceeded to walk away from her and continue to go to different locations by foot. She stated that she was with R1 at a close distance during the whole incident. She stated the incident took place for a couple of hours during which R1 continuously refused to go back to the facility. She had to then call S1 for assistance and the local police department. She stated that when S1 arrived to the location S1 assisted administrator with providing officers with a summary of what happened as she was with R1. She stated that R1 continued to refuse to go back to the facility even though police officers were telling R1 that they had to return. R1 then stated to officers that they were not feeling well and police officers called paramedics and R1 was transported to the hospital. LPA also spoke to R1FM who stated that they did receive a call from the administrator and the police on 1/20/23 informing them of what was happening and that R1 would be hospitalized. LPA Gonzalez reviewed Case Management visit which details the incident that occurred on 10/6/22. LPA also reviewed Unusual Incident/ Injury Report dated 1/20/23 which is reporting the above referenced incident and notifying CCLD of what happened and R1's hospitalization. Interviews conducted with staff revealed that the facility provides proper supervision at all times. Administrator Hernandez denied that the facility does not provide adequate supervision. She stated that she always ensures that the facility is fully staffed to provide proper care and supervision to facility residents. She stated that all staff are also aware of the higher supervision that R1 requires as they have attempted to leave the facility in the past. She stated that there is always someone in the front desk as that is where residents have to go when exiting the facility. Interviews conducted with 3 out of 4 residents revealed that they believe there are enough staff on schedule to provide adequate supervision. R1 was not interviewed as they were not able to be reached by phone. LPA reviewed facility schedule and observed that there is enough staff on schedule to properly oversee residents, facility operation and tend to residents daily needs. Based on interviews conducted with facility staff, facility residents, and LPA record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Facility Staff Elvira Cortez.the state’s words, verbatim · CDSS document, Feb 1, 2023 · control 28-AS-20230126090555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Feb 10, 2023

87224 Eviction Procedures(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in... This requirement is not met as evidenced by: Based on LPA interviews and record review, the administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with a 30 day eviction notice which poses a potential Health, Safety or Personal Rights risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 1, 2023

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alma Gonzalez conducted an investigation visit regarding complaint received 1/26/2023 to the facility. During the investigation visit, LPA reviewed Resident 1's (R1) facility file and observed the following : R1 did not have a reappraisal updating declining mental/ health issues while in the facility. Statements from administrator revealed that R1 had not been reassessed although staff observe decline in mental/ health conditions. Administrator stated that R1 continously refused all attempts to reassess. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the deficiencies observed were documented on the LIC-809D. Exit interview held/copy of report provided along with appeal form to Facility Staff Elvira Cortez.the state’s words, verbatim · CDSS document, Feb 1, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Feb 10, 2023

87463 Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This requirement is not met as evidenced by: LPA observed that R1 did not have a reappraisal to update her declining mental/ health issues, which poses a potential Health, Safety or Personal Rights risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 1, 2023

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC87466 · Plan of correction due date: Feb 10, 2023

87466 Observation of Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals un met needs. This requirement is not met as evidenced by: Based on interviews with staff which indicated that staff noticed a change in R1 after time of admission but did not conduct a reassessment due to R1 continous refusal, which poses a potential Health, Safety or Personal Rights risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 1, 2023

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Allegation investigated: Resident(s) sustained multiple pressure injuries due to neglect. Staff did not seek timely medical attention for residents in care. Resident is not safely transferred by staff.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to further investigate the above allegations. LPA met with Laura Hernandez and discussed the purpose of today's visit. On 07/12/22, Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Elvira Cortez and discussed the purpose of this visit. Laura Hernandez (Facility Administrator) arrived at approximately 1010AM and assisted with this visit. During this visit , LPA interviewed R-7, R-8 and R-9 and due to insufficient information, LPA Irra to return at a later time. Refer to LIC 9099C for the continuation of this report. Unsubstantiated On 04/14/22, LPA Irra conducted a subsequent visit to investigate the above allegations. LPA met with Laura Hernandez (Assistant Administrator/S-2) and discussed the purpose of the visit. During this visit, LPA Irra conducted a facility tour, reviewed Resident #1 through Resident #6 (R-1 through R-6) files and obtained relevant documentation. LPA Irra also interviewed Staff #2 through Staff #4 (S-2 through S-4) The initial 10 day investigation visit was conducted on 11/30/2020 by LPA Linda Almaraz. The following occurred during this visit: LPA conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. Resident rooms and common areas were properly furnished. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. Allegation: Resident(s) sustained multiple pressure injuries due to neglect. During this investigation, LPA Irra reviewed resident records, obtained relevant documentation and interviewed staff. LPA was unable to interview residents R-1 through R-6 (R-1 is deceased, R-2 moved out, R-3 moved out, R-4 is deceased, R-5 is non-verbal and R-6 moved out). LPA interviewed R-7 through R-9, however, they did not have any knowledge of residents sustaining multiple pressure injuries due to neglect. Staff interviews revealed R-1 received wound care services for a pressure sore provided by a hospice agency. LPA obtained records for R-1's wound care treatment provided by the hospice agency. Staff interviews revealed that R-5 did not have any pressure injuries. LPA was unable to locate any documentation in R-5's records indicating that R-5 had pressure injuries. Staff interviews and collected documentation do not corroborate this allegation. Allegation: Staff did not seek timely medical attention for residents in care. During this investigation, LPA Irra reviewed resident records, obtained relevant documentation and interviewed staff. LPA was unable to interview residents R-1 through R-6 (R-1 is deceased, R-2 moved out, R-3 moved out, R-4 is deceased, R-5 is non-verbal and R-6 moved out). LPA interviewed R-7 through R-9, however, they did not have any knowledge of staff not seeking timely medical attention for residents in care. R-7 through R-9 indicated they receive medical attention in a timely manner and do not have any concerns. Staff interviews revealed that they do not recall seeing R-3 having a big bump on R-3's left side of the forehead. LPA was unable to locate any documentation in R-3's records indicating that R-3 had injuries on R-3's left side of the forehead. Staff interviews and collected documentation do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Resident is not safely transferred by staff. During this investigation, LPA Irra reviewed resident records, obtained relevant documentation and interviewed staff. LPA was unable to interview residents R-1 through R-6 (R-1 is deceased, R-2 moved out, R-3 moved out, R-4 is deceased, R-5 is non-verbal and R-6 moved out). LPA interviewed R-7 through R-9, however, they did not have any knowledge of residents not being safely transferred by staff. R-7 through R-9 indicated they do not have any concerns. Staff interviews revealed R-5 previously had regular hoyer lift which was fully operational. Staff interviews revealed that R-5 hoyer lift was upgraded to an electric hoyer lift. Staff interviews revealed that R-5 has not fallen during the use of the hoyer lift and staff have not had any issues with transferring. Based on LPA's interviews conducted and records reviewed, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted, appeal rights and a copy of this report was provided to Laura Hernandezthe state’s words, verbatim · CDSS document, Jan 20, 2023 · control 28-AS-20201125084256

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to check the health and safety of residents, and to ensure Accusation/CDSS No. 6221326301D was posted as required by Law. LPA explained the purpose of the visit to Laura Hernandez. There are (5) residents currently receiving hospice care services. Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible. Per Ms. Hernandez, new admissions have been notified of this accusation. LPA conducted a tour of the premises and no health and safety concerns were observed. Exit interview conducted, a copy of appeal rights and this report provided to Laura Hernandez.the state’s words, verbatim · CDSS document, Jan 20, 2023

Allegation investigated: Resident fell while in care. Resident sustained bruises while in care. Staff did not notify resident's authorized representative of incidents. Staff tied resident to the bed. Staff not meeting resident's hygiene needs.

Licensing Program Analyst (LPA) Kruz Long conducted a subsequent complaint investigation at the facility. Upon arrival, LPA met with Laura Hernandez (Administrator) and explained the purpose of the visit. During the initial visit conducted on 12/17/20, LPA interviewed Staff #1 and requested a copy of the Staff/Resident roster. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library. In regards to the allegation: Resident fell while in care. Interviews with 6 of 6 Staff indicated they do not recall whether R1 had a fall while residing in the facility. Records indicate R1 had an un-witnessed fall on 09/08/20 while under Hospice care. Per Hospice notes, R1 denied pain and plan of care to continue. Continue to LIC9099C.... Unsubstantiated Based on the department's record review, evidence and interviews, in the investigation revealed: The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Laura Hernandez and a copy of this report and appeal rights provided. In regards to the allegation: Resident sustained bruises while in care. Review of R1's medical records indicate R1 has a medical condition resulting in progressive movement which caused R1 to be susceptible to bruising. Interviews with Staff and review of the Individual Services Plan indicate preventable measure were put in place to prevent R1 from bruising due to the medical condition. In regards to the allegation: Staff did not notify resident's authorized representative of incidents. Interviews with Staff indicate the authorized representative is notified if there is an incident with the Residents. Based on allegation details, R#1 had an un-witnessed fall. Hospice notes indicate the authorized representative was notified of the incident. In regards to the allegation: Staff tied resident to the bed. Interviews with 5 of 5 Staff indicate they have never tied a Resident to the bed. Interviews with 4 of 4 Residents indicated they have never been tied to a bed. In regards to the allegation: Staff not meeting resident's hygiene needs. Interviews with indicated Residents are meeting the Resident's hygiene needs. Interviews with 4 of 4 Residents indicate their hygiene needs are being met. Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Laura Hernandez and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 29, 2022 · control 28-AS-20201210143607

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

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 complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.the state’s words, verbatim · CDSS document, Dec 29, 2022

Plan of correction: Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Allegation investigated: Staff hit residents in care. Staff yell at residents in care. Staff speak inappropriately to residents in care. Staff force feed residents in care. Staff rough handle residents in care.

