Brookdale Ocean House

Allegation investigated: Staff do not provide resident with fluids when requested. Staff do not ensure resident is provided privacy. Staff do not treat resident with dignity and respect.

On 11/2/2023 at 10:56 AM, Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit to deliver complaint findings of the allegations listed above. LPA Montoya met with Helen Lee, the new Executive Director/Administrator, and explained the purpose of this visit. The investigations consisted of the following: On 9/12/2023, LPA conducted a tour of the facility. LPA Montoya interviewed 8 out of 76 residents and 7 out of 66 staff. LPA requested and obtained copies of Staff roster, Resident roster, and R1’s service records (Admission Agreement, Physician's Reports, Appraisals/Needs and Services Plans, and other pertinent records associated with this complaint. REPORT CONTINUED IN LIC 9099C Unsubstantiated INVESTIGATIONS REVEALED THE FOLLOWING: Allegation: Staff do not provide resident with fluids when requested. According to SOC 341, it was reported that staff declines to give R1 fluids/drinks. Based on interviews conducted with seven out of eight residents (R2-R8), it was denied that staff do not provide residents with fluids/drinks when requested. Two residents (R7 & R8) revealed they get anything they request from staff. The department was not able to conduct an interview with R1 because R1 has passed away and was no longer available at the time of the visit. Based on interviews conducted with seven out of seven staff (S1-S7), it was denied that staff do not provide residents with fluids/drinks when requested. Four staff (S1-S4) stated R1 has a reserve of water jug in the bedroom that staff refills it when empty; Staff assists R1 with drinking because R1 has difficulty in drinking and R1 drinks from a cup with a straw. S5 stated when residents ask for water or any other drinks, S5 would get it for them. S6 stated when residents have any concerns, staff or residents would report to S6 and S6 denied that there was any complaint about staff not providing residents with fluids when requested. S7 stated residents would call the front desk for services like requesting fluids but sometimes S7 would bring residents water or juice when requested directly from S7. Based on LPA's observations during the visit on 9/12/2023, care providers, dining crew and front desk staff are attentive to resident's requests. Allegation: Staff do not ensure resident is provided privacy. According to SOC 341, staff have exposed R1’s private areas while taking R1 to the restroom with other people at the present location. Based on interviews conducted with seven out of eight residents (R2-R8), it was denied that staff do not ensure residents are provided privacy. The department was not able to conduct an interview with R1 because R1 has passed away and was no longer available at the time of the visit. Based on interviews conducted with seven out of seven staff (S1-S7), It was denied that staff do not ensure resident is provided privacy. Four staff (S1-S4) stated R1 has a private bathroom in the bedroom and R1 did not like using the common bathrooms. S6 stated when residents have any concerns, staff or residents would report to S6 and S6 denied that there was any complaint about staff not ensuring resident is provided privacy. Based on LPA's observations during the visit on 9/12/2023, LPA did not observe any incidents that violate residents' privacy. LPA observed each resident's bedroom including R1's bedroom has ensuite bathroom. This page was amended to change the word "privacy" to dignity/respect on line #16. Allegation: Staff do not treat resident with dignity and respect. According to SOC 341, R1 is enduring abuse from a perpetrator consistently. Based on interviews conducted with seven out of eight residents (R2-R8), it was denied that staff do not treat resident with dignity and respect. Three residents (R2, R7 & R8) revealed staff are respectful. The department was not able to conduct an interview with R1 because R1 has passed away and was no longer available at the time of the visit. Based on interviews conducted with seven out of seven staff (S1-S7), It was denied that staff do not treat residents with dignity and respect. Two staff (S1-S2) stated staff respect the residents and their families. S3 stated S3 did not have any issue with R1. S4 stated one staff (S8) reported to S4 that one staff (S8) heard S9 telling R1 to stop whining. S4 investigated the issue, R1 and S9 denied the allegation. S4 stated no further investigation was made because there was not enough evidence to prove the allegation. S4 admitted S4 did not report the incident to the facility administrator. LPA made an attempt to interview S8 but S8 was not working at the time of visit. LPA was not able to interview S9 because S9 was no longer working at the facility. S6 stated when residents have any concerns, staff or residents would report to S6 and S6 denied that there was any complaint about staff not ensuring resident is provided dignity/respect. Based on LPA's observations during the visit on 9/12/2023, staff treat residents with respect. Based on interviews, available evidence, observations, information received, and records reviewed there was not sufficient evidence to support the allegations, "Staff do not provide resident with fluids when requested, Staff do not ensure resident is provided privacy, Staff do not treat resident with dignity and respect". 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 deemed UNSUBSTANTIATED. There were no deficiencies cited. An exit interview was conducted and a hard copy of the report was provided to Helen Lee.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 11-AS-20230905082714

Allegation investigated: Staff financially abused resident.

On 10/12/23, Licenising Program Analyst (LPA), Wendy Gibbs conducted an unnanounced visit to amend the report. LPA met with Executive Director Jayden Bennencourt and explained the purpose of today's visit. On 09/29/2023 at 10:00 a.m. Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced visit to deliver the findings of the complaint allegation: Staff stole resident's money while in care. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s). with Assoc. Executive Director Jayden Bettencourt. The Investigation Consisted Of The Following On 06/28/23 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced 24-hour visit to Brookdale Ocean House. LPA was met by Matan Burstyn Executive Director. The Purpose of the visit was explained to investigate the allegation " Personal Rights” and conduct a health and safety check on residents in care. Substantiated Cont from Pg 1 All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair. Residents were currently sitting in the movie screening room, activity room, and gaming rooms. Residents did not show any signs of distress or abuse. LPA requested pertinent documents pertaining to the investigation. The following documents were gathered: Resident Roster, Staff Roster, Copy of entire resident file for (R1) including Admissions Agreement, Needs and Services, physicians report. LPA requested facility staff schedules and other pertinent documentation such as staff files. On 6/28/2023 LPA referred this assignment case to the Investigations Branch (IB) of the Department of Social Services to conduct the interviews of the above allegation. Investigator Heidy Bendana (IB) interviewed the following individuals. Witness (W1), Victim (V1), Administrator (A1), Staff (S1-S2) and Residents (R1-R4). The Investigation Revealed The Following. Allegation: Staff financially abused resident. On 7/25/2023, at approximately 0754 hours, Investigator Heidy Bendana, interviewed Witness #1 via telephone. Witness #1 indicates W1 assist V1 with accounting due to V1 medical diagnosis but V1 is responsible for V1’s checkbook. W1 indicated during a review of V1 taxes W1 noticed on V1 bank account online a $9,000 check cleared made out to cash. W1 reported this to V1 and V1 denied writing a check for cash. On 7/25/2023, at approximately 1058 hours, Investigator Heidy Bendana, interviewed Victim #1. V1 had been a resident at Brookdale Ocean House. V1 informed Investigator that $9,000 was withdrawn from V1 First Citizen’s bank account and $1,000 from Bank of America account. V1 reported V1 checkbooks were stolen from Brookdale Ocean House. V1 confirmed S1 gave V1 a $8000 cashier’s check and said it solved the problem. V1 stated V1 asked S1 where’s the rest because the total amount stolen was $10,000. Cont from Page 2 On 7/27/2023, at approximately 0946 hours, I, Investigator Heidy Bendana, interviewed Matan Burstyn at her place of employment. Matan stated Victim #1 lived at the facility before she started her employment with the facility. Matan stated she was informed S1 stole $10,000 dollars from V1. On 08/2/2023, at approximately 0924 hours, Investigator Heidy Bendana, interviewed S3 via FaceTime. S1 stated V1 gave S1 a check for $1,000 & $9,000. S1 confirmed S1 cashed both checks at S1 bank. S1 stated later S1 attempted to return the money and V1 told S1 to keep some money therefore S1 only gave V1 a Cashiers check for $8,000. IB investigator interviewed Staff #2 and S2 corroborated the allegation. IB investigator interviewed Residents #1-4 and 4 of the 4 residents did not have any knowledge of the allegation. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the LIC 9099 and 9099D and Appeal Rights was provided to Assoc. Executive Director Jayden Bettencourt ,the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 11-AS-20230627152651

