Westchester Villa

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Resident sustained multiple severe pressure injuries resulting in death due to staff negelct. Staff did not provide adequate food service to resident.

On August 21, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. Maria Luisa Mascardo, Administrator, greeted the LPA. (LPA) explained that the purpose of the visit was to investigate the allegations mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Christine Ferris of the CDSS Investigation Branch. Interviews were conducted with Staff #1-Staff #3 (S1-S3), Witness #1 and Witness #2 (W1-W2), and Resident #2 - Resident #8 (R2-R8). The Department reviewed several documents, including the Facility Resident Roster (dated 06/08/26), Personnel Report LIC 500 (dated 06/01/26), (R1’s) Admissions Agreement (dated 01/24/24), Medical Assessment LIC 602A (dated 10/27/25), Appraisal/Needs and Service Plan LIC 625 (dated 01/06/25 & 01/30/26) Resident Appraisal LIC 603A (dated 01/06/25) and, Unusual Incident Report LIC 624 (dated 05/15/26), Death Report LIC 624A (dated 05/31/26), Providence Medical Associates Medical Records (dated 2023), Empire Wound Care Progress Notes (dated 05/06/26 through 05/13/26), and California Department of Public Health Death Certificate (dated 06/02/26). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident sustained multiple severe pressure injuries resulting in death due to staff neglect. It is alleged that Resident #1 (R1) sustained severe pressure injuries while in care, which ultimately led to (R1's) death due to staff neglect. Reports indicated that (R1) had significant health issues, including 18 bedsores, four of which were classified as Stage 4 pressure wounds. (R1) passed away on June 3, 2026, after being hospitalized on May 27, 2026. No further details were provided regarding this matter. On June 29, 2026, between 09:30 AM and 11:00 AM, the Department conducted interviews with staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) could not support the claim that (R1’s )death was a result of neglect in care with pressure wounds. (S1) explained (R1) resided in a care facility from January 11, 2024 to May 15, 2026, when (R1) was hospitalized and did not return. (R1) was placed on hospice care on April 26, 2026, but the process was delayed due to (R1’s) responsible party retiring. (R1) transitioned through several facilities before passing away on May 31, 2026. While at the facility, (R1) had four monitored wounds: on (R1’s) left elbow, right heel, right hip, and sacral area, receiving ongoing care from medical physician and wound care specialists. Community Care Licensing was informed of (R1's) condition and pending hospice placement. Several Unusual Incident/Injury Reports documented (R1’s) injuries and treatment, importance of the facility's protocol of reporting any skin issues to the appropriate staff for documentation and care. (S2-S3) reported that (R1) developed pressure injuries during (R1’s) stay at a facility and received care from home health caregivers and wound care specialists. Caregivers, including (S3), repositioned (R1) and reported changes in (R1’s) condition to (S1 and S2), and (R1’s) physician. The facility has a protocol for reporting changes in skin conditions. (S2) expressed no concerns about neglect or inadequate care. While (S3), assists residents with various needs, ensures (R1’s) wounds are properly treated, and reports no concerns regarding (R1’s) care. On June 29, 2026, and July 06, 2026, between 09:15AM and 10:30 AM, the Department interviewed with the witness identified as Witness #1 and Witness (W1-W2)). Two (2) out of the two (2) witnesses could not support this claim of neglect in care. (W1) reported to have treated (R1) for about a year and a half, visiting (R1) monthly. (W1) last saw (R1) in late April 2026 and noted (R1’s) decline, recommending hospice care, which (W1) initiated. (W1) ordered comfort and wound care for (R1). When asked about the care for (R1) regarding pressure injuries, (W1) said there were no concerns about neglect or poor treatment. (Evaluation Report continues LIC 9099-C) (W1) explained that (R1's) injuries were due to (R1's) declining health and confirmed that the facility provided appropriate care. (W2) requested that (W1) consider hospice care for (R1) in March 2026, and (W1) agreed. Still, (W1) needed support from another medical physician, to complete the necessary paperwork. This was delayed until May 2026. Just before hospice care began, (R1’s) condition did not improve, and (R1) was eventually transferred to a skilled nursing facility and then Long Beach Memorial Hospital, where (R1) passed away. (W2) stated that while (R1) developed pressure injuries, they did not stem from neglect, as such injuries are common during decline. (W2) noted that (R1) had been well cared for at the facility since 2024 until (R1’s) last months, when issues arose. The Department’s investigation found insufficient evidence to support claims of neglect or lack of care. According to the medical records from Long Beach Memorial Hospital, (R1’s) death was attributed to cardiopulmonary arrest resulting from ventricular fibrillation (V-fib), which may have been linked to underlying coronary artery disease. The Department could not interview Resident #1 (R1) because (R1) has passed away. The Department reviewed (R1’s) Admissions Agreement (dated 01/24/24), Medical Assessment LIC 602A (dated 10/27/25), Appraisal/Needs and Service Plan LIC 625 (dated 01/06/25 & 01/30/26) Resident Appraisal LIC 603A (dated 01/06/25) and, Unusual Incident Report LIC 624 (dated 05/15/26), Death Report LIC 624A (dated 05/31/26), Providence Medical Associates Medical Records (dated 2023), Empire Wound Care Progress Notes (dated 05/06/26 through 05/13/26), Long Beach memorial Hospital Medical Records (dated 05/31/26 through 06/03/26), 24/7 Home Health Services (dated 04/01/2 through 05/14/26) and California Department of Public Health Death Certificate (dated 06/02/26). Based on the information gathered, the facility's neglect and lack of care and did not provide an adequate level of care, resulting in Resident #1 (R1) sustaining severe pressure injuries and ultimately dying from these injuries. There is insufficient evidence to support the allegation. Allegation #2: Staff did not provide adequate food service to resident. It is alleged that Resident #1 (R1) was not provided with adequate food service. Reports have suggested that (R1) did not receive sufficient food. (R1) was admitted to the hospital on May 27, 2026, where a feeding tube was provided. No additional details concerning this issue were given. (Evaluation Report continues LIC 9099-C) On June 29, 2026, between 09:30 AM and 11:00 AM, the Department conducted interviews with staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) could not support the claim that (R1) was not provided with adequate food service. While (R1) was a resident at the facility, (S1-S3) reported that (R1) was constantly monitored by the staff, home health aides, and (R1's) primary care physician. (S1) stated that (R1's) health condition continued to decline, and a few days before hospitalization, (R1) had been consuming only a minimal amount of food for an extended period, which raised concerns about (R1's) health and well-being. The primary reason for (R1's) hospitalization was (R1's) persistent refusal to eat regular meals. As a result of this ongoing issue, (R1's) nutritional intake became severely inadequate, leading healthcare providers to determine that a gastrostomy tube (G-tube) was necessary to ensure (R1) received adequate nutrition. This intervention was essential to support (R1) health and aid in her recovery. (S1) stated that (R1) was provided with three meals and snacks throughout the day and that meals were coordinated with the dietitian. On June 29, 2026, and August 21, 2026, between 11:15 AM and 01:40 PM, the Department interviewed residents identified as Resident #2 and Resident #8 (R2-R8). Seven (7) out of seven (7) resident members could not corroborate this claim. Residents reported that meals were provided according to the Weekly Menu schedule and that the portion sizes were appropriate in good quality. No residents mentioned experiencing hunger or missing any meals. Interviews confirmed that meals are prepared and served three times a day, with snacks available in between. The Department could not interview Resident #1 (R1) because (R1) has passed away. On June 29, 2026, and July 06, 2026, between 09:15 AM and 10:30 AM, the Department interviewed with the witness identified as Witness #1 and Witness (W1-W2)). Two (2) out of the two (2) witnesses could not support this claim. (W1) verified that the facility offered suitable care. (W2) said that (R1) received good care at the facility and did not see any signs of neglect. The Department reviewed the facility’s posted menus and verified that meals provided during the visit matched the planned menu. The Department observed adequate food supply by hand, including perishable and non-perishable items sufficient for the required number of days. No documentation was found indicating missed meals or complaints related to food service. (Evaluation Report continues LIC 9099-C) The Department reviewed (R1’s) Admissions Agreement (dated 01/24/24), Medical Assessment LIC 602A (dated 10/27/25), Appraisal/Needs and Service Plan LIC 625 (dated 01/06/25 & 01/30/26) Resident Appraisal LIC 603A (dated 01/06/25) and, Unusual Incident Report LIC 624 (dated 05/15/26), Death Report LIC 624A (dated 05/31/26), Providence Medical Associates Medical Records (dated 2023), Empire Wound Care Progress Notes (dated 05/06/26 through 05/13/26), Long Beach memorial Hospital Medical Records (dated 05/31/26 through 06/03/26), 24/7 Home Health Services (dated 04/01/2 through 05/14/26) and California Department of Public Health Death Certificate (dated 06/02/26). Further review of Weekly Menu (dated 08/04/26 through 08/31/26) and Consultant Dietitian Report (dated 01/27/26). Based on the information gathered, there is not enough evidence to support the allegation that staff did not provide adequate food service to resident. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies cited. An exit interview was conducted with Maria Luisa Mascardo, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 11-AS-20260604155225