On 11/14/2022 at 9:50 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent complaint visit to deliver findings on the allegations listed above. The initial complaint visit was conducted by LPA Wesley on 12/18/20. LPA also conducted a subsequent complaint on 10/20/22. LPA met with Laura Hernandez and explained the reason for the visit. During the initial visit LPA Wesley conducted a telephonic interview and requested copy of: staff roster, resident roster, and current staff training documents included but not limited to Personal rights(resident's), Care for persons with Dementia, and Food service by Monday, December 21, 2020. Report continued on 9099c Unsubstantiated During the subsequent complaint visit, LPA Baptiste toured the facility and observed the resident’s lunch hour. LPA obtained resident roster, staff roster, staff training on resident’s personal rights, Resident #1(R1) physician’s report, R1’s new admit requirements, R1’s hospice information, R1’s personal rights dated 7/20/2020, R1’s physician consultation final report dated 1/16/2018, R1’s Identification and Emergency information, Resident #2 (R2) Hospice information, R2’s personal right’s, R2’s physician report, and R2’s Identification and emergency information. LPA interviewed Residents R3 through R7. LPA also interviewed administrator and Staff S3 through S6. Prior to returning to the facility LPA interviewed Family Members (FM) for resident R1 (FM1) and R2(FM2). LPA interviewed Former staff S6. LPA attempted to interview former staff S2, S7, S8, S9, S10 and S11. LPA interviewed current staff S1. The investigation reveals the following: Regarding "Staff hit residents in care", it is alleged that S1 hit R1. The Administrator and Current Staff interviewed denied the allegation. They stated that staff do not use physical force on the residents and have never witnessed staff hitting a resident. FM1 stated that they have never witnessed S1 hit R1 but have witnessed unexplained bruises on R1 during visitations. FM2 stated they have never witnessed staff hit residents nor has R2 complained about being hit by staff while living at the facility. S6 stated they did not witness staff hit residents. The investigation reveals the following: Regarding " Staff yell at residents in care.", it is alleged that S1 yells at the residents in care. The Administrator and Current Staff denied the allegation. 5/5 residents indicated that staff has not yelled at them at the facility. FM1 stated that they have witnessed a staff yelling at a resident during a visit but cannot recall which resident or staff was involved. FM2 stated that R2 complained that former staff S11 yell at R2. FM2 stated that S11 was confronted and did not deny the allegation. S6 stated that they did not witness S1 yelling at residents. The investigation reveals the following: Regarding "Staff speaks inappropriately to residents in care", it is alleged that S1 called R2 a “bitch” making R2 cry. The Administrator and Current Staff denied the allegation. 5/5 residents indicated that staff has not spoken to them inappropriately. FM1 stated that they have witnessed a staff yell at a resident during a visit but cannot recall which resident or staff was involved. FM2 stated that a former staff (S3) informed FM2 that the staff was yelling at R2 and made R2 cry. S6 stated that they have witnessed S1 and another staff teasing a resident about a deceased loved one. The investigation reveals the following: Regarding "Staff force feed residents in care", it is alleged that S1 forces food into residents’ mouths, to the point that they will start choking. S6 stated that they had witnessed S1 force-feed residents to the point of choking and leaving bruising on the residents. The administrator and the Current Staff denied the allegation. 5/5 residents also denied the allegations stating they can feed themselves and have not witnessed staff force-feeding other residents. FM1 stated that they have not witnessed a staff force feed a resident, but the food served was “watered-down broth, and there was nothing in the fridge”. FM1 stated that former staff reported the S1 slapped R1 when R1 did not eat. FM2 stated that the facility was not feeding R2 enough and R2 lost weight while in care. LPA observed lunch and did not observe staff force-feeding residents at the time of the visit. The investigation reveals the following: Regarding "Staff rough handle residents in care", it is alleged that S2 is abusive and aggressive with residents, that she rough handles residents and throw away the resident's food if they take too long to eat it. Interviews with FM1 revealed that they did not witness staff rough-handle residents but heard from a former staff that residents were being rough handled. FM2 stated R2 reported that staff was rough handling, yelling, and mean to residents. S6 stated S2 rough handled residents. During the visit, LPA was informed that S2 is no longer employed at the facility. LPA was unable to contact S2 for an interview. The administrator and Current Staff denied the allegation. 5/5 residents do not remember S2 and denied the allegation. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Laura Hernandez and a copy of this record provided.the state’s words, verbatim · CDSS document, Nov 14, 2022 · control 28-AS-20201211182520

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Kimberly Ramirez and Elizabeth Irra conducted a Case Management to obtain further information regarding a Special Incident involving R-1 and R-2 which occurred on 10/04/2022. LPAs met with Laura Hernandez and discussed the purpose of today's visit. The Special Incident alleges that R-3 witnessed R-1 grabbed R-2 on the breast. R-1 has mild cognitive impairment and R-2 has Dementia. R-3 no longer resides at this facility. During this visit, LPAs obtained a copy of the staff roster with contact information and a copy of the resident roster. At approximately 10 A.M., LPA reviewed resident files for Resident #1 through Resident #3 (R-1 through R-3) and obtained documentation. LPAs were unable to conduct interviews as there are (7) residents and (1) staff that tested COVID 19+ on 10/27/2022 (results were provided to Laura Hernandez today). Exit interview conducted and a copy of this report was provided to Laura Hernandez.the state’s words, verbatim · CDSS document, Oct 28, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Elizabeth Irra and Noemi Galarza conducted a Case Management-Deficiencies visit due to an immediate health and safety observation made during today's annual inspection. The purpose of the visit was explained to Administrator Laura Hernandez and receptionist staff Daisy Fitter. At approximately 10:04 AM, LPA Galarza observed cognitively impaired resident (R1) walking by itself onto oncoming traffic on Baseline Road Street. The front door in the administration building was observed to be opened. Staff (S1) was observed running towards the street in an attempt to redirect the resident. However, the resident did not comply and proceeded to cross the major street onto oncoming traffic. The resident walked westbound passed Mountain Avenue. The Claremont Police Department was driving by and assisted with the elopement incident. The resident and staff were not injured. Pictures were taken. The following documents were obtained: Resident (R1's) file documents [Identification and Emergency Information, Physician's Report, Functional Capability Assessment, and ALW Individual Service Plan]. Staff Roster Resident Roster Claremont Police Department DR#: 22126477. Exit interview was held with Administrator Laura Hernandez. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Oct 6, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 7, 2022

87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation at approximately 10:04 AM resident (R1) eloped out of the facility after exiting the memory care unit through the unlocked front door exit without staff knowledge. Staff did not ensure the front door was closed properly. This posed an immediate safety risk to this resident in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Administrator agreed to submit a plan of correction including staff scheduling and supervision of residents. Update resident (R1’s) care plan. In addition, a staff in-service training regarding delayed egress exits, Dementia wandering behavior, methods of redirection, and resident care and supervision shall be conducted by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2(a)(4) · Plan of correction due date: Oct 7, 2022

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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 is not met as evidenced by: Based on LPA observation resident (R1) eloped to the main street without staff knowledge. This poses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2022

Plan of correction: Administrator agrees to submit a written plan stating how this was corrected, and what was done. Submit proof of staff training and attach training topics.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs): Elizabeth Irra and Noemi Galarza and conducted an annual comprehensive inspection visit. LPA Irra met with Laura Hernandez and explained the purpose of today's visit. During this visit, Accusation CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible. A tour of the facility was conducted. This facility consists of (2) single story buildings. The front building consists of a reception area, administrative offices, employees lounge, conference room, and commercial-size kitchen. The back building includes a medication room, residents rooms, living room, dinning room, bathrooms, and indoor/outdoor areas. Residents bedrooms have the required furniture. Bathrooms are clean and operational. The following bathrooms hot water temperature was not within the required range of 105-120 degrees F; Restroom in Wing #2 water temperature measured at 123*. Restroom between room #2 and room #3 water temperature measured at 124.5*. Restroom between room #6 and room #7 water temperature measured at 122.3*. Restroom between room #8 and room #9 water temperature measured at 124*. Restroom between room #18 and room #19 water temperature measured at 103.2*. Restroom between room #14 and room #15 water measured at 100.4*. LPA's observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. There is an additional storage area of food supply for emergency preparedness. All storage areas for chemical compounds, cleaning solutions, toxins, knives or hazardous items are located in the front building. Refer to LIC 809C for the continuation of this report. Carbon monoxide device(s) were tested and were found to be operational. Fire extinguishers are fully charged and were last serviced on 01/19/2022. The facility signal systems are not operational throughout the facility. Per Administrator, the signal system has been out of service for approximately (2) months. Per Administrator, Residents that are able to request for assistance were given a hand held bell to use. Passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris. There are no security bars nor weapons or bodies of water (pool/spa) on the premises. LPAs reviewed Staff files for Staff #1 though Staff #5 (S-1 through S-5). LPAs also reviewed Resident files for Resident #1 through Resident #10 (R-1 through R-10). LPA observed the CCL "Let us no" complaint poster posted. However, the poster measured 8" x10" as opposed to the required measurement of 20" x 26" as per Title 22. The following deficiencies were observed to be in violation under California Code of Regulation Title 22. Refer to LIC 809D. Exit interview, Appeal Rights and a copy of this report was provided to Laura Hernandez.the state’s words, verbatim · CDSS document, Oct 6, 2022