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(e) · Plan of correction due date: Sep 29, 2023

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, such as withholding residents’ money....This requirement is not met as evidenced by: Based on interview and records review, the licensee failed to ensure resident's personal rights due to staff person #1 mis- appropriating residents money from Resident V1 personal bank account. This poses a personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator will provide LPA, per fax, staff meeting sign in sheet, regarding review of resident's personal rights - specifically abuse, or other actions of a punitive nature, such as withholding residents’ money, by 10/09/23. LPA fax number (323) 981-1781

Type of visit: Case Management - Deficiencies

On 09/29/23, Licensing Program Analyst (LPA) Jeremiah Randle conducted a case management visit in conjunction to a complaint visit conducted today at this facility. LPA met with Assoc. Executive Director Jayden Bettencourt and explained the purpose of the visit. During a complaint investigation visit on 06/28/23 control # 11-AS-20230627152651, LPA identified Staff Trevor Weiss in conjunction to a complaint visit conducted on 06/28/23. Staff Trevor Weiss does not have a Criminal Record Clearance associated to the facility named above in the Complaint. During a complaint investigation visit on 06/28/23 control # 11-AS-20230627152651, LPA identified Administrator Matan Burstyn, or designated staff did not timely report incident of Financial Abuse to CDSS CCLD. The licensee violated Title 22 Regulations 82711- Reporting Requirements and 87355 - Criminal Record Clearance California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). Civil Penalties are Assessed. An exit interview was conducted and a copy of this report and appeal rights provided to Assoc.Executive Director Jayden Bettencourt.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 29, 2023

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) This requirement was not met as evidenced by Based on LPA observation and interview conducted, the licensee failed to ensure that staff Trevor Weiss was cleared or associated to the facility on 6/28/2023 and prior during employment.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee will have cleared staff on schedule, staff has been adequately fingerprinted and background cleared and associated to facility. Per administrator staff Trevor Weiss has been terminated. Administrator to provide LPA updated LIC 500.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(d) · Plan of correction due date: Sep 29, 2023

Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Any incident which threatens the welfare, safety or health of any resident...This requirement was not met as evidenced by Based on LPA observation and records review conducted, the licensee failed to ensure that staff or administration reported incident in complaint referenced to CDSS CCLDthe state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator will provide LPA, per fax, staff meeting sign in sheet, regarding review of incident reporting requirement for Facilities per CDSS CCLD Regulations

Allegation investigated: Facility staff did not provide resident assistance for an extended period of time after falling.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, September 18, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Executive Director Matan Burstyn. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: On 11/07/2022, and 09/18/2023, LPA Bunker conducted interviews with both staff and residents concerning the allegation, which suggested that facility staff had failed to provide timely assistance to a resident who had fallen. Staff 1 through Staff 3 (S1-S3) and Residents 1 through 8 (R1-R8) were interviewed. S1 disclosed that R1 had reported her fall on 10/05/2022; however, the specific time of the fall was not mentioned by R1. S1 also noted that S2 had previously assessed the functionality of R1's pendant before the incident date, certifying its proper working condition. However, on 10/05/2022, staff rechecked the pendant, finding it operational. In an effort to reassure R1, a new call pendant was promptly provided to her on the same day. Both S1 and S2 affirmed the functionality of the call button within R1's room. We toured R1's room for a health and safety check. See page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation: Facility staff did not follow reporting requirements. On 10/05/2022 R1 fell around 11:00 P.M., and did not receive staff assistance until the following day near breakfast time around 7:45 A.M., When staff brought up R1 breakfast that is when staff contacted the nurse and Med Tech to come and assist R1. R1 reported staff offered to send R1 to the hospital but R1 refused and decided not to go to the hospital. Staff was unable to prevent the fall from happening. Staff did not know of the fall until the next morning. R1 never called for assistance. The facility staff failed to report the special incident report to Community Care Licensing according to Title 22 Regulations on Reporting Requirements. Investigation revealed the following: On 11/07/2022, Interviews were conducted with staff 1-3 (S1-S3), and residents 1-8 (R2-R8), S1-S3 and R2-R8 stated staff provided the resident with immediate assistance. S1-S3 and R2-R8 stated residents never have to wait an extended period of time for assistance. S1-S3 stated the facility was unaware of the fall and the facility is fully staffed. Staff stated they had no control over the fall and could not have prevented the incident from happening. Staff did not report or submit a special incident report to the licensing agency or the person responsible for the resident within seven days of the occurrence regarding the incident Based on LPA’s observations, interviews that were conducted, and records reviewed, 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 LIC9099-D. Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D were provided to the Executive Director. Continued LIC9099-C page 2 During the tour, we tested R1's pendent and the room's call button, and both were found to be fully operational. S1 emphasized that the staff could not influence or prevent the fall incident, as they remained unaware of the event until the morning when the dining room staff visited R1's room to serve breakfast. R1 had not made any prior calls for assistance. Investigation revealed the following: During interviews conducted with Staff 1 to Staff 3 (S1-S3), it was established that they had no prior knowledge of Resident 1's (R1) fall on the evening of October 5th, 2022, at approximately 11:00 P.M. S1-S3 attested that R1 did not seek assistance nor did she report the incident at that time. It was emphasized that the facility maintains 24-hour care, with staff members consistently patrolling the premises. None of the staff reported hearing any indications or witnessing any movement associated with a fall during that particular timeframe. S1-S3 were unanimous in affirming that immediate assistance was promptly provided to R1 once they became aware of the incident, which occurred the following morning when staff was delivering breakfast at approximately 7:45 A.M. Upon being informed of R1's fall, staff promptly summoned the nurse and Med Tech to render aid. While staff offered to arrange for R1's transfer to a hospital, it was ultimately her decision to decline this option. Staff unequivocally asserted that they had no foreknowledge of the fall, as R1 did not contact them for assistance during the night. S2, a member of the staff, conveyed that she conducted a comprehensive body examination of R1 and found no evidence of bruises or injuries resulting from the fall. In R1's interview, she confirmed that on the date in question, October 5th, 2022, she had indeed experienced a fall within her room at approximately 11:00 P.M. However, she did not seek assistance at that time. Instead, it was during breakfast service at around 7:45 A.M. the following day that she brought the incident to the attention of staff, who promptly responded to her request for assistance. R1 reiterated that she did not make any prior attempts to contact staff for assistance. Residents 2 through 8 (R2-R8), when interviewed, expressed a unanimous sentiment regarding the accessibility of staff assistance. They affirmed that staff members are readily available to provide aid, and residents do not experience undue delays in receiving assistance. Additionally, R2-R8 conveyed their satisfaction with the level of care and supervision provided, highlighting the absence of any noteworthy issues, problems, or concerns in this regard. These residents expressed a sense of comfort and safety within the facility. Staff stated they had no control over the occurrence of the fall, rendering them incapable of preventing the incident from transpiring. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 18, 2023 · control 11-AS-20221028153233