Allegation investigated: Staff did not administer medication to a resident in care. Facility did not prevent staff from falsifying records.

On August 4, 2026, Licensing Program Analyst (LPA) Antonine Richard conducted an initial complaint visit to gather information regarding the above allegations. LPA Richard met with the licensee, Chinichian, Matthew, and explained the purpose of the visit. Later, LPA was joined by the Administrator (A1) Mascardo Ma Luisa. The investigation consisted of the following: On August 4, 2026, LPA Richard reviewed and obtained the Staff roster (dated 07/01/2026), the Resident roster (dated 08/01/2026), and records for resident #1 (R1), including Electronic Medication Administration Records (MARs) (dated 07/2026 to 08/2026), Physician Report, Admission Agreement, and Appraisal/Needs and Services Plan. LPA also obtained facility notes and Med Techs' certificate of completion. On August 4, 2026, LPA interviewed nine residents (R1-R9), two Med Techs (MT1-MT2), three staff members (S1-S3), the Licensee, Administrator (A1), and a family member witness (W1). LPA also interviewed the pharmacy witness (W2). Report continued on LIC9099C Unsubstantiated Allegation #1: Staff did not administer medication to a resident in care. The complaint alleged that the resident R1 has not received R1's medication for a month. On August 4, 2026, the LPA interviewed the Licensee regarding the allegation. The Licensee denied the allegation and stated that the medication had not been delivered to the facility; therefore, staff could not administer it. During the same, LPA interviewed the Administrator (A1), who denied the allegation, stating that on June 30, 2026, A1 had called Witness (W1) to inform them that the medication refill for R1 had not been received after W1 took R1 to the doctor. At that time, R1 only had half a month's worth of medication left. On July 14, 2026, A1 called W1 again about the facility not having received the medications. W1 indicated that the doctor had already sent the order to the pharmacy. After this, A1 contacted the pharmacy and learned that the doctor had mistakenly sent the order to the wrong pharmacy. A1 then had to call the doctor's office to request a new order be sent to the correct pharmacy. A1 explained that this was the reason R1's medication could not be administered. Finally, on July 29, 2026, the doctor's office verbally ordered the medications, and the facility received the medications the same day. On August 4, 2026, LPA interviewed 2 Medical Technicians (MT1-MT2), all of whom denied the allegations and stated that they ensure all resident medications are administered on time and that they follow the doctor's orders. Additionally, LPA interviewed 3 staff members (S1-S3); they all denied the allegations and stated that Med Tech assisted with medication they do not assist with meds. On the same day, LPA interviewed nine residents (R1-R9), all of whom stated that the staff helps them with their medications. On August 4, 2026, LPA interviewed a family member witness (W1), who denied the allegations and stated that it was the doctor's office that didn’t send the order to the right pharmacy, and that the facility had to call the doctor's office to expedite the order verbally so R1 could have the medication. On August 4, 2026, the Licensing Program Analyst (LPA) reviewed the ALIS Medication Administration Records (E-MAR) for July 2026 and noted that the medication was on hold from July 14 to July 29, 2026. During this review, the LPA also examined facility notes, which indicated that A1 made three calls to W1 regarding the facility not receiving the medication for R1 from the pharmacy. On the same day, August 4, the LPA contacted the pharmacy witness (W2), who confirmed that they received a verbal medication order from the doctor's office for R1 on July 29, 2026. 