Allegation investigated: Resident sustained scabies while in care.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Daisy Fritter, Receptionish). LPA/RA spoke to Asst. Administrator (A2: Elvira Cortez) upon entering the facility to conduct a risk assessment. A2 informed LPA that the facility has no "new" COVID cases nor do any of the residents or staff have symptoms. The purpose for today's visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. The initial 10-Day visit was conducted by LPA Joe Katrdzhyan on 09/21/21 who met with (then) Staff #1 (S1: Activities Director, Elvira Cortez); as Administrator (A1: Laura Hernandez) was unavailable at the time of this visit. LPA/RA Ceniceros interviewed Administrator and (5) facility staff members and did not interview Resident #1 who moved and (0) residents due to their cognitive impairment (approx.) 1:15 pm - 2:15 pm. LPA/RA Ceniceros reviewed documentation (Admission Agreement, Emergency I.D. and Information, Physician's Report, Appraisal/Needs and Services Plan, Incident Reports, Facility Progress Notes, MAR, Referral/Order Requisition, and Physician's Medication Order) for Resident #1 (from 2:15 pm - 3:00 pm). Unsubstantiated Regarding Allegation #1: this investigation revealed that Resident #1 moved into the facility on 01/28/20. On 02/13/20, facility staff notified the resident's doctor to advise of a rash on the resident's inner side of both arms that the resident was complaining of itchiness. On 04/14/20, a call was placed to the resident's doctor to let him know of the rash to the resident's left arm; and, staff was given a video call appointment for 04/15/20 at 2:30 p.m. and a physician's order for medication (hydrocortisone cream) was prescribed for atopic dermatitis. On 08/07/20, Resident #1 received the referral for a dermatologist. On 08/25/20, Resident #1's Responsible Person took the resident for its dermatology appointment and Resident #1 was diagnosed with papular dermatitis and possible eczema on upper trunk and worsening on hands. Resident #1 was prescribed medications (Ivermectin and Elimite cream) to apply cream and take pill once and repeat in one (1) week. On 09/17/20 a second call was placed to Resident #1's Dermatologist (Dr. David Thomas Robles, M.D., PhD) to request a second treatment for the scabies. Based on interviews conducted of facility staff, the majority indicated that there were no reports of staff members or residents diagnosed with scabies (between 01/28/20 - 09/22/20); therefore, when Resident #1 was admitted to the facility, the resident already showed signs of atopic dermatitis and later diagnosed with scabies on 08/25/20. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Resident sustained scabies while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Laura Hernandez).the state’s words, verbatim · CDSS document, Aug 16, 2022 · control 28-AS-20210914163636

Allegation investigated: Staff do not report incidents to Authorized Representative. Resident has had multiple falls.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Daisy Fitter, Receptionist). LPA/RA spoke to Asst. Administrator (A2: Elvira Cortez) upon entering the facility to conduct a risk assessment. A2 informed LPA that the facility has no "new" COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Angelica Rea on 12/21/20 (via telephone) with On-Call Administrator (A3: Trupti Moody) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed Administrator, (6) facility staff members, and did not interview Resident #1 or Resident #2 who moved or (0) residents due to their cognitive impairment (approx.) 9:15 am - 10:30 am. LPA/RA Ceniceros reviewed documentation (Admission Agreement, Emergency I.D. and Information, Physician's Report, Appraisal/Needs and Services Plan, Incident Reports, Home Health Agency Record, Facility Progress Notes) for Residents #1 and #2 (from 8:10 am - 9:15 am). Unsubstantiated Regarding Allegation #1: this investigation revealed Resident #1's Unusual Incident/Injury Report (dated 12/13/20) was submitted to CCLD regarding Resident #1's diagnosis and receiving the treatment; however, when the facility received the results, Resident #1 had already moved out of the facility on 12/11/2020 by the Public Guardian. Resident #2's Unusual Incident/Injury Report was submitted to CCLD on 12/15/20 regarding an incident that occurred on 12/11/20 regarding personal rights. Based on reporting incidents, the facility documented and made the appropriate notifications to Resident #1 and #2 authorized representative. Based on evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation of REPORTING REQUIREMENTS: Staff do not report incidents to Authorized Representative is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed that Resident #1's functional capabilities (based on a Record Assessment, dated 01/28/19), the resident does not use a brace or crutch or walker, but uses a wheelchair and can get in and out unassisted. A review of the "Physician's Report" (dated 01/17/19), documented Resident #2 is ambulatory and under "Physical Health Status" the resident does not require assistive device and is in fair condition. A review of the "Facility Progress Notes" (from 05/14/20 to 09/08/20) documented the resident's last known fall at the facility on 05/14/20 at 2:10 p.m. Resident #1 had become more anxious and agitated in the evenings and fell out of bed and out of the recliner chair. Based on interviews conducted of facility staff, the majority indicated that Resident #1 had a home health (Care More) nurse practioner that would visit the resident once a week. Facility staff had not witnessed Resident #1 to be found on the floor covered in feces during their shift rounds. Resident #1 would slide out of its bed or the recliner; however, there had not been reported falls up until the time that Resident #1 moved on 12/11/20. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Resident has had multiple falls is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator, Laura Hernandez.the state’s words, verbatim · CDSS document, Aug 16, 2022 · control 28-AS-20201210153051

Allegation investigated: Facility is not following reporting requirements

Licensing Program Analyst (LPA) Vasallo and Yang conducted a subsequent complaint visit to investigate the allegations listed above. The initial complaint visit was conducted by LPA Rivas on 12/16/20. A subsequent complaint visit was conducted by LPA Vasallo on 3/18/22. LPA met with Staff #1 (S1) and explained the reason for the visit. The investigation consisted of the following: LPA Rivas interviewed licensee representative, Trupti Mody a medication technician (Med Tech) and 2 caregivers. During the subsequent complaint visit, LPA Vasallo reviewed Resident #1's (R1's) records. LPA also interviewed 4 staff and requested and obtained copies of staff training records from 2020 and R1's hospice documents from 2020. After the subsequent complaint visit another staff member was interviewed along with the Long Term Care Ombudsman. The investigation revealed the following: It’s alleged facility did not report positive COVID cases or scabies cases. Continued on 9099C Substantiated LPA reviewed the department's database and confirmed facility reported several COVID cases in July and August of 2020. However, the facility did not report that 3 residents were diagnosed with scabies in August 2020. Based on the information obtained, the allegation is substantiated. Based on records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held. A copy of the report and appeal rights were provided. Staff interviewed denied ever seeing staff be rough with residents and denied any abuse. LPA obtained pictures of R1’s bruising. The bruising appears as light red in color on the upper lip, left cheek bone, left side of forehead and elbow. R1 was unavailable to be interviewed and there were no other witnesses to the alleged incident. Hospice documents were reviewed and there were no concerns noted. Residents have severe dementia and therefore, were not interviewed. Based on the information obtained, the allegation is unsubstantiated. Allegation - Staff are not following resident's care plan. R1’s care plan was reviewed. Staff were interviewed and indicated all services were being provided to R1. R1 is unavailable to be interviewed as R1 was discharged from this facility in 2020. Hospice documents were reviewed and there were no concerns noted. Based on the information obtained, the allegation is unsubstantiated. Allegation - Resident(s) sustained multiple pressure injuries due to neglect. Staff interviewed denied that R1 had any pressure injuries. R1 is unavailable to be interviewed. R1’s file was reviewed which included care plan, hospice documentation, hospital notes, and nurses notes. There was no documentation that R1 had any pressure injuries. There was no documentation or witnesses to confirm that R1 had pressure injuries. Therefore, the allegation is unsubstantiated. Allegation - Untrained staff are assisting with medications. It’s alleged that in 2020 facility staff were not trained in medication assistance. Interviews conducted with staff did not corroborate the allegation. Staff files were reviewed, and they contained the required staff medication training. Medication records were reviewed and they did not corroborate the allegation. There was no evidence that staff was ever responsible for a medication error. Based on the information obtained, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 12, 2022 · control 28-AS-20201210145037

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 26, 2022

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency. (D) Any incident which threatens the welfare, safety or health of any resident. This deficiency was evidenced by the following: The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health, CCL was not notified.the state’s words, verbatim · CDSS document, Aug 12, 2022

Plan of correction: Administrator was called and agreed to send a written statement that facility will report all communicable/contagious diseases to CCL in a timely manner.