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

87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. Staff did not report a special incident report that resident 1 had fallen on 10/05/2022. The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2023

Plan of correction: The facility should submit a written plan on Reporting Requirements to Community Care Licensing. By the POC due date of 09/25/2023

Type of visit: Required - 1 Year

On 09/02/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Required - 1 Year Annual visit using the new CARE Inspection Tools. Upon arrival at the facility, LPA verified that the facility has an approved Mitigation Plan Report. LPA met with staff Jesus Correa and the purpose of today's visit was explained. LPA Richard and Staff Correa toured the facility inside and outside grounds. The facility is a 10-story high-rise apartment building located in a residential beach neighborhood. The facility consisted of the following: 116 apartment units/with bathrooms, (16) 1- bedroom, (92) studio, and (8) deluxe studio Common area includes 1st-floor concierge desk, open patio area, in front of the facility, with patio chairs, (2) living rooms with piano and audio speaker sound system, restaurant style dining room, private dining room for special occasions, and a kitchen. The 2nd-floor includes an exercise/game room and wellness/medication room. The 3rd-floor includes a beauty salon including a manicure/pedicure station. The 10th-floor includes a library/computer/lounge room, activity/ exercise room, outside patio/ garden area, TV/movie theater room. All areas were observed to be properly furnished, free of hazards, and appropriate for group activities. The kitchen was inspected and observed to be clean and operational. In addition, appliances and fixtures appeared functional. Daily Activity Schedule and meal menu observed to be posted at the concierge desk, lobby, and inside the elevators. Refrigerated and frozen foods were stored at proper temperatures. Residents do not have access to the kitchen. The facility menu appears to meet the daily dietary needs for the residents. All toxins and knives are locked/secured and inaccessible to residents. There were no pesticides or poisons observed near any food areas. On 09/02/2023 LPA Richard was later joined with Executive Director Matan Burstyn. LPA Richard and Executive Director Burstyn inspected eight (8) resident's apartments they were inspected for, safety, privacy, and comfort. The living areas are clean. Resident apartments were found to be clean, well furnished, and in good repair. The resident's apartment’s windows have no sliding window locks with thumbscrews. All resident's rooms have private bathrooms. The living areas are clean. LPA observed the following during inspection of resident’s apartments: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All rooms inspected appeared properly furnished, sanitary and free from hazards. Bathrooms contained the required grab bars, and showers/tubs had non-slip safety bath mats. LPA observed bathrooms clean and operational. The following Title 22 regulated areas were audited and found to be in compliance: Apartments contain the required furniture. First aid kit is fully stocked with manual, hot water temperature in apartments #207; #309; #310; #311; #509; #515; #609; #611; and #710 measured at 108.5F to 110.4F degrees Fahrenheit. The facility has working telephones. The facility has an installed hardwired smoke alarm system. Apartments smoke and carbon monoxide detectors were in compliance. Each resident apartment has a night light and push bottom alert system, in the bathroom, for emergency assistance, as well, each resident wears a call alert pendent for immediate emergency assistance. The facility has two working elevators. The fire extinguishers are fully charged. Medications were centrally stored and properly locked on the 2nd-floor medication room in the records are current and documented on the Point Click Care Electronic Medical Records system. LPA Richard observed an ample supply of perishable and nonperishable food, adequate linen supply, and covered shaded patio areas. The fire/emergency drill was conducted on 08/28/2023. No firearms on the premises, all exit doors were in compliance, covered trash cans, and Hazardous items are inaccessible to clients, the yard is free of debris and hazards. Executive Director Matan Burstyn states staff was given training on dependent adult and elder abuse reporting. According to the California Code Of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time. Exit interview held and a copy was provided to Executive Director Matan Burstyn.the state’s words, verbatim · CDSS document, Sep 2, 2023

Allegation investigated: Facility staff did not respond to residents' call buttons in a timely manner

