The Villa

Allegation investigated: Resident sustained injury while in care. Timely medical care not sought for resident. Staff are restraining residents. Facility staff served moldy food to residents. Staff did not report incident to licensing agency.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with David Kim (Administrator) and explained the purpose of the visit. During a the initial investigation on 04/08/21, LPA requested a copy of the staff and resident roster and interviewed Staff #1. During today's visit, LPA obtained a copy of the Staff and Resident roster, toured the kitchen and food storage areas with Staff #1 and reviewed records for Residents #1, #2 and #3, interviewed Staff #1, #2 and #3 in the dining room and interviewed Residents #4 to #9 in various locations of the facility. In regards to the allegation: Resident sustained injury while in care. Records review did not indicate an incident of Resident #1 sustaining injury while in care. Interviews with 3 of 3 Staff indicate they are not aware of Resident #1 sustaining injury. Continue to LIC9099C........ Unsubstantiated Interviews with 6 of 6 Residents indicate they have never sustained an injury while in care and have never witnessed other Residents sustaining injury while in care. In regards to the allegation: Timely medical care not sought for resident. Interviews with 3 of 3 Staff indicate Resident #1 did not sustain injury, therefore medical care was not sought. Staff also indicated if medical care is needed, Staff would immediate seek medical care for Residents. Interviews with 6 of 6 Resident also indicate that timely medical care is sought if needed. In regards to the allegation: Staff are restraining residents. Per allegation detail, Resident #1, #2 and #3 were tied to their wheelchair or bed. Interviews with 3 of 3 Staff indicate Residents have never been tied to their beds for wheelchairs. Interviews with 6 of 6 Residents also indicate they have never been tied to the bed or a chair and never witnessed other Resident being restraint in such a way. In regards to the allegation: Facility staff served moldy food to residents. LPA toured the kitchen and food storage areas and observed food to be of healthy quality. Interviews with 3 of 3 Staff indicate moldy food is never served to Residents. If food becomes moldy or bad then it is discarded. Interviews with 6 of 6 Residents indicate they have never been served moldy food. In regards to the allegation: Staff did not report incident to licensing agency. Review of records indicate facility has a history of providing incident reports to the department. Interviews with Staff also indicate incident reports are sent to the department upon occurrence. Per allegation detail, incident of Resident #1 sustaining injury was not reported to the department. There is no proof of Resident #1 sustaining a foot injury while in care therefore an incident report for this alleged incident was not drawn. Based on LPA's record review, observations and interviews, 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 David Kim (Administrator) and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 4, 2023 · control 28-AS-20210402143323

Allegation investigated: Resident sustained an unexplained injury while in care. Resident fell while in care and sustained a hip fracture. Staff left resident in soiled diapers for an extended amount of time. Residents call buttons are not being answered in a timely manner. Staff yells at residents and do not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with David Kim (Administrator) and explained the purpose of the visit. During the initial complaint investigation on 03/30/21, LPA conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA toured the facility via Facetime video with David Kim 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. During today's visit, LPA obtained/reviewed a copy of the Staff schedule, Resident roster, Incident Report, Resident #1's records and Hospice patient incident report. LPA interviewed Staff #1 to #4 in the dining room and interviewed Residents #3 to #8 in their bedrooms. Continue to LIC9099C.... Unsubstantiated In regards to the allegation: Resident sustained an unexplained injury while in care. Interviews with 3 of 3 Staff indicate they do not recall injuries sustained by Resident #2. Interviews with 6 of 6 Residents indicate Staff has never caused injury to Residents. In regards to the allegation: Resident fell while in care and sustained a hip fracture. Based on record review, R#1 had a fall on 01/20/21 in the facility. Facility Staff notified the department and the Hospice agency. Review of Hospices records and text conversation indicate Hospice determined there were no signs and symptoms of a fracture. Hospice record did not indicate R#1 sustained a fracture. Interviews with 3 of 3 Staff indicate they were not aware of R#1 sustaining a fracture. In regards to the allegation: Staff left resident in soiled diapers for an extended amount of time. Interviews with 3 of 3 Staff indicate Residents were not left in soiled diapers for an extended amount of time. Interviews with 6 of 6 Resident also indicate they were not left in soiled diapers for an extended amount of time. In regards to the allegation: Residents call buttons are not being answered in a timely manner. Interviews with 3 of 3 Residents indicate call buttons are optional but none of the Residents are using a call button. Residents are consistently monitor throughout the day and night and provided timely service. Interviews with 6 of 6 Residents also indicate they do not use a call button. If assistance is need, Resident would use there phones to call Staff or verbally call out for assistance. Residents interviewed indicate assistance is provided in a timely manner. In regards to the allegation: Staff yells at residents and do not treat residents with dignity and respect. Interviews with 4 of 4 Staff indicate they have never yelled at or treated Residents without dignity or respect and never witnessed other Staff yell at Residents or treated Residents without dignity or respect. Interviews with 6 of 6 Residents indicate Staff have never yelled at them or treated them without dignity or respect. Based on LPA's record review and interviews, 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 and a copy of this report provided to David Kim (Administrator).the state’s words, verbatim · CDSS document, Jun 27, 2023 · control 28-AS-20210323093521