Allegation investigated: Staff did not seek timely emergency medical services for resident. Staff prevent resident from making and receiving phone calls. Medication not properly discarded. Facility has mold.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Elvira Cortez and discussed the purpose of today's visit. Laura Hernandez (Facility Administrator) arrived at approximately 1010AM and assisted with today's visit. On 04/14/22, LPA Irra conducted a subsequent visit to investigate the above allegations. LPA met with Laura Hernandez (Assistant Administrator/S-2) and discussed the purpose of the visit. During this visit, LPA Irra conducted a facility tour, reviewed Resident #1 through Resident #6 (R-1 through R-6) files and obtained relevant documentation. LPA Irra also interviewed Staff #2 through Staff #4 (S-2 through S-4) The initial 10 day investigation visit was conducted on 11/30/2020 by LPA Linda Almaraz. The following occurred during this visit: LPA conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. Resident rooms and common areas were properly furnished. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA interviewed Licensee and Staff #1. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff did not seek timely emergency medical services for resident. During this investigation, LPA reviewed resident files. Per file review, 911 was called due to R-6 choking. Per documentation reviewed, R-6 was choking during mealtime, staff performed CPR and Heimlich Maneuver and 911 was called for assistance. R-6 was taken to the local hospital and was treated. Staff interviews also revealed that staff did seek emergency medical services for R-6. R-6 was unable to be interviewed as R-6 moved out from this facility. Staff interviews and file review does not corroborate this allegation. Allegation: Staff prevent resident from making and receiving phone calls. During this investigation, facility tours (virtual and in person) were conducted, Resident #1 through Resident #6 (R-1 through R-6) files were reviewed and relevant documentation was obtained. LPA Irra conducted in person tours and observed telephone to be operational and accessible to residents. Staff interviews were also conducted. Per staff interviews, residents are not prevented from making nor receiving phone calls. However, per staff interviews, most residents residing at this facility do not use the telephone often due to their dementia and/or family involvement. Per staff interviews, staff are trained in resident rights. LPA was unable to interview R-1, R-2, R-3, R-4 and R-6 as they are no longer residents at this facility. R-5 was resting during today’s visit. During today’s visit, LPA interviewed R-7, R-8, R-9. Resident interviews revealed that residents are able to make and receive phone calls. Interviews conducted do not corroborate this allegation. Allegation: Medication not properly discarded. During this investigation, staff interviews were also conducted. Per staff interviews, staff properly discard medications. Staff interviews revealed they are trained in medication administration including destruction of medication. LPA was unable to interview R-1, R-2, R-3, R-4 and R-6 as they are no longer residents at this facility. R-5 was resting during today’s visit. During today’s visit, LPA interviewed R-7, R-8, R-9. Resident interviews revealed that medication is administered as prescribed. Interviewed residents were not aware of the facility’s medication discarding procedures. Interviews and collected documents do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Facility has mold. During this investigation, facility tours (virtual and in person) were conducted, Resident #1 through Resident #6 (R-1 through R-6) files were reviewed and relevant documentation was obtained. LPA Irra conducted in person tours on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe mold in the facility. Staff interviews were also conducted. Per staff interviews, facility does not have mold. LPA was unable to interview R-1, R-2, R-3, R-4 and R-6 as they are no longer residents at this facility. R-5 was resting during today’s visit. During today’s visit, LPA interviewed R-7, R-8, R-9. Resident interviews revealed that the facility does not have mold. Interviews and tours conducted do not corroborate this allegation. Based on LPA's interviews conducted and records reviewed, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted, appeal rights and a copy of this report was provided to Laura Hernandez. Allegation: Resident not provided with proper bed. During this investigation, facility tours (virtual and in person) were conducted and staff interviews were conducted. LPA Almaraz observed R-2’s bed to be on the floor during the virtual tour conducted on 11/30/2020. Staff interviews revealed R-2’s bed was on the floor due to R-2 being a fall risk. LPA Irra conducted tours of this facility on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe any beds to be placed on the floor. R-2 was not interviewed as R-2 moved out of this facility. LPA Almaraz’s observation and staff interviews corroborate this allegation. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Health and Safety Code Title 22, Division 6 and Article 3 are being cited on the attached LIC 9099D. An exit Interview was conducted, appeal rights and a copy of this report was provided to Laura Hernandez.the state’s words, verbatim · CDSS document, Jul 12, 2022 · control 28-AS-20201125084256

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A) · Plan of correction due date: Jul 12, 2022

Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:the state’s words, verbatim · CDSS document, Jul 12, 2022

Plan of correction: Facility Administrator to ensure each bed is equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. LPA Irra conducted tours of this facility on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe any beds to be placed on the floor. DEFICIENCY CORRECTED.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(A) · Plan of correction due date: Jul 12, 2022

THIS IS A CONTINUATION OF ABOVE. (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for matresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This standard is not met as evidence by: LPA Almaraz observed R-2’s bed to be on the floor during the virtual tour conducted on 11/30/2020. Staff interviews revealed R-2’s bed was on the floor due to R-2 being a fall risk.the state’s words, verbatim · CDSS document, Jul 12, 2022

Plan of correction: k

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to check the health and safety of residents, and to ensure Accusation/CDSS No. 6221326301D was posted as required by Law. LPA explained the purpose of the visit to Laura Hernandez. There are (5) residents currently receiving hospice care services. Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible. LPA conducted a tour of the premises and no health and safety concerns were observed. LPA informed Laura Hernandez that all new residents being admitted into this facility be informed of the accusation noted above. During this visit, LPA also reviewed and collected documentation pertaining to a request for locked perimeters of this facility. Exit interview conducted, a copy of appeal rights and this report provided to Laura Hernandez.the state’s words, verbatim · CDSS document, Jul 12, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to check the health and safety of residents, and to ensure Accusation/CDSS No. 6221326301D was posted as required by Law. LPA explained the purpose of the visit to Laura Hernandez. There are (6) residents currently receiving hospice care services (same total as previous visit conducted 05/26/2022). Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible. LPA conducted a tour of the premises and no health and safety concerns were observed. LPA informed Laura Hernandez that all new residents being admitted into this facility be informed of the accusation noted above. Exit interview conducted, a copy of appeal rights and this report provided to Laura Hernandez. Note: LPA was experiencing technical difficulties during this visit. This report will be emailed to Ms. Hernandez at the email.the state’s words, verbatim · CDSS document, Jun 8, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to check the health and safety of residents, and to ensure Accusation/CDSS No. 6221326301D was posted as required by Law. LPA explained the purpose of the visit to Elvira Cortez LPA conducted a physical plant tour of the facility. There are (6) residents currently receiving hospice care services. Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible. No health and safety concerns were observed during this visit. Exit interview conducted, a copy of appeal rights and this report provided to Elvira Cortez.the state’s words, verbatim · CDSS document, May 26, 2022

Type of visit: POC

Licensing Program Analysts (LPA) Elizabeth Irra conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citations issued during the 04/14/2022 case management visit. The purpose of this visit was explained to Elvira Cortez. On 04/14/2022 this facility was cited for: California Health and Safety Code: 1569.38 (b)(1) Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. Licensee failed to disclose a written notice to a resident, the resident’s responsible party and the local long-term ombudsman within 10 days from the occurrence. On 04/28/2022, LPA Irra conducted a Plan Of Correction (POC) visit to follow up on the citation noted during the 04/14/2022 visit. As of the 04/28/2022 visit, DEFICIENCY WAS NOT CLEARED. Civil Penalties were issued for period 04/19/2022-04/28/2022. Total of 10 days, at $100.00 per day. The amount noted on the issued Civil Penalty (LIC 421FC) was $ 1,000.00. A civil penalty of $100 per violation per day to be assessed until corrected. As of today, Facility Administrator provided evidence to LPA Vasallo (visit completed on 05/03/2022) that the notification was sent to families about the accusation. Evidence provided included the letter sent to families along with copies of certified mail certificates and receipts.. During today's visit, LPA obtained contact information for residents authorized representatives. Once verification with resident/resident’s authorized representative is completed, it will be determined if another citation will be issued. Exit interview conducted, a copy of appeal rights and this report provided to Elvira Cortez..the state’s words, verbatim · CDSS document, May 11, 2022

Allegation investigated: Facility did not comply with the terms of the license revocation.

Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Laura Hernandez and explained the reason for the visit. The investigation consisted of the following: Administrator was interviewed and facility was toured. The investigation revealed the following: It's alleged facility has not complied with the terms of the license revocation. On 4/14/22, LPA Irra visited the facility to ensure the Accusation No. 6221326301D was posted as required by law. At the time the Accusation was not posted. The facility was given a Plan of Correction (POC) to post the Accusation and notify in writing the residents' responsible parties and the Ombudsman as required by law. On 4/28/22, LPA Irra returned to the facility to ensure the Accusation was posted and all required parties were notified. The Accusation was posted, however the responsible parties and the Ombudsman were not notified in writing as required. LPA Irra issued civil penalties for the POC not being cleared. Continued on 9099C. Substantiated During today's visit the facility was toured and the Accusation dated 4/8/22 was seen posted in a frame at the entrance of the facility. Administrator was interviewed and confirmed the Ombudsman and the residents' responsible parties have not been notified in writing about the Accusation as required by law. Administrator indicated the Licensee's attorney is drafting a letter that will be sent to all required parties soon. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Health and Safety Code Title 22, Division 6 and Article 3 are being cited on the attached LIC 9099D. Exit interview held. A copy of the report, appeal rights and civil penalty form were provided to Administrator.the state’s words, verbatim · CDSS document, May 3, 2022 · control 28-AS-20220425111119

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.38(b)(1) · Plan of correction due date: May 4, 2022

Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This deficiency was evidenced by the following: Accusation is dated 4/8/22 and Administrator confirmed responsible parties and Ombudsman have not been notified in writing.the state’s words, verbatim · CDSS document, May 3, 2022

Plan of correction: Facility will provide proof to the department that all residents' responsible parties and the Ombudsman have been notified in writing of the Accusation.