On 08/25/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannouced subsequent visit to the facility listed above to deliver findings for a complaint. LPA Gibbs met with Administrator, Matan Burstyn, and explained the purpose of today's visit. During today's visit LPA toured the facility and rendered findings. On the previous visit on 06/22/23, LPA Gibbs toured the physical plant with Administrator Burstyn. LPA Gibbs reviewed and received resident roster, staff roster, and staffing schedule. LPA Gibbs conducted interviews with Executive Director (S1), Staff (S2-S6), and Residents (R1-R8). The investigation revealed the following: CONTINUED ON LIC9099-C Substantiated Allegation: Facility staff failed to provide meal service to residents in their rooms. The allegation entails that staff forgot to turn in meal slips for resident who receive meals in their room, because of this three (3) residents did not receive their meals. During interviews with staff (S1-S5), four (4) out of five (5) staff stated they check on residents who receive room service to ensure they have gotten their food, and if they did not, they will get it for them. Interviews with residents (R1-R6), six (6) out of six (6) residents say they get three (3) meals a day and snacks in-between meals. Five (5) out of six (6) residents (R1, R3, R4, R5 and R6) stated sometimes it takes a while for their food to come because they know staff are busy, but it does come. Resident R2 stated if it takes too long for their food to come up their caregiver will go down and go get it. During a tour of the dining room and meal service, LPA observed all residents got their meals and the cart for room service was on its way up to residents room. Unsubstantiated Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Facility staff did not respond to residents’ call buttons in a timely manner. The allegation entails that a residents pressed their call light for assistance to the restroom and the resident had to wait thirty (30) minutes for assistance. Interviews with staff A1 and S1-S5 revealed the following. During interview Administrator (A1) stated staff respond to pendant call buttons as soon as possible. Staff S1 stated they try to respond as soon as possible but it they are assisting another resident it could take some time. Staff (S2-S5), four (4) out of four (4) stated, they try to go as soon as possible but it can take 15 to 40 minutes before we are able to respond. Interviews with residents (R1-R6) revealed the following. Residents R1 stated the soonest a caregiver has come to assist, after pressing the call button, was 10 minutes and the longest has been over an hour. R1 also stated, they had to wheel themselves to the door and was yelling for help, and still no one came. R1 stated they had to call their family who called the front desk for R1 to get assistance. Resident R2 stated they hired a private caregiver because they tried the pendant, but staff were busy, and R2 couldn’t wait. Interviews with residents R 3 and R4, two (2) out of two (2) stated staff never come when they press their pendants. Resident (R5) during interviews stated, when they press their pendant, it takes 30-40 minutes before a caregiver comes. Additionally, R5 stated they now call the front desk when they need assistance because the caregivers take to long. During an interview, LPA and R2 pressed the call button and it took staff 23 minutes for staff to respond to the call button. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 11-AS-20230614132722

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 1, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in 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: (4) 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. Based on interviews and observation the Licensee did not ensure residents callthe state’s words, verbatim · CDSS document, Aug 25, 2023

Plan of correction: The Administrator will provide a written plan of action explaining what steps they are going to do to ensure residents call buttons are answered within a timely manner. buttons were answered within a timely manner. This possesses a potential Health and Safety risk to residents in care.

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by the "new" Administrator (A2: Matan Burstyn, Executive Director) whom RA interviewed and explained the purpose of today's visit. LPA/RA conducted a risk assessment prior to entering facility. A2 informed LPA/RA that the facility has no COVID cases to report at this time nor do the residents or staff have symptoms. The purpose for this subsequent visit is to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day visit was conducted by LPA Martessa Brown on 12/01/22 with Staff #1 (S1: Amanda Monroy, Wellness Director) and was later met by Administrator (A1: Olga Kirskey, Executive Director). During this visit, LPA interviewed Administrator and Resident #1. LPA toured four (4) residents’ rooms on the 6th and 7th floors. LPA reviewed and obtained copies of the following documents: facility staff and resident rosters. Substantiated During today's subsequent visit, RA Ceniceros interviewed the "new" Maintenance Director (S3: Chris King). RA also re-visited Resident #1 Room #704 for observation of the repairs. RA Ceniceros obtained the following documents: updated staff and residents’ rosters and repair invoices (dated 05/04/23). Regarding Allegation #1: this investigation revealed following a physical plant tour conducted on 12/01/22 by LPA Brown of a total of four (4) residents’ bedrooms on the 6th and 7th floors (included Resident #1’s Room), LPA observed a hole in the bathroom ceiling (above the shower) that had not been repaired and covered with a board due to a damaged water pipeline. The carpet in Room #704 was torn and worn out and a safety hazard. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of PHYSCIAL PLANT: Facility is in disrepair is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the new Administrator (Matan Burstyn, Executive Director).the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 11-AS-20221123152901

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 3, 2023

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include profision of maintenance services and procedures for the safety and well-being of residents, employee and visitors. This was not met as evidence by: A hole in the bathroom ceiling (above the shower) had not been repaired and covered with a board due to a damaged water pipeline. The carpet was torn and worn out and a safety hazard LPA Martessa Brown's observations on 12/01/22.the state’s words, verbatim · CDSS document, Jul 27, 2023

Plan of correction: RA Elizabeth Ceniceros observed the ceiling and "new" flooring in Resident #1's Room #704 during the subsequent visit. POC was cleared by visit on 07/27/23.

Allegation investigated: Licensee does not ensure facility is adequately staffed to meet residents’ needs.

On 06/22/23, Licensing Program Analyst (LPA), Wendy Gibbs, initiated a complaint visit at the facility listed above. LPA Gibbs met with Executive Director, Matan Burstyn, and explained the purpose of today's visit. During today's visit LPA Gibbs toured the physical plant with Executive Director Burstyn. LPA Gibbs reviewed and received resident roster, staff roster, and staffing schedule. LPA Gibbs conducted interviews with Executive Director (S1), Staff (S2-S6), and Residents (R1-R8). Today's investigation relealed the following: Allegation: Licensee does not ensure facility is adequately staffed to meet residents’ needs. During the visit LPA interviewed three (3 )caregivers, and two (2)Med-Tech/Caregivers. Two (2) of the caregivers and one (1) MedTech/Caregiver work the morning shift 6am-2 or 2:30pm. One (1) Caregiver covers floors 2- half of 6 and the other covers half of 6-10. On the evening shift there is one (1) Caregiver and one (1) Med-Tech/Caregiver from 2:00- 10:00pm. The nurse is on 11-8pm. Substantiated Interviews revealed that each caregiver is assisting 3-4 residents with showers daily, 5-10 residents need assistance dressing and general grooming, helping residents in and out of wheelchairs, 5-10 resident who need assistance while using the restroom or with incontinent care and 5 residents who need escorted to the dining room for meals. Based on the information provided by the caregivers, each of them is spending at least 2 hrs to provide assistance to Residents using the bathroom (10-15min per person, 4 times per shift), 1.5-2 hours to provide escort assistance to 3-5 residents, (5-10min per resident, 3 times a day to and from meal service). Each caregiver provides 3-4 shower assistance approximately 25-30 minutes. Care givers are assisting 5-7 residents with dressing and general grooming 1.5-2 hours. After assisting residents, with their activities of daily living, some caregivers are taking out the trash, and making beds, which takes at list 40-50min. Based on interviews, observation, review needs and services plan of current population and staff schedule, it was concluded that within 8-hour shift staff is mainly assisting residents requiring help with daily needs, and are not always able to assist other residents when needed. Overall investigation revealed that additional qualified personnel is needed, to assist overall population with all their activities of daily living. The Executive Director and staff have indicated that staff scheduling have been changed around to add assistance in peak hours. The information and evidence obtained during this investigation, is sufficient enough to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Per California Code of Regulation, Title 22, Division 6, Chapter 8, following citations were issued and recorded on LIC9099Dthe state’s words, verbatim · CDSS document, Jun 22, 2023 · control 11-AS-20230614132722