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. The purpose of the visit was explained to Administrator David Kim. There are 10 residents ages 60 and above [ 6 ambulatory, 3 non-ambulatory, & 1 bedridden]. A Dementia waiver and an approved hospice waiver for 6 residents is in place. The last fire emergency drill was conducted on 2/6/2023. The last fire Inspection was completed on 8/29/2022 by Eminent Fire Protection. Administrator certificate expires 3/9/2024. OBSERVATIONS Infection Control: COVID-19 Infection Control Practices and signs were observed in the main entrance and restrooms. A visitor sign in station was observed outside the main entrance. Per Administrator, visitors are no longer being screened due to public health order changes in 2022. Visitors are screened by staff only if needed. Staff wear masks. Residents do not wear masks due to health and cognitive issues. Sufficient supply of Personal Protective Equipment (PPE's) was observed. The facility has a contingency plan for back-up staffing if needed. The facility submitted a COVID-19 Mitigation Plan. An Infection Control Plan (ICP) has not been submitted. Submit the ICP as soon as possible. The plan should be reviewed and updated as necessary. Administrator has agreed to submit their Infection Control Plan by [up to 60 days from inspection]. Medications: 30-day centrally stored resident medications were observed. *See LIC 809C for report continuation. Physical Plant: The facility is a single story building consisting of 11 resident bedrooms, 7 bathrooms, living room, dining room, tv room kitchen, indoor patio, laundry room, two (2) shaded patio areas, and detached garage. The majority of resident beds did not have mattress pads. Administrator put mattress pads on all beds during the visit. The auditory alarm in the main entrance door was turned off. Administrator immediately turned it on. Eleven (11) resident rooms were inspected. Rooms 1 & 2 are presently being used as living quarters by Licensee. Administrator was advised to update and submit to Community Care Licensing the updated Plan of Operation/Program Design and facility sketch to reflect the changes in facility operation. Food Service: Sufficient food supply is stored in the kitchen and outdoor food storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Resident Files: Three (3) residents are in enrolled in hospice and one (1) resident is bedridden. Staff Files: Criminal Background Clearance was checked. Liability Insurance: Proof of liability insurance was provided. It expires 12/31/2023. A technical advisory was issued pertaining to Infection Control Plan. Deficiencies were cited Exit interview was conducted with Administrator David Kim. A copy of the report and appeal rights was issued.the state’s words, verbatim · CDSS document, Feb 15, 2023

Allegation investigated: Insufficient staffing to meet the residents' needs. Residents sustained pressure injuries while in care. Staff are unable to manage residents' incontinence needs.