Type of visit: POC

Licensing Program Analysts (LPA) Elizabeth Irra conducted an unannounced Plan Of Correction (POC) visit to follow up on the Plan of Correction citations issued during the 04/14/2022 case management visit. The purpose of this visit was explained to Elvira Cortez. Laura Hernandez (Assistant Administrator) arrived at approximately 10:05 A.M. and LPA re-explained the purpose of this visit. On 04/14/2022 the facility was cited for: California Health and Safety Code: 1569.38(b)(1) Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. Licensee failed to disclose a written notice to a resident, the resident’s responsible party and the local long-term ombudsman within 10 days from the occurrence. As of today, DEFICIENCY IS NOT CLEARED. Civil Penalties are being issued for period 04/19/2022-04/28/2022. Total of 10 days, at $100.00 per day. The amount noted on Civil Penalty (LIC 421FC) is $ 1,000.00. A civil penalty of $100 per violation per day shall be assessed until the violation is corrected. Deficiencies are cited per Health & Safety Code Sections 1569.38. LPA explained the citations, civil penalty assessment, and appeal rights. Exit interview conducted, a copy of appeal rights, civil penalties and this report provided to Laura Hernandezthe state’s words, verbatim · CDSS document, Apr 28, 2022

Allegation investigated: Resident had unexplained injury Staff did not notify authorized representative of residents injury

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced subsequent visit to interview additional residents for the above allegations. LPA met with receptionist Daisy Fitter and explained the reason of the visit and shortly after, the assistant administrator Laura Hernandez arrived and assisted with the visit. On On 12/23/2020, LPA Almaraz conducted a virtual tour of the facility and residents. LPA conducted interviews with Mody, Singhvi and Staff #1-3 and requested a Staff and Resident Roster. On 10/26/2021, LPA Almaraz re-interviewed Staff #2-3 and interviewed Staff #4. LPA attempted to interview Resident #1 but the resident was no longer residing at the facility after being evicted on 12/10/2020. LPA requested Resident #1's file. On today's date, LPA Wong interviewed three residents (R2-R4) and reviewed three residents' file. (See LIC9099C for continuation) Unsubstantiated The investigation revealed of the following: Allegation#1 "Resident had unexplained injury" it was alleged Resident #1 received a black eye while living at the facility. Interviews with staff indicated the resident never had a black eye while residing at the facility. Interviews with staff revealed the resident was aggressive and would hit staff but did not have self injurious behaviors. Staff stated they never witnessed any staff hit the resident or hear about a staff hitting the resident or any other resident. LPA also interviewed residents and residents families and reported residents they never had any unexplained injury and the staff take good care of them and they are doing their best for the residents. Allegation#2 "Staff did not notify authorized representative of residents injury" it was alleged the facility did not notify the responsible party of Resident #1 after sustaining a black eye at the facility. Interviews and records reviewed indicated the resident did not have a black eye, therefore the facility never contacted the responsible parties. A photograph was provided of the resident with the alleged black eye and LPA could not verify if it was the angle of the picture or a black eye. LPA also interviewed the residents and residents families and reported the facility staff always notified the authorized representative with any concerns of the residents. The staff are on top of it and they always provide good care to the residents. They have no concerns or complaints about the facility. Based on the additional residents interviews conducted, the complaint investigation findings remain the same: UNSUBSTANTIATED. Exit interview was conducted with the Assistant Administrator Laura Hernandez and a hard copy was provided. Interviews revealed the resident was put in the Gerry Chair with the table tray during meals and while caregivers put back the dishes back in the kitchen. Per interviews, the chair was used because it helped the resident stay more calm while eating. Interviews with staff also revealed the chair was used to elevate the residents legs when they were swollen. Staff stated they would put the resident in the chair for about an hour to help his legs. Interviews and records showed the Gerry Chair did not belong to the resident and belong to other residents at the facility who were on hospice and had physicians orders for the chair. Community Care Licensing (CCL) never received a request/plan for approval prior to using the Gerry Chair. It is unclear how long the resident was left in the chair during the day or if it was used for other than meal time and leg elevation. LPA received a photograph of the resident in the Gerry chair with the table tray on, in what appeared to be a resident room at the facility. The table tray did not have any food on it. The residents file revealed the resident had Dementia and needed assistance with several of the residents Activities of Daily Living (ADL's). In an appraisal conducted on 7/3/2020, it indicated the resident was unable to communicate clearly. While living at the facility he became aggressive towards staff and the facility later determined they could not care for the resident due to the residents behaviors. Based on the interviews conducted and the prior investigation, the complaint investigation findings remain the same: SUBSTANTIATED. Exit Interview Conducted and a copy of the report was provided to Assistant Administrator Laura Hernandez.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 28-AS-20201216154032

Allegation investigated: : Resident was sexually assaulted by another residents in care. 2: Resident was exposed to scabies.

Licensing Program Analysts (LPAs) Kruz Long and Ashley Calderon conducted an unannounced subsequent complaint visit to deliver complaint findings for the above allegations. Upon arrival, LPAs met with Elvira Cortez (Activity Director) and discussed the purpose of the visit. During the initial complaint investigation conducted on 12/23/20, LPA’s Kruz Long and Linda Almaraz conducted a health and safety check and requested a copy of the Staff and Resident roster. LPAs also toured the facility via Facetime with Smita Sanghvi and observed that the facility is clean and in good repair. There are nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Wash basins, showers/bathtubs and toilets are operable. There are no immediate health and safety concerns during today's investigation. Per cross compliant investigation #28-AS-20201216144646, LPA Almaraz interviewed current and former staff along with a witness #1 (telephonically) on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/2/2021, LPA Almaraz requested copies of additional resident’s records. Continue to LIC9099C..... Substantiated In regards to the allegation: “Resident was sexually assaulted by another residents in care”. The department interviewed administrator, current and staff #24, resident #1 to #6, witnesses and resident family members, review client records and Los Angeles County Sheriff's Department report #020-06398-0878-444. The investigation revealed information from staff #24 and resident's family who personally witnessed many of the actions and behaviors of resident #7. Former staff members reported seeing resident #7 touch, fondle and rub female residents on their breasts and vaginal area. Resident #7 was found in another resident's room while resident #7 pants were down and resident #7 was also found in the bed of a female resident and was caught taking a female dementia resident to the back area of the facility. Resident #7 also attempted to sexually assault a female resident while under the influence of a substance. Despite, staff #24 being aware of resident #7 inappropriate sexual actions and behaviors with facility residents, no substantive action was taken by staff #24 to stop resident #7 behaviors and facility residents continued to be victimized by resident #7. In regards to allegation, "Resident was exposed to scabies while in care" it was alleged a few residents had scabies at the facility. It was also alleged staff was not notified or given proper instructions on handling contagious residents. Records reviewed revealed Resident #9 was diagnosed with scabies on 8/25/2020 and Resident #10 on 09/21/20. Interviews with staff revealed that they were never trained on how to handle residents with scabies. Staff #24, who worked as the former administrator stated that Resident #3 and Resident #8 did in fact have scabies. Per Staff #24, both residents were roommates. Interviews with staff stated that Resident #9 had scabies first and later gave it to Resident #3. Per staff #24, hospice agency said it was not scabies and later determined that it was. The facility did not report scabies to Community Care Licensing. former administrator stated the Licensee, staff and families were notified of the outbreak. During the 04/13/21 site visit, LPA Almaraz received documents indicating that the Los Angeles County Public Health was being notified and a case was being opened. Based on records reviewed, evidence, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Immediate civil penalties of $500 is being issued with appeal rights. "The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f), or 1548 (e) or (f), 1568.0822(e) or (f)." Exit interview conducted with Elvira Cortez (Activity Director)and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 19, 2022 · control 28-AS-20201215092514

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 20, 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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The investigation revealed information from staff #24 and resident's family who personally witnessed many of the actions and behaviors of resident #7. Former staff members reported seeing resident #7 touch, fondle and rub female residents on their breasts and vaginal area. Resident #7 was found in another resident's room while resident #7 pants were down and resident #7 was also found in the bed of a female resident and was caught taking a female dementia resident to the back area of the facility. Resident #7 also attempted to sexually assault a female resident while under the influence of a substance. Despite, staff #24 being aware of resident #7 inappropriate sexual actions and behaviors with facility residents, no substantive action was taken by staff #24 to stop resident #7 behaviors and facility residents continued to be victimized by resident #7.the state’s words, verbatim · CDSS document, Apr 19, 2022

Plan of correction: Administrator to provide a letter from licensee indicating licensee has read and will comply with section 87468.1 (a) (3). Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: May 3, 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: Interviews with staff stated that Resident #9 had scabies first and later gave it to Resident #3. Per staff #24, hospice agency said it was not scabies and later determined that it was. The facility did not report scabies to Community Care Licensing. former administrator stated the Licensee, staff and families were notified of the outbreak. During the 04/13/21 site visit, LPA Almaraz received documents indicating that the Los Angeles County Public Health was being notified and a case was being opened.the state’s words, verbatim · CDSS document, Apr 19, 2022

Plan of correction: Cleared during visit. Administrator provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to ensure the Accusation/CDSS No. 6221326301D was posted as required by law, and that the residents, the residents' responsible parties, and the Local Long Term Care Ombudsman have been notified of the Accusation. LPA met with Laura Hernandez and discussed the purpose of today's visit. At 10:30 A.M., LPA conducted a physical plant tour of both, the front and back buildings and did not observe the Accusation posted. Laura Hernandez showed LPA all postings and the Accusation was not posted. Ms. Hernandez confirmed that the Accusation had not been posted. As of today, residents, their responsible parties and Local Long Term Care Ombudsman have not been provided a copy of Accusation/CDSS No. 6221326301D. A notice will be issued to all required parties by 04/18/2022. Health & Safety Code Section 1569.38 does require the licensee to provide written notification to a resident, the residents' responsible party, if any, and the local Long Term Care Ombudsman within 10 days from the date indicated on the Accusation. The licensee is also required to post the Accusation in a conspicuous location, written in at least 14-point type, stating that legal action is being taken against the facility to revoke the license. A copy of this section of Health and Safety Code was provided to Laura Hernandez. At 11:15 A.M., Ms. Hernandez showed LPA the Accusation that was received and posted it in a conspicuous location. The written notification to the above parties remains pending. Civil penalties shall be assessed against any facility which fails to take corrective action within described time periods. Per California Health and Safety Code section 1569.38, you are hereby notified that a $100 civil penalty per day will be assessed until the violation is corrected. This assessment will not exceed $100/day regardless of the number of notices the licensee fails to send. The total civil penalty for a continuous violation shall not exceed $5,000. ***REFER TO LIC 809C for the continuation of this report*** APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement concerning the proper application of licensing laws and regulations with the licensing agency. When civil penalties are involved, the licensee may request a formal review by the licensing agency to amend, extend the due date, or to dismiss the penalty. Requests for civil penalty appeal must be in writing, must be postmarked within 10 days of receipt of this form, and must be addressed to the Regional Office or licensing office with jurisdiction over the facility. The agency has a duty to review the facts presented without prejudice within a 10-day period. Upon review of the facts upon which the appeal is based, the agency may amend any portion of the action taken, or may dismiss the violation. The licensing agency review of the appeal may be conducted based upon information provided in writing by the licensee. The licensee may request an office interview to provide additional information. The licensee will be notified in writing of the results of the agency review. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited per Health & Safety Code Section 1569.38 (Refer to LIC 809-D). Citations, civil penalties, and appeal rights were discussed. Exit Interview was conducted with Assistant Administrator Laura Hernandez and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 14, 2022

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.38(b)(1) · Plan of correction due date: Apr 18, 2022

Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This standard is not met as evidence by: LPA toured facility grounds with Laura Hernandez and did not observe the Accusation to be posted. Ms. Hernandez also confirmed that the Accusation had not been posted.the state’s words, verbatim · CDSS document, Apr 14, 2022

Plan of correction: Assistant Administrator posted the Accusation in a conspicuous location in the facility prior to LPA's departure today. PENDING: Licensee shall provide written notification of Accusation to residents, resident's responsible parties, and the Long Term Care Ombudsman by due date of 04/18/22 and provide proof of given notification to LPA Irra by 04/18/22.