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jun 30, 2023

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by. Based on interviews, record review Licensee did not insure a sufficient number of competent staff. During 8 hours shift staff cannot assist all residents requiring assistance with daily needs. This possess potential Health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 22, 2023

Plan of correction: The Administrator will provide written plan of action explaining what steps they are going to do to retain sufficient number of qualified personnel to assist current population. POC must be completed by POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility equipment is in disrepair

On 03/29/2023, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint investigation to address the allegation listed above. LPA Scott met with Holly Rice, Associate Executive Director, and explained the purpose of this visit is to gather information for the complaint and deliver findings. On 03/29/2023, the investigation consisted of the following: LPA Scott conducted a tour of the facility grounds. The facility is a 10-story high-rise apartment building located in a residential beach neighborhood. The facility is licensed for a capacity of 150 non-ambulatory residents; with a hospice waiver for 5. The facility consisted of the following: 116 apartment units/with bathrooms with 2 elevator shafts. LPA interviewed the Assistant Executive Director, residents, reviewed records, and delivered findings. LPA Scott requested the following documents: 1) A copy of the staff roster, 2) a copy of the resident roster, 3) Any elevator repair invoices or repair proposals, and certificate of liability insurance for the elevators. The investigation revealed the following: Regarding the allegation: Facility equipment is in disrepair. Continued on LIC9099-C Substantiated LPA spoke with Holly Rice, (S1) Assistant Executive Director, and she reported that the one elevator has been out service and that parts for the elevator were on back order. (S1) submitted invoices that show the elevator has been serviced and maintained. The facility uses TK Elevator Corporation and has the Gold-Full Maintenance package with phone monitoring, as a warranty, to service both elevators. The elevator was last serviced on 03/01/23, 02/14/23, 02/01/23, 01/24/23, 01/18/23, 01/01/23, 12/28/22, 12/01/22, 11/01/22, 10/01/22, 09/20/22. On each occasion parts were ordered, maintenance completed, and the elevator was returned to service. The elevator has history of service problems. S1 reported that there are plans to have both elevators replaced, but the elevator that is down now should take approximately twelve weeks to complete. S1 also reported that the new Executive Director, Matan Burstyn, who will officially start on 03/30/23; is planning to have a meet and greet on that day and announce that both elevators will be replaced. On 03/29/23, LPA toured the laundry areas with maintenance technician (S2) and S1. On the 7th and 3rd floor LPA observed that the washing machines were out of service, and have signs posted. LPA was presented with two work orders created on 02/25/23 & 03/24/23 to be completed by the first weekend in April of 2023. On 03/29/23 LPA was presented with a construction agreement between owner and contractor by S1 which details elevator modernization that will commence on 4/1/23 with a completion date 4/1/25 to have both elevators replaced. The construction will allow the use of one elevator while the new elevator is being installed, explained S1. S1 also indicated that CCLD knows about the issue because another LPA was here last year investigating it as well. LPA advised that the fire department needs to be made aware of the issues barring any emergency that may arise. On 03/29/23 LPA interviewed residents R1-R5, and 5 of 5 residents confirmed the allegation to be true. 5 of 5 confirmed that one of the elevators has been out of service for months. They all confirm that the elevator has a history of breaking down, however when it does, the facility does call to have it repaired. But added that it takes a long time to get parts in stock which leaves them feeling inconvenienced. Additionally, 5 of 5 of the residents confirmed that they also have issues with the washing machines. In that they too have to be fixed often. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation: Facility equipment is in disrepair, are found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. An exit interview was conducted. Plans of corrections were developed. A copy of this report and appeal rights were given to Holly Rice, Associate Executive Director.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 11-AS-20230321151417

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 7, 2023

87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on Interviews conducted, record review and observation. All residents and staff unanimously confirmed the allegation to be true and there is a history issues. A review of service request shows frequent service calls due to the elevator malfunction and washing machine issues. LPA observed one of the two elevators out of service, as well as two washing machines in need of service.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Facility will submit documentation from TK Elevator Corp verifying when the elevator and washing machine repairs will be completed by POC due date. Additionally, Facility will develop a plan to address how they will ensure the residents’ personal rights are not violated due to their inability to access the elevator. POC letters must be sent to LPA via email or fax by POC due date.

Allegation investigated: Facility did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, October 03, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Associate Executive Director Joshua Castillo and Executive Director Olga Kirksey. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: LPA Bunker interviewed staff 1-2 (S1-S2) and residents 1-8 (R1-R8). S1-S2 stated the facility staff safeguard residents’ personal belongings, property, and valuables. They were not aware of any residents missing any personal belongings until last week. Associate Executive Director Joshua Castillo stated that R1 mentioned her silver flatware sets were missing from her room over two (2) years ago during COVID-19. R2-R8 stated their personal belongings are safeguarded and not missing. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation: Facility did not safeguard resident's personal belongings Staff 1-2 (S1-S2) stated the facility staff does safeguard residents’ personal belongings, property, and valuables. They were not aware of any residents missing any personal belongings until last week. R2-R8 stated their personal belongings are safeguarded. R1 stated she believes one of the caregivers took her sterling silver during COVID-19 over two (2) years ago. R1 stated she had no proof of who removed her personal belongings. Mr. Catillo and LPA Bunker observed R1's room and the corners of the room were stacked with boxes and bags. R1-R8 state staff is providing them with a comfortable environment. R2-R8 stated that they do not have any issues, problems, or concerns regarding any theft at the facility. Investigation revealed the following: Interviews were conducted with staff 1-2 (S1-S2), and residents 2-8 (R2-R8), who stated staff safeguard resident's personal belongings. Associate Executive Director Joshua Castillo stated that R1 mentioned her silver flatware sets were missing from her room over two (2) years ago during COVID-19. Mr. Castillo stated he spoke to R1's daughter regarding the incident and she stated there was nothing missing from her mother's room. R1 stated she has a lot of boxes in her room, she is not organized, and it's hard to move from a big house to two (2) rooms. R1 stated she's not sure what happened to her sterling silver flatware, tea/coffee set with tray, and serving dishes. R1 stated the caregiver was helping her put the items away over two (2 ) years ago during COVID-19. R1 stated she reported her personal belongings missing to the facility staff and they did a search, but they were unable to find the box of sterling silver items. R1 stated the caregiver was still working during the search for her personal items that went missing. R1 stated she has no proof of who took the items. R1 stated she assumed the caregiver took her personal belongings since she was the person assisting her. R1 stated that the caregiver is no longer working at the facility. R1-R8 states they are happy at the facility, they love the ocean view and going for walks on the beach. R1-R8 stated staff is providing the necessary care and supervision to meet the resident's needs. Staff provided LPA Bunker with a copy of R1's personal property and valuables document and there was no description of any valuable sterling silver listed. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the facility There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Oct 3, 2022 · control 11-AS-20220923133915

