Royal Vista San Gabriel

Allegation investigated: Staff handled resident in a rough manner resulting in resident falling.

Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met with Nelida Estrella Arlante, administrator. LPA explained the purpose of today's visit regarding the above-mentioned allegation. Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #4 (S4) and attempted to interview staff#5 (S5); interviews residents from resident#1 (R1) to resident#5 (R5); reviewed resident records; and toured the facility. LPA obtained copies of staff and resident rosters; and resident#1/ staff files with relevant information. In regard to allegation of “staff handled resident in a rough manner resulting in resident falling,” it was alleged that facility staff pulled resident through resident’s sleeve and resident fell. The investigation revealed the following: LPA interviewed residents, all five (5) residents interviewed could not corroborate the allegation. Three (3) out of four (4) staff interviewed denied the allegation. (-continued in LIC 9099C-) Substantiated One (1) out of four (4) staff stated resident#1 (R1) was handled with rough manner resulting in falling. Per file reviews, staff training records showed facility provided proper in – service training to staff. Per video footage review, dated 8/15/23, staff#1 had handled resident#1 with rough manner resulting resident#1 fell. Therefore, staff had handled resident in a rough manner resulting in resident falling. Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D. An exit interview was conducted with Nelida, administrator. A hard copy of this report and appeal right were provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 28-AS-20230818093551

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(2) · Plan of correction due date: Aug 29, 2023

Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met by evidence of: Per reviews of staff record, staff interview and video footage (dated 8/15/23), the administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 24, 2023

Plan of correction: Licensee agreed to review Title 22 Regulations, Section 87413 (a)(2) and submit a written plan detailing how administrator would ensure that staff provide care and supervision without physical or verbal abuse. Licensee would provide proper training to staff on physical abuse. POC due on 8/29/23.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on multiple AWOL incidents involving Memory Care resident(s). LPAs met with Administrator Nelida Arlante was explained the purpose of the visit.The purpose of today's visit is to check on the health & safety of residents in care. On July 31,2023 at 6:15 pm, there was an electrical fire in the 1st floor/Memory Care Unit storage room located inside the break room. Fire department inspected the incident and stated the fire was a result of an electrical fire in a lower power outlet that had boxes nearby. Staff immediately evacuated all Memory Care residents to the front and back parking lots. No resident injuries were sustained. As a result of the electrical fire, the 1st floor sprinkler system was triggered throughout the 1st floor and caused major water damage. The facility has scheduled repairs with a tentative completion date of 2 months. In the interim Memory Care residents have been relocated to the 2nd and 3rd floor. On 8/8/2023 at 4:15 pm and 8/15/2023 8:00 pm Dementia resident (R1) AWOL. During the 8/15/2023, incident the resident fell and sustained a facial injury resulting in hospitalization. During today's visit the following was conducted: A physical plant tour of the damaged 1st floor Memory Care Unit was conducted. There is a current COVID-19 outbreak in the 2nd floor. Infection control protocols are in place. A deficiency was cited according to Title 22. See LIC 809D. An exit interview was with Administrator Nelida Arlante. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 18, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87411(a) · Plan of correction due date: Aug 25, 2023

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: On 8/8/23 & 8/15/2023 Dementia resident (R1) eloped out of the facility. During the 8/15/23 elopement the resident fell and sustained a facial injury resulting in hospitalization. Due to a recent fire Dementia residents are not in a locked perimeter. This poses an immediate safety risk to this residenst in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Administrator agreed to submit a written plan addressing staff supervision, protocols, and staff scheduling. Submit proof of staff in-service training regarding Dementia wandering behavior, methods of redirection, and resident care and supervision.