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. Report Continued on LIC9099C Allegation #2: Facility did not prevent staff from falsifying records. The complaint alleged that resident R1's three medications were on hold for a month while staff logged them as administered. On August 4, 2026, the Licensing Program Analyst (LPA) interviewed the Licensee, who denied the allegation. The Licensee stated that the facility used the ALIS Medication Administration Record (MAR), an electronic medication administration record (E-MAR). They explained that staff could not falsify records if the medications were not actually available. Additionally, the Administrator denied the allegation, stating that the medication technicians could not falsify records because the resident's medications were placed on hold until the facility received the necessary orders, a fact clearly documented in ALIS. During the same visit, the LPA interviewed two Medical Technicians (MT1 and MT2), who corroborated the denial of the allegations. They explained that they had to initial the Medication Administration Record (E-MAR) and indicate an exception mark whenever a medication was not administered due to being on hold. On August 4, 2026, the LPA reviewed the ALIS Medication Administration Record (E-MAR) for the period from July 14, 2026, to July 29, 2026. The record indicated that the scheduled time, recorded time, and reason for not administering the medications were all marked as on hold. The LPA also confirmed that the Med Techs' Certificates of Completion are on file. Report Continued on LIC9099C. 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. No deficiencies were cited. An exit Interview was conducted. A copy of this report was provided to Administrator Mascardo Ma Luisa.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 11-AS-20260730101622

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management-Annual Continuation visit to complete the Annual Required - 1 Year, dated August 27, 2025. On August 28, 2028, LPA Bunker met with Administrator Maria Mascardo and explained the purpose of today's visit. LPA Bunker continued to review medications, staff files, and residents' records. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the evaluation, the facility is clear of COVID-19 infection. LPA Bunker met with Administrator Maria Mascardo and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan and Infection Control Report. There are currently 84 residents and in placement. LPA Bunker verified the current staff fingerprints that were cleared and associated with the facility. The facility's annual fees are up to date. The facility has a Dementia Program. The facility is licensed for three hospice care residents. The facility has sufficient staff available and competent to provide the services necessary to meet resident needs. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records-Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." See continued LIC809-C page 2 Continued LIC809-C page 2 The above facility is a two-story commercial building. Administrator Ms. Mascardo, LPA Bunker toured the facility which consisted of the following: The first-floor Lobby/receptionist area, business office/copy area, medication room, Administrator's office, record office, 24 bedrooms and bathrooms, emergency supply room, storage rooms, 3 living rooms, 2 dining rooms, kitchen, resident's private laundry room, commercial laundry room, activity room, recreation/activity director's office, men and women public restrooms, 2 employee's lounges, men and women employee's restrooms, beauty salon, linen room, housekeeping supply room, patios, shaded area, indoor/outdoor activity area, and gated security parking lot. The Memory Care Unit (MCU) has 8 bedrooms and bathrooms, a living room/dining room, an Activity/TV area, and men's and women's public restrooms. The second floor consisted of 52 resident bedrooms and bathrooms, a Doctor's office, a Home Health agency office, men's and women's public restrooms, men's and women's employees' restrooms, a resident's private coin laundry room, TV room, library/living room, game room, storage rooms, and storage closets, and an upstairs patio area. Administrator Ms. Mascardo and LPA Bunker observed 25 residents' bedrooms that had the required furniture: a bed, one chair, a nightstand, adequate lighting, a closet, and drawer space. There was ample space to accommodate each resident comfortably. Documents are posted as mandated. Bedrooms contain the required furniture, and Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including grab bars and non-slip surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. See continued LIC809-C page 3 Continued LIC809-C page 3 LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and being clear of any potential hazards to the residents. The first aid kit is fully stocked with a manual, smoke detectors, sprinklers, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 115.3 on the first floor and 119.1 degrees Fahrenheit on the second floor, fire extinguishers are fully charged, adequate linen supply, the residents' emergency call light is operable, the facility telephones are in working condition, resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were properly covered. The last Fire/Emergency Drill was conducted on 07/07/2025. Staff were given training on the dependent adult and elder abuse reporting video. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 27, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management Visit on Thursday, September 12, 2024, 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 Administrator Tawny Gant LPA Bunker explained the purpose of today's visit was to amend the Complaint Report received by Community Care Licensing on August 08, 2023, under Complaint Control Number 11-AS-20230808165054. The amended LIC9099 dated September 12, 2024, will supersede the original LIC9099 dated August 09, 2024, to reflect the correct allegation. A copy of the Facility Evaluation Report LIC809 was provided to Administrator Tawny Gant. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 12, 2024

Allegation investigated: Resident sustained an unexplained injury while in care.

"Please note that this amended Complaint Investigation Report LIC9099 dated 09/12/2024 will supersede the original LIC9099 dated 08/09/2024, to include the correct allegation." Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Friday, August 09, 2024. 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 Licensee Matthew Chinichian and Administrator Tawny Gant. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: During the investigation Interviews were conducted with staff members 1-4 (S1-S4) and residents 2-9 (R2-R9). Staff Member 4 (S4) stated she was not employed at the time of the incident and had no knowledge of the allegation in question. R1 was unavailable for an interview. LPA Bunker asked pertinent questions relevant to the nature of the complaint. During visits on 08/11/2023 and 08/09/2024, we toured the entire facility, including all buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats or concerns. See LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 No evidence of neglect or abuse was observed during these visits. We reviewed the resident files, including the physician's report, medical records, admission agreement, identification and emergency information, medication records, medication administration records (MARs), medication logs, medical assessments, consent forms, hospital records, incident reports, appraisal & needs service plan. LPA Bunker requested copies of supporting documents. Allegation: Resident sustained an unexplained injury while in care. Interviews with staff members 1-3 (S1-S3) indicated that the resident did not sustain an unexplained injury while in care. S1-S3 stated that the resident does not receive one-on-one care. S1-S3 reported that on August 8, 2023, at approximately 6:30 A.M., after completing the resident's morning grooming routine, caregiver Karina Portillo (S2) assisted the resident in being seated on the bed. While retrieving the resident's clothing from the closet, S2 suddenly heard a loud noise coming from the bathroom. Upon further investigation, S2 discovered that the resident had gotten up independently and proceeded to the bathroom. R1 had accidentally fallen and was found attempting to get up from the bathroom floor. S2 immediately assisted the resident back to bed, where she noticed a cut on the resident’s left cheek, which was bleeding. S2 promptly called for assistance, and Med Tech Edwin Villanueva responded immediately. The Med Tech called 911 without delay, and the resident was transported to Cedar Sinai-Marina Del Rey Hospital. The resident’s responsible party, family, and physician were notified. S1-S3 stated that S2 could not have prevented R1 from falling. S1-S3 stated that staff are adhering to the resident's discharge instructions, monitoring the resident's condition closely, and keeping the family informed of the resident's progress. S1-S3 stated that the resident was not hit, and no staff member witnessed any such incident. Interviews with Residents 2-9 (R2-R9) revealed that they did not witness the resident falling or any instance of a resident being hit. R2-R9 expressed that they feel safe, are happy with the care and supervision provided, and believe that the staff are doing an excellent job. S1-S4 emphasized that this is a 24-hour care facility, operating 7 days a week, 365 days a year, ensuring the safety of residents at all times. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Investigation revealed the following: Staff members 1-3 (S1-S3) stated that the resident experienced an accidental fall on the morning of August 8, 2023. Emergency 911 services were immediately contacted, and the resident was transported to Cedars-Sinai Marina Del Rey Hospital. According to S1-S3, the fall was unavoidable, and no staff members or residents witnessed the incident or observed any physical altercation involving the resident at the facility. The Inglewood Police Department responded to a call from Westchester Villa and concluded that no crime had occurred, resulting in no police report being filed. Medical records from the resident's physician and Cedars-Sinai Marina Del Rey Hospital confirmed a diagnosis of dementia, indicating that the resident is unable to manage their treatment, medication, or equipment. The resident also suffers from significant cognitive impairments, including difficulties with thinking, remembering, reasoning, judgment, and decision-making, which interfere with their ability to perform daily living activities or engage in social or occupational activities. Staff members S1-S4 emphasized that Westchester Villa operates on a 24/7 basis, ensuring that residents are never left unattended. Residents R2-R9 confirmed that staff members are consistently available to assist and expressed satisfaction with their living conditions at the facility. S1-S4 and R1-R9 stated that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents. S1-S3 and R2-R9 denied any occurrence of a fight. Investigator Juan Lozano of the Investigations Branch (IB) completed his investigation Care Report and determined that the findings were unsubstantiated. 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 Administrator Tawny Gant. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 11-AS-20230808165054

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Licensee Matthew Chinichian and Administrator Tawny Gantn and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan and Infection Control Report. There are currently 91, residents and in placement. LPA Bunker verified current staff fingerprints that were cleared and associated with the facility. The facility's annual fees are current. The facility has a Dementia Program. The facility is licensed for three hospice care residents. The facility has sufficient staff available and competent to provide the services necessary to meet resident needs. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records-Staff Training, Residents Rights-Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records-Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." See continued LIC809-C page 2 Continued LIC809-C page 3 LPA Bunker observed the facility’s infection control practices, screening protocols for residents and visitors, sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of Personal Protective Equipment (PPE) was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff wearing a face covering and social distancing. Medications are locked and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, sprinklers, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 112 first floor and 115 degrees Fahrenheit on the second floor, fire extinguishers are fully charged, adequate linen supply, residents emergency call light is operable, the facility telephones are working, resident's bedroom windows have no sliding window lock with thumbscrew, all exit doors were in compliance, yard free of debris hazards, and trash cans were covered. The last Fire/Emergency Drill was conducted on 07/22/2024. Staff was given training on dependent adult and elder abuse reporting video. There were no deficiencies cited. Exit interview conducted. Continued LIC809-C page 2 The above facility is a two-story commercial building. Administrator Tawny, LPA Bunker toured the facility which consisted of the following: The first-floor Lobby/receptionist area, business office/copy area, medication room, Administrator's office, record office, 24 bedrooms and bathrooms, emergency supply room, storage rooms, 3 living rooms, 2 dining rooms, kitchen, resident's private laundry room, commercial laundry room, activity room, recreation/activity director's office, men and women public restrooms, 2 employee's lounges, men and women employee's restrooms, beauty salon, linen room, housekeeping supply room, patios, shaded area, indoor/outdoor activity area, and gated security parking lot. The Memory Care Unit (MCU) has 8 bedrooms and bathrooms, a living room/dining room Activity/TV area, and men's and women's public restrooms. The second floor consisted of 52 resident bedrooms and bathrooms, a Doctor's office, a Home Health agency office, men's and women's public restrooms, men's and women employee's restrooms, a resident's private coin laundry room, TV room, library/living room, game room, storage rooms, and storage closets, upstairs patio area. Licensee Matthew, Administrator Tawny, and LPA Bunker observed that 9 residents' bedrooms had the required furniture, a bed, one chair, a nightstand, adequate lighting, a closet, and drawer space. There was ample space to accommodate each resident comfortably. Documents are posted as mandated. Bedrooms contain the required furniture, and Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including grab bars, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. See LIC809-C page 3the state’s words, verbatim · CDSS document, Aug 1, 2024