Allegation investigated: Facility did not adhere to the Admission Agreement. Resident's hygiene needs were not met. Staff did not meet resident's needs while in care.

On 08/11/2022 Licensing Program Analyst (LPA) Don Senaha initiated a subsequent complaint visit for the allegations listed above and to deliver findings. Today’s complaint investigation was conducted with Associate Executive Director Joshua Castillo. On 07/21/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Associate Executive Director Joshua Castillo. The investigation consisted of the following: LPA requested service documents and interviewed residents (R1-R9) and staff (S1-S4). A plant inspection of the facility was conducted. Unsubstantiated Investigation revealed: Allegation: Facility did not adhere to Admission Agreement. During the course of the investigation, LPA was unable to find any witnesses or documentation supporting the allegation above. There is no evidence that supports the facility did not adhere to Admission Agreement. Residents (R1-R9) stated they have not had any issues with the facility adhering to their Admission Agreement. Associate Executive Director stated the facility is month to month for rent and requires a 30-day written notice from a resident to get reimbursement of the deposit. LPA observed the Admission Agreement signed and dated with specified date agreed upon for “Schedule of Services and Rates to commence”. LPA reviewed previous complaint 11-AS-2022113153405 which was a similar allegation stated in a different verbiage and LPA investigated found the complaint to be “unsubstantiated”. Based on LPA’s interviews conducted and records reviews, the preponderance of evidence standard has not been met. 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 Allegation: Resident’s hygiene needs were not met. During the course of the investigation, LPA was unable to find any witnesses or documentation supporting the allegation above. There is no evidence that resident’s hygiene needs were not meet. LPA interviewed residents (R1-R9) who stated no issues with ADLs being met at the facility. Residents (R1-R9) stated they are given a comfortable living environment at the facility. Resident (R2, R7-R9) who get help with showers have no issues with the shower schedule and staff assisting. Staff (S2-S4) stated residents ADLs are being met on a daily basis. Staff (S2-S4) stated they assist residents with showers according to the scheduled services. LPA obtained a copy of a Personal Service Plan (PSP) which includes personalized assisted living based on an individual preferences. This PSP is itemized and includes but is not limited to assistance with medications, showering or bathing, bathroom, escort and mobility and dressing and grooming. Based on LPA’s interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation 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 allegation is Unsubstantiated Allegation: Staff did not meet resident’s needs while in care. During the course of the investigation, LPA was unable to find any witnesses or documentation supporting the allegation above. There is no evidence that staff did not meet resident’s needs while in care. LPA interviewed residents (R1-R9) who stated no issues with ADLs being met at the facility. Residents (R1-R9) stated they are given a comfortable living environment at the facility. Resident (R2, R7-R9) who get help with showers have no issues with the shower schedule and staff assisting. Staff (S2-S4) stated residents ADLs are being met on a daily basis. LPA reviewed and did observe any incident reports regarding issues with resident’s needs while in care. Based on LPA’s interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation 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 allegation is Unsubstantiated There were no deficiencies found at the time of the visit. An exit interview was conducted with Joshua Castillo and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 11, 2022 · control 11-AS-20220711140330

Allegation investigated: Facility elevator(s) are not maintained in operating condition.

On 08/09/2022, Licensing Program Analyst (LPA) Troy Agard conducted an initial complaint investigation to address the allegation listed above. LPA Agard met with Joshua Castillo, Associate Executive Director and explained the purpose of this visit is to gather information for the complaint and deliver findings. On 08/09/2022, the investigation consisted of the following: LPA Agard conducted a tour of the facility grounds. The facility is a 10-story high-rise apartment building located in a residential beach neighborhood. The facility is licensed for a capacity of 150. The facility consisted of the following: 116 apartment units/with bathrooms with 2 elevator shafts. LPA interviewed staff and residents, reviewed records, and delivered findings. LPA Agard requested the following documents: 1) A copy of the staff roster, 2) a copy of the resident roster with their date of birth, 3) Any elevator repair invoices or repair proposals. On 08/09/2022, LPA delivered findings. Cont on 9099c Substantiated The investigation revealed the following: Regarding the allegation: Facility elevator(s) are not maintained in operating condition. “It’s being alleged there are one or two very old elevators in the building that break down often.” On 08/09/2022 LPA interviewed 8 out of a total of 79 residents. 8 out of 8 residents confirmed the allegation to be true. R2 states, “it’s been about 3 months. It’s dangerous. Many of us can’t make it down the stairs.” R5 states, “I’ve been here for 8 years. I’m on the third floor. The broken elevator has been down for at least 3 months. It’s frustrating.” R6 states, “Oh yeah, the elevator has been broken for months. I’m on the 7th floor. I have to wait awhile but I’m getting used to it. My main concern is if the second one breaks down. What will they do then?” R7 states, “this is an ongoing issue. This is not the first time these elevators have broken down. I think this might be the longest. Sometimes I can’t get to my room for almost 20 minutes because I live on the 10th floor.” During interviews with staff, on 08/09/2022 LPA interviewed 5 out of a total of 54 staff. 5 out of 5 staff confirmed the allegation to be true. S1 states, “yes it’s been ongoing for 3 months now. There was an issue with the parts. Parts are taking some time to come in. We noticed some shaking with it, so we stopped it. If we ever had to evacuate, we wouldn’t use the elevator. We have evacuation chairs located on each stairwell (2), fire doors and the staff are trained in what to do.” S2 states, “yes, the elevator has been down since April. It hasn’t always been like this. It has never been down for this long.” S3 states, “yes, I have observed the elevator as not working. It has worked on and off a little in June and it went down again. The residents have brought up their concerns to us about it.” S5 states, “yes it has been broken for about two months. If we are doing trays it takes us longer to deliver. The residents will make comments that things are taking forever, or they had to wait for the elevator. So, we hear it one way or another.” On 08/09/2022, LPA Agard reviewed the following records: A staff roster dated 06/28/2022: 5 of the staff interviewed match with the roster. A resident roster dated 08/09/2022: 9 of the residents interviewed match with the roster. An account history report from thyssenkrupp dated 08/09/2022. Under the “On Site Repair” section it shows the elevator underwent repair on 03/07/2022, 05/04/2022, 05/19/2022, 05/25/2022, 06/02/2022, 06/28/2022. Under the “Callback” section of the report it indicates the elevator has had several call backs for repairs on 03/18/2022, 03/30/2022, 05/02/2022, 05/17/2022, 06/04/2022, 06/23/2022. The report indicates both elevators had been down on 03/30/2020. On 10/02/2021, the elevator broke down with residents trapped inside. During walkthrough, LPA observed signage indicating 1 of 2 elevators as out of Cont on 9099C service. Based on LPA’s observation, interviews conducted, and record review, 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 (1) are being cited on the attached LIC 9099D. An exit interview was conducted. Plans of corrections were developed. A copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Aug 9, 2022 · control 11-AS-20220803142332