Allegation investigated: Resident was sexually assaulted while in care Resident was exposed to scabies while in care

Licensing Program Analyst's (LPA's) Jewel Baptiste and Linda Almaraz conducted a subsequent visit to investigate and deliver findings for the allegations listed above. Allegation #1 was referred to the Investigation Bureau and was investigated by Investigator Brian Slatic. LPA's met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit. On todays visit LPA's conducted additional file review and collected documents for Residents. The investigation consisted of the following: On 12/23/2020, LPA Linda Almaraz and Kruz Long conducted a virtual tour of the living and dining area, kitchen, outside patio, common areas and resident rooms and bathrooms. The kitchen was clean and had sufficient perishable and non-perishable food. Resident rooms and common areas were properly furnished. Bathrooms were operable. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA Almaraz interviewed Administrator Trupti Mody, Licensee Smita Sanghvi and Staff #1-3. LPA requested copies of staff and resident rosters along with Residents #1-5 file to be emailed by 12/23/2020 to LPA Almaraz. (Conitnued on an LIC 9099C) Substantiated LPA interviewed current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/2/2021, LPA's requested copies of additional residents records. Investigator Brian Slatic conducted interviews with current and former staff, family members, and residents in regards to allegation #1. The investigator also obtained records for residents. The investigation revealed the following: In regards to allegation, "Resident was sexually assaulted while in care ," During the course of the investigation, the investigator obtained information from individuals who personally witnessed many of the alleged actions and behaviors of Resident #9. Former staff members report seeing Resident #9 touch, fondle and rub female clients on their breasts and vaginal areas. Resident #9 was found in another residents room, while the other resident had their pants down. Resident #9 was found in the bed of a female resident and caught taking a female dementia resident to the back area of the facility. Resident #9 also attempted to sexually assault a female resident while under the influence of drugs. Multiple staff informed Staff #1, the Administrator at the time of the incidents. However, no substantive action appeared to have been taken to stop the behaviors and residents continued to be victimized by Resident #9. There is no information or evidence that any of these incidents were reported to Community Care Licensing (CCL) or other agencies. In regards to allegation, "Resident was exposed to scabies while in care" it was alleged a few residents had scabies at the facility. It was also alleged staff was not notified or given proper instructions on handling contagious residents. Records reviewed revealed Resident #8 was diagnosed with scabies on 8/25/2020, Resident #6 on 8/27/2020 and Resident #13 sometime later that year. Interviews with staff revealed that they were never trained on how to handle residents with scabies. Staff #1, who was the administrator at the time stated that Resident #6 and #8 did in fact have scabies. Per staff #1 both residents were room mates. Interviews with staff stated that Resident #8 had scabies first and later gave it to Resident #6. Per Staff #1, hospice said it was not scabies and later determined that it was. It was never reported to CCL. Staff #1 stated the Licensee, staff and families were notified. LPA received documents on todays visit from the County of Los Angeles Public Health being notified and a case being opened. Based on records reviewed, evidence, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Immediate civil penalties of $500 is being issued. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). An exit interview was conducted with Assistant Administrator, Laura Hernandez and caregiver Elvira Cortez, hard copy of this report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Nov 3, 2021 · control 28-AS-20201216144646

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 4, 2021

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The Administrator was notified and aware about the sexual abuse Resident #9 was doing to other residents and did not take action to mitigate the abuse.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 10, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency.....(D) Any incident which threatens the welfare, safety or health of any resident..... . This requirement was not met as by evidence: The facility had (3) residents diagnoses with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health and CCL was not notified.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.

Allegation investigated: Lack of supervision resulting in residents sexually abusing other residents. Facility has Insufficient staff to meet the residents' needs. Residents are restrained. Facility has scabies/C-diff outbreak. Facility is in disrepair. Residents are not provided with general hygiene supplies.

Licensing Program Analyst's (LPA's) Jewel Baptiste and Linda Almaraz conducted a subsequent visit to conduct further investigation, file review and to deliver findings for the allegations listed above. Allegation #1 was referred to the Investigation Bureau and was investigated by Investigator Brian Slatic. All other allegations were investigated by LPA Almaraz. LPA's met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit. On todays visit LPA's reviewed and collected documents for Residents #9-18. The investigation consisted of the following: During the initial visit conducted on 11/25/2020, LPA Almaraz conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. The kitchen was clean and had sufficient perishable and non-perishable foods. Resident rooms and common areas were appropriately furnished. LPA did not observe any visible signs of neglect, abuse or any obvious immediate health and safety threats. LPA requested copies of staff and resident roster along with files for Residents #1- 8 to be emailed or faxed to LPA by 11/25/2020. LPA also conducted an interview with the Administrator, Trupti Mody (Staff #16). (Conitnued on an LIC 9099C) Substantiated LPA interviewed current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/2/2021, LPA requested copies of additional residents records. The investigation revealed the following: In regards to allegation,"Food service is inadequate," LPA interviewed staff in regards to meals served. (12) out of (18) staff members indicated they never seen any issues with the food the facility served and they quantity was enough. They stated the quality was also good and never heard of the facility running out of food. Staff indicated the residents had (3) meals a day and (2) snacks. In regards to allegation, "Facility has inadequate laundry service," based on interviews conducted (12) out of (18) interviews conducted stated they never had an issue with the laundry being done for the residents and never heard of the facility running out of laundry soap. Per interviews, the residents had their clothes washed by the laundry person and would get done. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the Assistant Administrator, Laura Hernandez and Caregiver, Elvira Cortez and a hard copy was provided. current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/3/2021, LPA requested additional copies of residents records. The investigation for allegation #1 was referred to the Investigation Bureau and was investigated solely by Investigator Brian Slatic. He conducted interviews with current and former staff, family members, and also obtained relevant resident records. The investigation revealed the following: In regards to allegation: Lack of supervision resulting in resident sexually abusing other residents - During the course of the investigation, the investigator obtained information from individuals who personally witnessed many of the alleged actions and behaviors of Resident #9. Former staff members report seeing Resident #9 touch, fondle and rub female clients on their breasts and vaginal areas. Resident #9 was also found in another residents room, while the other resident had their pants down. Resident #9 was found in the bed of a female resident and caught taking a female dementia resident to the back area of the facility. Resident #9 also attempted to sexually assault a female resident while under the influence of drugs. Multiple staff informed Staff #1, who was the Administrator at the time of these incidents. However, no substantive action appeared to have been taken by Staff #1 or the Licensee to stop Resident #9's behaviors. The residents continued to be victimized by Resident #9. There is also no evidence that any of these incidents were reported to Community Care Licensing (CCL) or cross reported to other agencies. In regards to allegation: Facility has insufficient staff to meet the residents' needs - several former and current staff stated that at some point last year there wasn't sufficient staff at the facility. Staff members revealed that sometimes they did not have help for transferring residents to their beds or up from their beds who required a 2-3 person assistance to transfer. Staff also stated sometimes during the night shift there was only one (1) staff member from the hours of 11PM- to about 5AM because the second staff member would call off and the facility would not get coverage. Per interviews, it happened very often and the one (1) caregiver could not finish their rounds. Caregivers indicated sometimes they could not complete diaper changes at night when it was just one (1) caregiver. Some of the things caregivers stated they could not complete due to staffing issues was showers, repositioning and grooming. They also stated that breakfast was rushed and the residents were pressured to eat quickly so they can complete other duties. Per staff interviews, this was brought up to the attention of Staff #1 and the Licensee and nothing was ever done. (Continued on an LIC 9099C) In one instance, a caregiver was told that CCL did not mandate a staff to resident ratio and could have one (1) caregiver only for all the residents. Per interviews conducted, the total resident census at the time was between 25 -30 residents. LPA received photographs of residents left soiled on the floor, and bed rails not in place with bed sheets falling off the beds. Another picture received was of a resident naked from the waist down in a fetal position and their bed soiled with feces. In regards to allegation: Residents are restrained - it was alleged the facility was tying the residents with bedsheets to their wheels chairs and using Gerry chairs with a table tray on residents who did not have an order for the chair, and gait belts to keep the residents in place. Interviews conducted revealed a number of residents were tied with bedsheets to their wheelchairs in order to prevent them from falling off their wheelchair and to help caregivers complete their duties with other residents. Caregivers interviewed stated that they would have them tied from the waist to the wheelchair and sometimes from the chest to prevent them from falling and injuring themselves. Several current and former staff indicated that Resident #5 was put in Gerry chair with the table tray because the resident was very aggressive. LPA also received a picture of the resident in the Gerry chair with the tray on top of the resident. No physicians orders were observed in resident's file for the Gerry chair. LPA received pictures of another resident tied with a light blue/gray bedsheet around the stomach and chest area and the knot at the back of the wheel chair. In regards to allegation: Facility has scabies/C-diff outbreak- it was alleged a few residents had scabies and C-diff at the facility and that appropriate medical follow-up did not occur with the residents. It was also alleged staff was not notified or given proper instructions on handling contagious residents. Records reviewed revealed Resident #8 was diagnosed with scabies on 8/25/2020, Resident #6 on 8/27/2020 and Resident #13 sometime later that year. Interviews with staff revealed that they were never trained on how to handle residents with scabies or C-diff. Staff #1, who was the administrator at the time stated that Resident #6 and #8 did in fact have scabies. Per staff #1 both residents were room mates. Interviews with staff stated that Resident #8 had scabies first and later gave it to Resident #6. Per Staff #1, hospice said it was not scabies and later determined that it was. It was never reported to CCL. Staff #1 stated the Licensee, staff and families were notified. LPA received documents on todays visit from the County of Los Angeles Public Health being notified and a case being opened. In regards to allegation: Facility is in disrepair - it was alleged the facility had broken beds, clogged toilets, plumbing issues and the facility was in disrepair. (Continued on an LIC 9099C) Interviews with staff indicated the facility did have plumbing issue but was later fixed. Interviews with staff revealed the mattresses were dirty and old and some were placed directly on the floor without box springs or bed frames. Interviews also reveal that there is broken closet doors inside a resident's room. Picture was obtained. LPA obtained pictures of dirty mattresses with what appeared to be feces. LPA also obtained a picture with a ripped box spring with pillows in between the mattress and box spring and a resident laying on the bed and pictures of dirty mattresses. In regards to allegation: Residents are not provided with general hygiene supplies - it was alleged the facility had no soap, paper towels, and toilet paper and that the Administrator would lock away supplies making it inaccessible to staff during their shift. Based on interviews conducted, during the night shift staff couldn't ask for supply because management was not on the premises and would run out of supply during the night shift. Staff also stated that even during the day they do not get supply because the facility always runs out. Caregivers stated they had to use the same shampoo, bar soap, hairbrush, deodorant and toothpaste for all residents. Per caregivers, it's the facilities practice for each staff to carry their own small bucket with hygiene supply and assist the residents. The only thing the resident have of their own is their toothbrush. Staff also stated they would run out of wipes. Based on records reviewed, evidence, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies cited under California Code of Regulations Title 22 . Immediate Civil Penalties of $500 is being issued. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). An exit interview was conducted with Assistant Administrator, Laura Hernandez and Caregiver Elvira Cortez and hard copy of this report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Nov 3, 2021 · control 28-AS-20201124163559