Allegation investigated: Staff do not notify resident's responsible party of incidents.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to Nelida Arlante. The investigation consisted of the following: On 6/1/2023, a physical plant tour of the facility, staff (S1- S3). and resident (R1) were interviewed. Resident (R1's) file documents [Face Sheet, bill (5/4/2023), Physician's report, Resident Appraisal, Appraisal Needs/Services Plan, LIC 500 Personnel Report, and roster were reviewed and obtained. During today's visit, incident report dated (4/25/2023) was provided. LPA interviewed four (4) responsible parties, staff (S4) and residents (R2-R4). *** report narrative on next page. Substantiated Allegation: Staff do not notify resident's responsible party of incidents. It is alleged that on April 25, 2023 at approximately 2:30 PM, emergency medical personnel responded to a 911 phone call pertaining to resident (R1), but facility staff failed to inform R1's authorized representative of the incident because they felt that the incident was not severe enough. The resident's responsible party learned about an outstanding Emergency Medical Service bill from R1 and not facility staff. According to staff interviews, medical personnel deemed the incident a non-medical emergency and the resident was not transported to a hospital. Resident (R1) informed staff of the bill received, but staff did not notify R1's responsible party until two (2) weeks later. Resident (R1) was interviewed, but due to cognitive impairment the resident was not able to provide details related to the aforementioned incidents. Administrative staff interviews revealed that R1's responsible party was not notified of the April 25, 2023 incident or the bill received. Staff (S2)/Administrator Assistant stated staff deemed the incident a false alarm since emergency personnel stated there was no need for medical treatment and did not report the incident to responsible party and Community Care Licensing. In regards to the bill, staff stated that facility staff tried handling the bill charges without notifying R1's responsible party. Staff contacted the fire department to try to get the bill waived but were not successful. Staff also contacted Medi-Cal regarding the outstanding bill. LPA called four (4) responsible parties; of which two (2) stated that in the past the facility has failed to notify them of incidents. A total of four (4) residents were interviewed. They did not report notification issues. However, pertaining to resident (R1's) incident (4/25/2023) and bill (5/4/2023) the facility failed to follow policy and procedure regarding incident notification. Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D. Exit interview was conducted with Interim Administrator Nelida Arlante and Administrative Assistant Sau Lee. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 26, 2023 · control 28-AS-20230530124614

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jul 3, 2023

Personal Rights of Residents in All Facilities.Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based on record review and interviews conducted staff did not notify R1's responsible party of 911 incident (4/25/23) and bill received pertaining to the incident; which poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2023

Plan of correction: Administrator agreed to provide in-service training regarding 87468.1, and provide written statement of how the facility will document responsible party contact when incidents occur, and/or there is a change in condition.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 26, 2023

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... Based on record review and interviews conducted, staff failed to notify R1's responsible party and CCL within 7 days of the incident; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2023

Plan of correction: Administrator agreed to conduct in service training with staff. Send a copy of the inservice training log sheet. Note: A copy of the incident report was provided today and faxed to CCL on 6/2/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Nelida Arlante arrived shortly after. There are currently 52 elderly residents 60 years and older residing in the facility. Four (4) residents are receiving hospice care, and five (5) residents are bedridden. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: A current Plan of Operation at the facility is incomplete; only the Dementia plan was reviewed.The Infection Control Plan has been added to the Plan. The facility has a Dementia Waiver in place. A Hospice Waiver for 5 residents is approved. A fire clearance for 100 non-ambulatory residents; of which 10 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. A Surety Bond is in place. The facility handles resident monies. Physical Plant/Environment Safety: The facility has a Dementia unit. A hospice waiver for 5 residents is in place. Facility is a 3-story building consisting of 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, and 2 courtyard patio areas. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. On 1/24/2023, City of San Gabriel FIre Department conducted an inspection. No violations were noted at the time of the inspection. The facility has fully charged fire extinguishers. The signal system was tested and is operational. Water temperature readings did not measured within the required 105 - 120 degrees Fahrenheit. A total of 7 rooms had water temperatures ranging from 126.5 - 131.7 Degrees Fahrenheit. Dementia unit flooring is in disrepair. Contractor has been hired to make the repairs. Staffing: Sufficient staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator completed recertification education, but has not received an RCFE certificate from CCL. Proof that the training was submitted was provided. Staff have criminal background clearance and training. Seven (6 staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and 1st Aid/CPR training was observed. ****Narrative continues next page**** Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. ***A total of 2 Dementia residents had Physician Report's older than 12 months. RCFE complaint poster and Personal rights were observed posted. The Incident report binder was reviewed. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted. The facility does not have an active Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Five (5) centrally stored resident medications were reviewed; which contained 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. There is no evacuation chair at each stairway. Citation was issued. The last quarterly emergency drill was conducted on 5/22/2023. Records of resident Appraisal and Needs services plans are part of Emergency training. See next page Residents with Special Health Needs: Eight (8) residents are receiving home health services. Four (4) residents receive hospice care. Postural support physician orders are on file. Half and full bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Nelida Arlante. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 1, 2023