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 9, 2022

87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Interviews conducted, record review and observation. All residents and staff unanimously confirmed the allegation to be true and the history of the issues. A review of service request shows frequent service calls due to the elevator malfunction. LPA observed elevator out of service.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Facility will have elevator(s) repaired by POC due date. Facility will develop a plan to address how they will ensure the residents’ personal rights are not violated due to their inability to access the elevator. POC must be sent to LPA via email or fax by POC due date.

Allegation investigated: A resident was charged for services not received

Licensing Program Analysts (LPA) Jey Cardenas conducted subsequent complaint investigation visit to the above facility to continue investigation. LPA met with Associate Executive Director, Joshua Castillo and conducted covid-19 risk assessment, facility has one positive covid-19 case at this time. LPA explained the purpose of today’s visit. Investigation consisted of the following: Initial 10 day visit was conducted on 1/21/22 LPA Cardenas interviewed Health & Wellness director, Amanda Monroy. On 5/18/22 LPA interviewed Joshua Castillo in person and Former Executive Director, Thomas Rekowski via telephone. LPA obtained and reviewed Resident#1s (R1) admission agreement, physician report, Account History Report, Residency Application, and Preplacement appraisal. -Regarding allegation: A resident was charged for services not received- It is being alleged that on 5/27/2021 agreement was made with former Executive Director, Thomas; that R1 was not going to move in to the facility until an approval from Long term Care insurance claim was obtained. Unsubstantiated (cont' pg 2) Thomas was made aware that R1 was collecting SSI and didn’t have the funds to pay facility fees without insurance coverage. On 5/31/21 admission agreement was signed. On 7/28/2021 R1 moved in to facility even though resident hadn’t received approval from insurance company. Facility assure R1 that insurance company would be approved and costs would be covered. On 9/3/2021 resident received insurance claim denial notice. R1 has since been billed and is now responsible for repayment from 5/31/21 to 09/15/21 although R1 didn’t move into the facility until 07/28/21. On 5/18/22 LPA Cardenas interviewed Thomas via telephone regarding allegation. He indicates that Long Term Care insurance claim can only be filed until resident is admitted to a care facility. Facility doesn’t conduct income verifications, R1 disclosed being employed and having savings, but never being on SSI. Facility doesn’t accept SSI eligible recipient. Facility is private pay and only accepts personal checks. R1 was working with a referral agent, not associated to the facility, who was responsible for reviewing residents’ budget and going over facility costs. Resident was presented with the option to move into the facility and was never pressured. Worst case scenarios were discussed with R1 such as insurance denial. R1 told Thomas this was not an issue because resident was already pre-approved and was formally going through the process. Thomas encourage R1 to reach out to insurance company to iron out the terms and conditions. Facility doesn’t get involved with insurance claims. R1 was told that per admission agreement, resident was taking financial responsibility as of 5/31/21 and payments would be expected thereon. Thomas states that R1s insurance claims was denied due to physician submitted paperwork to residents insurance determining that R1 didn’t need to live at a facility due to resident was self-sufficient due to still working and driving. On 5/18/22 LPA Cardenas interviewed Joshua Castillo who indicate that Facility doesn’t not conduct a income verification regarding residents source of income. Facility takes resident self-attestation that they have the funds to cover the cost. It is ultimately the residents decision to move in and make arrangements to ensure they have sufficient funds to cover cost. On 5/18/22 LPA Cardenas reviewed R1’s admission agreement with Joshua to clarify charges. Per admission agreement: Rate: you agree to pay the basic service rate and, if applicable the Personal service rate as indicated in Exhibit A. We do not accept SSI/SSP eligible residents for admission to the community. Per Exhibit A Schedule of services and rates: “I agree to above scheduled of services and rates to commence as of May 31, 2021. I have reviewed Exhibit X, selected services listed…I agree that I will be charged each time I utilize one of those services at the community. Admission agreement is signed by R1 dated 5/31/2021. R1 was considered a community member as of that date and charges started to accrue thereon. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited, Exit Interview conducted, and report given facility representative.the state’s words, verbatim · CDSS document, May 18, 2022 · control 11-AS-20220113153405