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 4, 2021

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The Administrator was notified and aware about the sexual abuse Resident #9 was doing to other residents and did not take action to mitigate the abuse.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 5, 2021

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The facility allowed staff members to tie residents with bedsheets onto the back of their wheel chairs were it was not reachable for residents to un tie themselves.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure no residents are tied with bedsheets and will conduct personal rights training with all staff. Administrator will provide proof of personal rights training conducted by POC due date. Administrator will submit proof via fax only to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 10, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency.....(D) Any incident which threatens the welfare, safety or health of any resident..... . This requirement was not met as by evidence: The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health and CCL was not notified.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Nov 10, 2021

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need ...... The licensing agency shall be authorized to require other additional documentation..... This requirement was not met as evidence by: The Administrator was allowing staff to put residents in Gerry chairs without a physcians order in place and tying residents with bedsheets without any orders.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement stating they have read and understood the section and will abide by it. Administrator will fax documents by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 10, 2021

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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of..... The licensing agency may require any facility to provide additional staff whenever it determines..... . This requirement was not met as evidence by: The Administrator did not provide sufficient staff to assist all residents in care which resulted in residents not being assisted with their ADL's at times.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will reasses all current residents needs and assess new one's to determine the needs of residents and put a plan of action in place to ensure the facility has the appropriate staffing. Administrator will submit a staff schedule and a LIC 500 by POC due date via fax to LPA. Staffing agencies???

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 10, 2021

87468 Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: The facility had dirty matresses, ripped box springs and broken closet room doors. Images also provided showed a resident sleeping on a matress on the floor without a bed framethe state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure all resident have a bed frame and will replace or sanitize any dirty or ripped mattresses and/or box springs. Administrator will ensure extra bed frames and mattress are available on the premesis by POC due date and will submit proof via fax to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Nov 10, 2021

87307 Personal Accomadations and Services (a) Living accommodations and grounds shall be related to the facility's function..... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.... (D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidence by: Based on in interviews conducted the facility would run out of hygiene supply and when there was some it was inaccesible to staff, specially during the night shift. Residents had to share deodorant, shampoo, soap and hair brush's.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will purchase extra hygiene and ensure each resident has their own personal hygiene and ensure staff have access to the supply when needed. Administrator will submit picture of supply available to LPA via fax only by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: Nov 10, 2021

87415 Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures,.... and shall be available as indicated below to assist in caring for residents in the event of an emergency. (2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement was not met as evidence by: Only one caregiver was on shift at night, several times and was not able to assist all residents with their ADL'sthe state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Administrator will ensure at least 2 staff are on shift when there is more than 14 residents at the facility or they determine they need 2 caregivers based on the residents needs. Administrator will send a signed statement stating their plan of action by fax by POC due date.

Allegation investigated: Resident had unexplained injury Staff did not notify authorized representative of residents injury

Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit. The investigation consisted of the following: On 12/23/2020, LPA Almaraz conducted a virtual tour of the facility and residents. LPA conducted interviews with Mody, Singhvi and Staff #1-3 and requested a Staff and Resident Roster. On 10/26/2021, LPA Almaraz re-interviewed Staff #2-3 and interviewed Staff #4. LPA attempted to interview Resident #1 but the resident was no longer residing at the facility after being evicted on 12/10/2020. LPA requested Resident #1's file. The investigation revealed the following: In regards to allegation, "Resident had unexplained injury" it was alleged Resident #1 received a black eye while living at the facility. (Continued on an LIC 9099C) Unsubstantiated Interviews with staff indicated the resident never had a black eye while residing at the facility. Interviews with staff revealed the resident was aggressive and would hit staff but did not have self injurious behaviors. Staff stated they never witnessed any staff hit the resident or hear about a staff hitting the resident or any other resident. In regards to allegation "Staff did not notify authorized representative of residents injury" it was alleged the facility did not notify the responsible party of Resident #1 after sustaining a black eye at the facility. Interviews and records reviewed indicated the resident did not have a black eye, therefore the facility never contacted the responsible parties. A photograph was provided of the resident with the alleged black eye and LPA could not verify if it was the angle of the picture or a black eye. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the Assistant Administrator and a hard copy was provided. Interviews revealed the resident was put in the Gerry Chair with the table tray during meals and while caregivers put back the dishes back in the kitchen. Per interviews, the chair was used because it helped the resident stay more calm while eating. Interviews with staff also revealed the chair was used to elevate the residents legs when they were swollen. Staff stated they would put the resident in the chair for about an hour to help his legs. Interviews and records showed the Gerry Chair did not belong to the resident and belong to other residents at the facility who were on hospice and had physicians orders for the chair. Community Care Licensing (CCL) never received a request/plan for approval prior to using the Gerry Chair. It is unclear how long the resident was left in the chair during the day or if it was used for other than meal time and leg elevation. LPA received a photograph of the resident in the Gerry chair with the table tray on, in what appeared to be a resident room at the facility. The table tray did not have any food on it. The residents file revealed the resident had Dementia and needed assistance with several of the residents Activities of Daily Living (ADL's). In an appraisal conducted on 7/3/2020, it indicated the resident was unable to communicate clearly. While living at the facility he became aggressive towards staff and the facility later determined they could not care for the resident due to the residents behaviors. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Please see LIC 9099D An exit interview was conducted with Assistant Administrator and copy of this report was provided. Appeal Rights provided.the state’s words, verbatim · CDSS document, Oct 27, 2021 · control 28-AS-20201216154032

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Nov 1, 2021

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need ...... The licensing agency shall be authorized to require other additional documentation..... This requirement was not met as evidence by: Staff at the facility were putting resident #1 in a Gerry chair and using the table tray without prior approval or physcians order.the state’s words, verbatim · CDSS document, Oct 27, 2021

Plan of correction: Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement stating they have read and understoof the section and will abide by it. POC due by 11/01/2021.