**** This amended report supersedes report dated 12/29/2022. It was created to remove confidential information. Revision did not change any other aspects of the report and all aspects remain the same.**** Licensing Program Analyst (LPA) Alberto Lopez initiated a subsequent complaint visit to deliver findings on the allegations listed above. Previous visit was initiated telephonically on 08/04/2020 LPA Almaraz contacted Administrator and requested copies of staff and resident roster along with other pertinent documentation to be emailed to LPA. LPA Lopez made visit on 11/10/2022 and requested 2020 staff and resident’s rosters and asked Administrator for contact information (phone numbers of 2020 staff) and physician’s report for 2020 residents. On 12/20/2022 LPA made another visit to obtain medical/hospice records of several of the residents that resided at facility in 2020. LPA met with Administrator David Kim and discussed the purpose of today’s visit. (continued on 9099C) Unsubstantiated Regarding Allegation: Insufficient staffing to meet the resident's needs. It is Alleged that that the facility only has four caregivers and that the owners themselves will work 24-hour shifts to cover. And because of this, the quality of care of the residents has slipped. It is alleged that on a regular basis, caregivers would arrive for their shifts (after the owners have worked a 24-hour shifts) to find the residents briefs/diapers to be soiled and it is alleged that two of the residents have developed pressure injuries due to sitting in soiled diapers for too long. It is alleged that there are times when a resident calls for assistance but that it can take up to 30 minutes for a caregiver to respond to the alarm. The investigation reveals that in 2020 facility had 10 total staff, that included 7 caregivers and the LIC 500, time sheets, and schedule showed that shifts had coverage 24 hours a day, 7 days a week. LPA Interviewed current staff and 3/3 denied the allegations. 9/9 current residents could not collaborate the allegations. LPA Interviewed staff that was present during 2020 and no longer employed at facility. 3 of 4 former staff interviewed collaborated the allegations as did 1 of 2 witness. No documented evidence was discovered regarding the allegation. Therefore, the allegation is unsubstantiated Regarding Allegation: Residents sustained pressure injuries while in care. It is alleged that residents sustained pressure sores while in care. LPA interviewed current residents and 9/9 did not collaborate the allegations and none had a pressure sore at the time of visit. 3/3 current staff denied the allegation. LPA interviewed former staff. 4/4 staff and 1/2 witness collaborated the allegation. Staff and one witness were able to identify former residents: FR10, FR15 and FR22 who were alleged to have developed pressure sores while in care. Review of the former resident’s FR22 file and documentation revealed that FR22 did not have pressure ulcer at the time of allegation and was under hospice care. Review of FR10 documentation revealed that FR10 arrived at facility under hospice care and with stage 4 pressure sore. Review of FR15 hospice records show that resident was admitted to hospice on 01/07/2019 and FR15 developed skin tear and wound while under hospice care. No documented evidence was discovered regarding the allegation. Therefore, the allegation is unsubstantiated Regarding Allegation: Staff are unable to manage residents' incontinence needs. It is alleged that resident’s incontinence needs were not taken care of and may have developed pressure injuries due to sitting in soiled diapers for too long. 3/3 current staff denied the allegations. 9/9 current residents could not collaborate the allegations. 1 of 2 witness did not collaborate the allegations. 4/4 former staff collaborated the allegations, however review of documentation revealed that no residents developed pressure sore due to incontinent needs not being taken care of. Only 2 resident’s that were present during 2020 are still at facility. Former residents are all presumed to have passed away. No documented evidence was discovered regarding the allegation. 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 conducted with Administrator David Kim and copy of report provided.the state’s words, verbatim · CDSS document, Dec 29, 2022 · control 28-AS-20200803133247

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator David Kim and the purpose of the visit was discussed. As a part of the inspection, LPA used the inspection tool, reviewed (6) client records, (2) staff files, and (6) client medications. Currently the facility has (10) clients. LPA also toured the facility. Facility is a one story residence with eleven (11) bedrooms. There are (7) bathrooms, a living room, family room, kitchen, central air and heating, dining area, laundry room, (2) shaded outdoor patios. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Resident bedrooms are equipped with required accomodations. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in for each resident. Fire alarms are interconnected and operational. Facility has a sprinkler system. Required postings observed. Water temperature within required tittle 22 regulations. Infection control domain completed. Deficiency cited on 809-D page. An exit interview was conducted. Copy of this report provided to Administrator David Kim. Appeal rights providedthe state’s words, verbatim · CDSS document, Feb 25, 2022