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on the Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called the above facility and spoke to Lead Receptionist Rose Linesch via telephone and conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA verified that the facility has an approved Mitigation Plan Report. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the storage room; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. Executive Director Tom Rekowski stated that all staff except one is fully vaccinated. The facility residents are also vaccinated. The facility is doing COVID-19 testing weekly. Executive Director Mr. Rekowski and LPA Bunker toured the facility inside and outside grounds. The facility is a 10-story high-rise apartment building located in a residential beach neighborhood. The facility consisted of the following: 116 apartment units/with bathrooms, (16) 1- bedroom, (92) studio, and (8) deluxe studio See continued LIC809-C on page #2 Continued LIC809-C page #2 Common area includes 1st-floor concierge desk, open patio area, in front of the facility, with patio chairs, (2) living rooms with piano and audio speaker sound system, restaurant-style dining room, private dining room for special occasions, and a kitchen. The 2nd-floor includes an exercise/game room and wellness/medication room. The 3rd-floor includes a beauty salon including a manicure/pedicure station. The 10th-floor includes a library/computer/lounge room, activity/ exercise room, outside patio/ garden area, TV/movie theater room. All areas were observed to be properly furnished, free of hazards, and appropriate for group activities. The kitchen was inspected and observed to be clean and operational. In addition, appliances and fixtures appeared functional. Daily Activity Schedule and meal menu observed to be posted at the concierge desk, lobby, and inside the elevators. Refrigerated and frozen foods were stored at proper temperatures. Residents do not have access to the kitchen. The facility menu appears to meet the daily dietary needs for the residents. All toxins and knives are locked/secured and inaccessible to residents. There were no pesticides or poisons observed near any food areas. LPA Bunker inspected ten (10) resident's apartments they were inspected for, safety, privacy, and comfort. The living areas are clean. Resident apartments were found to be clean, well furnished, and in good repair. The resident's apartment’s windows have no sliding window locks with thumbscrews. All resident's rooms have private bathrooms. The living areas are clean. LPA observed the following during inspection of resident’s apartments: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All rooms inspected appeared properly furnished, sanitary and free from hazards. Bathrooms contained the required grab bars, and showers/tubs had non-slip safety bath mats. LPA observed bathrooms clean and operational. Continued LIC809-C page #3 The following Title 22 regulated areas were audited and found to be in compliance: Apartments contain the required furniture. First aid kit is fully stocked with manual, hot water temperature in apartments #206; #212; #309; #314; #415; #417; #505; #515; #608; and #615 measured at 112.5 to 113 degrees Fahrenheit. The facility has working telephones. The facility has an installed hardwired smoke alarm system. Apartments smoke and carbon monoxide detectors were in compliance. Each resident apartment has a night light and push bottom alert system, in the bathroom, for emergency assistance, as well, each resident wears a call alert pendent for immediate emergency assistance. The facility has two working elevators. The fire extinguishers are fully charged. Medications were centrally stored and properly locked on the 2nd-floor medication room in the records are current and documented on the Point Click Care Electronic Medical Records system. LPA Bunker observed an ample supply of perishable and nonperishable food, adequate linen supply, and covered shaded patio areas. The fire/emergency drill was conducted on 08/16/2021. No firearms on the premises, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. Mr. Rekowski states staff was given training on dependent adult and elder abuse reporting. There were no deficiencies cited. LPA Bunker provided Mr. Rekowski with copies of the Facility Evaluation Reports. Exit interview conductedthe state’s words, verbatim · CDSS document, Aug 25, 2021

Allegation investigated: Resident sustained a death while in care Staff do not properly maintain a resident's room while in care Staff is not properly assisting the residents while in care Residents are being mistreated while in care

On 08/24/2021, Licensing Program Analyst (LPA) Stephanie CIfuentes conducted an unannounced subsequent complaint visit at this facility. LPA met with Thomas Rekowski, Executive Director and explained the purpose of today's visit is to deliver findings for the allegations listed above. The investigation consisted of the following: On 3/16/2021 LPA Cifuentes spoke with administrator via Facetime, was given a tour of facility grounds and requested facility records. On 3/16/2021 tone of the allegations was accepted by the CCLD Investigation Unit and assigned to IB Investigator Robert Kujawa. On 4/14/2021, 6/8/2021 and 6/24/2021 Investigator Kujawa conducted interviews with staff, residents and witnesses. On 8/24/2021 LPA Cifuentes conducted interviews with Resident 4-Resident 8(R4-R8) and staff 1-staff 5(S1-S5) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained a death while in care The complainant states (R1) died from neglect while in care of facility staff. IB Investigator Robert Kujawa reviewed records, interviewed staff and witnesses. and found that R1 did not sustain a death while in care of facility staff. Facility notes show that R1 contracted covid-19 and was transferred to a rehab facility. Upon R1’s return, several notes outline that resident was monitored for temperature, oxygen, body weakness and eating habits. Facility reached out to R1’s authorized representative regarding their medical condition and need for medical follow-up. R1 was hospitalized upon doctors’ orders and per facility notes R1 passed from covid-19 related pneumonia and had been out of the facilities care for 19 days at the time of their passing. IB Investigator Kujawa did not find any evidence of neglect in the residents’ care. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Allegation: Staff do not properly maintain a resident's room while in care The complainant reported that human waste was seen in bathroom of R2. IB Investigator Robert Kujawa spoke with R2 on 6/8/2021. Per R2, there has been no human waste on the floor of room. On 8/24/2021 LPA Cifuentes toured facility grounds and did not see or smell any human waste in residents’ rooms. On 8/24/2021 LPA Cifuentes spoke with residents R4-R8 and asked how often rooms were cleaned and if staff were properly maintaining their rooms. 5 out of 5 residents interviewed agreed that staff cleaned their rooms once per week and rooms were properly maintained. On 8/24/2021 LPA Cifuentes interviewed staff (S1-S5) regarding maintenance of resident’s rooms. 5 out of 5 staff stated rooms are cleaned minimum once per week and that residents’ rooms are properly maintained. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Continued on 9099-C Allegation: Staff is not properly assisting the residents while in care The complainant reports staff members are lazy and do not take good care of the residents. IB investigator Kujawa spoke with R2 on 6/8/2021, who stated they felt they get the care they need. On 8/24/2021 LPA Cifuentes spoke with residents R4-R8 about the assistance they received from facility staff. 4 out of the 5 interviewed residents stated they felt staff are properly assisting them. On 8/24/2021 LPA Cifuentes spoke with staff (S1-S5) regarding assistance to residents. Alld 5 staff felt they were properly assisting residents. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. Allegation: Residents are being mistreated while in care The complainant reported overhearing R3 state that staff are mean to them. Per report by IB investigator Kujawa, no evidence was found through records or interviews of neglect of residents in care. On 8/24/2021 LPA Cifuentes interviewed residents R4-R8 and asked if staff were polite or if they mistreated them. 5 out of 5 resident stated staff are polite and did not feel they were being mistreated by staff. LPA Cifuentes interviewed staff on 8/24/2021 regarding politeness to residents and whether or not they felt residents were being mistreated. 5 out of 5 staff stated they were polite to residents an Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of residents records, incident report, and interviews conducted and found no evidence to support the allegations: “Resident sustained a death while in care”, ”Staff do not properly maintain a resident's room while in care”, “Staff is not properly assisting the residents while in care”, “Residents are being mistreated while in care”. 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 Tom Rekowski and a copy of the report was provided by email.the state’s words, verbatim · CDSS document, Aug 24, 2021 · control 11-AS-20210315160314