Allegation investigated: Staff pushed resident

Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit. The investigation consisted of the following: On 12/29/2020, LPA Almaraz conducted interviews with Administrator, Trupti Mody which will be referred as (Staff #5) and Hernandez (Staff #6). LPA also interviewed Staff #1 and #3 telephonically and requested Staff and Resident Roster, and Staff #1-4 files. On 10/26/2021, LPA interviewed Staff #2, Staff #4, Staff #7-8, reinterviewed Staff #6 and requested Staff #9's file along with training records for all staff. LPA also interviewed Residents #1-4 and was unable to interview Resident #5. Resident #1 was not able to answer LPA's questions due to the residents limitations. The investigation revealed the following: It was alleged a former staff had pushed a former resident at the facility. (Continued on an LIC 9099C) Unsubstantiated Based on interviews conducted, the former staff member who allegedly pushed the resident gave the impression to other caregivers that the staff member disliked Resident #5. Interviews with staff stated that although they got that impression they never witness the staff push the resident or any other resident. Staff members also stated they have never witness any of the other staff pushing or hitting any of the residents. Staff #8 stated there was an incident that occurred around December 2020 between Staff #9 and Resident #5 where the mother of Resident #5 complained about witnessing Staff #9 pushing Resident #5. Staff #8 said the staff did not witness the incident but the staff recalls it was about Staff #9 pushing Resident #5. Per Staff #8, the mother informed Staff #6, who was the Administrator at the time and was aware of it. Staff #6 denies of any report made in regards to Resident #5 and Staff #9. On 10/26/2021, LPA re-interviewed Staff #6, who stated staff recalls the mother of Resident #5 complaining about Staff #9. Staff #6 stated staff does not remember if the mother said Staff #9 pushed the resident but recalls the mother saying screaming to Resident #5. Staff #6 stated there was a discussion with Staff #9 where the staff denied pushing the resident but had rather blocked the resident from entering the front building where the resident can leave the premises or interrupt the visitor exiting the building. Staff #9 denied to Staff #6 pushing the resident and stated to Staff #6 that the staff did not realize it was a family member of Resident #5. Per Staff #6, the residents are re-directed because they all have Dementia or Alzheimer's. LPA also conducted interviews with Residents #1-4. Three (3) out of the (4) residents stated they are happy at the facility and staff are nice. One (1) resident was unable to answer LPA's questions do to the residents limitations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Assistant Administrator and a hard copy was provided.the state’s words, verbatim · CDSS document, Oct 26, 2021 · control 28-AS-20201221091943

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst's (LPA's) Linda Almaraz and Elizabeth Irra conducted a subsequent visit for the purposes of completing the Annual/Required inspection. LPA's were greeted by staff member Daisy Fitter and former Administrator Laura Hernandez who assisted with the visit. Later during the visit at approximately 11:20AM, Administrator Trupti Mody arrived. During today's annual continuation inspection, LPA's completed the Residents with Special Health Needs domain. The following was reviewed: Resident hospice files and staff training files. On 9/16/2021, LPA's did a walk-through of the facility, resident rooms and storage room. Resident #7 was missing re-appraisals for the year of 2018, and 2020. Resident #9 was missing re-appraisals for 2017 and 2018. Staff records did not have training records on administration of Oxygen for the year of 2020. LPA was provided with 2021 Oxygen training dates/record. Resident #4 and #9 had half bed rails and both had orders on file for full bed rails. During the following annual inspection visits (9/1/21, 9/16/21, and 9/30/21) LPA's observed the exterior gate and gate door locked at all times. The gate was locked with a chain and pad lock, and the gate door was locked on both sides by a key. Per interviews conducted, all caregivers have a key for the side gate door and would need to unlock if someone needs to exit through the door. Deficiencies cited under California Code of Regulations Title 22. An exit interview was conducted with the Administrator and provided a copy of this report. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Sep 30, 2021

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst's (LPA's) Linda Almaraz and Elizabeth Irra conducted a sub-sequent visit for the purposes of completing the Annual/Required inspection. LPA's were greeted by staff member Daisy Fitter who assisted with the visit. Later during the visit at approximately 11:30AM, Administrator and Med-tech Elvira Cortez arrived. During today's annual continuation inspection, LPA's completed the Disaster Preparedness domain. The following was reviewed: Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E), Emergency food supply, hygiene supply, incontinent supply, and medical supply. LPA's also verified emergency vehicles plan and found there was no vehicle set in place or emergency keys available to transport the residents and their medical supply. Fire drills documentation was provided and reviewed. There was no Disaster emergency training records provided. Per interviews, no training is provided and only new hires are shown around the facility. Due to time constrains the following domain was not completed: Residents with Special Health Needs which will be reviewed at a later time. Note: Any deficiencies observed during the visit that are not cited today will be cited on the next visit. Deficiencies cited under California Code of Regulations Title 22. An exit interview was conducted with the Administrator and provided a copy of this report. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Sep 16, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPA's) Linda Almaraz, Christine Wong, Tony Vasallo and Nina Galarza conducted a visit for the Annual/Required inspection. LPA's met with Licensee, Smita Sanghvi and former Administrator Trupti Mody. Staff member Daisy Fitter and Med-tech Elvira Cortez assisted with the facility walk-through. A tour of the facility includes a single-story building with administrative offices, employees lounge, conference room, and commercial-size kitchen. The second single-story building includes a, medication room, residents rooms, bathrooms, and indoor/outdoor areas. All residents bedrooms have the required furniture for privacy, comfort, and safety. Bathrooms are clean and operational. The following bathrooms hot water temperature was not within the required range of 105-120 degrees F; the first bathroom of the left wing of the building was tested at 125.7 degrees F, bathroom in room #9 which was at 123.8 degrees F, and bathroom in between rooms 4 and 5 was at 121.8 degrees F. Bathroom in room #20, on the right wing of the building was at 102.9 along with bathroom between rooms 18 and 19 which was at 80.1. Bathroom in room #18 on the right side wing has a peeling boarder on the wall of the bathroom floor near the toilet. Bathroom #4 was missing non-skid mat. Both linen closets on the left wing had what appeared to be rat droppings. The commercial-size kitchen was observed for the ability to prepare and serve food. LPA's observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. There is an additional storage area of food supply for emergency preparedness. All storage areas for chemical compounds, cleaning solutions, toxins, knives or hazardous items are located in the front building. Facility’s central air & heating system is operational. LPA's observed the carbon monoxide device(s) which were tested and appear to be operational. A pull switch, fire alarm sounding device was observed in the hallway/main entrance in second building. Fire extinguishers are fully charged with posted sign. First-aid kit is fully stocked. Facility's call system was not operational. According to Staff #2 the system has not worked for some weeks and they provided small bells to residents until they repair the call system. (Cont LIC 809-C) Landscape and the passageways are free of obstruction. The outdoor activity area is free of visible hazards, debris, and the containers have covered lids. There are no security bars nor weapons or bodies of water (pool/spa) on the premises. LPA's reviewed the facility’s profile, personnel summary report, staff roster & work schedules, personnel files & training records, register of residents, residents’ administrative files & medical records, medications (for proper storage, documentation, and system implementation). LPA's observed the following; Staff #4's personnel file did not have a health screening form. Resident #9's medication (Aquaphor ointment, grratorpium/Albueerol, and PRN Lactulose 10mg/15 solution) was not present at the facility. Resident #6's medication (PRN melatonin 5mg) was not present at the facility. Resident #4's medication (Calmoseptine ointment) was not labeled with the residents name. Resident #6's medication (D-Mannose with Cranberry Dandelion Extract) was not labeled with the residents name. LPA also observed the required mandated documents/poster were not posted in a prominent place, such as Personal Rights and CCL "Let us no" complaint poster. The following deficiencies were observed to be in violation under California Code of Regulation Title 22. Refer to LIC 809D. Due to time constrains the following domains were not completed: Disaster Preparedness and Residents with Special Health Needs and will be reviewed at a later time. Note: Any deficiencies observed during the visit that are not cited today will be cited on the next visit. An exit interview was conducted telephonically due to networking issues at the facility. LPA Almaraz contacted former Administrator Trupti Mody later in the afternoon and also provided a copy of the Facility Evaluation Report via email for a signature. Appeals Rights provided.the state’s words, verbatim · CDSS document, Sep 1, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vasallo conducted a case management visit. The purpose of the visit was to gather the following documents for all 11 residents: Resident roster Identification/emergency contact information for each resident. Physician's report Means of income Med Tech, Erin Richardson assisted with obtaining copies of the documents. Exit interview held. A copy of the report was provided to Erin Richardson.the state’s words, verbatim · CDSS document, Aug 25, 2021

Allegation investigated: Facility failed to provide resident's medical records to authorized POA. Facility Staff failed to seek proper medical attention for UTI.

Licensing Program Analysts (LPA's) Linda Almaraz and Nina Galarza conducted a complaint visit to investigate the allegations listed above. LPA's met with Administrator, Lee Stotts and discussed the reason for todays visit. The investigation consisted of the following: LPA's interviewed Administrator, Staff #1 and attempted to interview Staff #2 and 3 who were off. LPA's also interviewed Residents #1-4. LPA's requested copies of Staff and Resident Rosters, Resident #1's File and MAR logs, and reviewed medication. The investigation revealed the following: It was alleged the facility failed to provide resident medical records for Resident #1. Interviews and records reviewed revealed the facility sent the residents Power of Attorney (POA) the medical records via email on 7/21/2021, at about 11:33AM. Records show the POA stated she did not receive the records and the Administrator re-sent the records at about 1:27PM. (continued on LIC-9099C) Unsubstantiated Interviews revealed Resident #1 has a history of UTI and had recently developed a strong urine smell. Per interviews conducted, the doctor was contacted on 7/15/21 in regards to the urine smell. Facility provided a urine sample to the POA on 7/19/21 and the resident was diagnosed with a UTI on 7/25/21. Order for medication was placed with pharmacy and the medication was received today 7/27/21. Based on LPA's interviews conducted and records reviewed, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided. Upon reviewing Medication Administration Log (MAR log), LPA observed the 20mg Furosemide for today 7/27/21 not administered and still packaged. The MAR log was signed off as administered but the medication was still packaged and not dispensed for 7/27/21. Records indicated the medication was supposed to be administered at 8AM. LPA's also noted the following discrepancies, Potassium and Setraline was administered at 8AM and not signed off. The State of California, Department of Social Services, Community Care Licensing Division investigated the allegation "Staff failed to provide residents medications as prescribed", based on records reviewed and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies cited under California Code of Regulations Title 22. Exit interview was conducted with the Administration and a hard copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 27, 2021 · control 28-AS-20210721121852

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 3, 2021

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, ....provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Facility failed to provide Resident #1, Flurosemide 20mg on 7/27/21 at 8AM.the state’s words, verbatim · CDSS document, Jul 27, 2021

Plan of correction: Administrator will have a pharmacy conduct training with all staff who administer medication. Administrator will send material of subjects covered and sign in sheet of attendees by POC due date.