Allegation investigated: Staff failed to provide a comfortable environment for residents in care. Facility does not have an Administrator. Facility is in disrepair.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the above allegations. The purpose of the visit was explained to Administrative Assistant Sau Lee. Interim Administrator Nelida Arlante works next door at the Skilled Nursing Facility (SNF) and arrived later. Administrator on record Chia Demurjian is not available due to leave of absence. The investigation consisted of the following: A physical plant tour of the facility with a focus on water supply/plumbing operation, facility maintenance, and Emergency and Disaster Plan responsibilities. A copy of LIC 610D Emergency and Disaster Plan, LIC 500 Personnel Report, resident roster. Staff (S1-S3) and residents (R1- R6) were interviewed. *Change of Administrator documents are still pending. See next page. Substantiated Allegation: Staff failed to provide a comfortable environment for residents in care. It is alleged that on Sunday, April 23, 2023 at approximately 6:30 PM, the facility water supply was shut off. Residents did not receive notification of the reason for the water shut off because allegedly facility staff do not speak and/or are not able to communicate with residents in their Asian language. Facility staff in charge on the premises at the time of the incident were the security guard and med-tech staff. Per staff interviews, room #230's bathtub plumbing fixture could not be turned off. Maintenance staff was called and it directed the security guard to shut off all of the building water supply. Maintenance staff immediately returned to the facility and fixed the issue. Some residents were informed that the water would likely be restored until the following morning and were not able to provide emergency guidance or plan procedures. Other residents and their families were not notified of the issue. Interim Administrator stated it had no knowledge of the plumbing water incident that occurred. The findings indicate that facility staff on duty during the incident did not follow emergency policy procedure notification to residents and their responsible parties. The incident was resolved a couple of hours later. Allegation: Facility does not have an Administrator. It is alleged that the facility has not had an Administrator since February 2023 because the Administrator has been on a leave of absence. The two staff in charge are the Wellness Nurse and Administrative Assistant and neither staff are certified Administrators. It is alleged that it is unclear whom is in charge of facility operations because families have not received notification of Administrator changes and Administrator Chia Demurjian has not responded to phone calls of emails. According to staff interviews, Administrator Ms. Demurjian has been on leave since February 17, 2023. Interim Administrator Ms. Nelida Arlante stated that she began working at this facility and the Skilled Nursing Facility (SNF) next door on February 1, 2023. However, on 3/24/2023 LPA visited the facility and an Administrator had not been appointed, nor was CCL notified of the Administrator changes. On 3/31/2023, facility staff submitted an incomplete change of Administrator document packet. As a result the Administrator on record has not been changed. Ms. Arlante confirmed she does not have an office at the facility and only makes quick rounds at the facility. Therefore, the Interim Administrator appointed is not on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. Per staff interviews, the Licensee asked the Wellness Nurse and Administrative Assistant to take RCFE Administrator education classes, but neither staff is yet certified and/or may not meet the qualification requirements. A total of six (6) residents were interviewed none of the residents are are that Ms. Nelida Arlante has been appointed the Interim Administrator. Two (2) out of the six (6) residents stated they think Administrative Assistant Sau Lee is the Administrator. See next page. Allegation: Facility is in disrepair. It is alleged that the facility has had plumbing issues since approximately April 2021. LPA conducted a physical plant tour of common areas and randomly selected resident rooms. A total of 17 resident rooms were inspected. Based on observation, the Dementia unit located in the 1st floor has laminate flooring that is in disrepair in the main hallways; which poses a tripping hazard to residents in care. Six (6) out of the 17 rooms had heavily stained carpets. In addition, the 2nd floor carpet near the administrative offices is torn. Several resident room doors need repairs. According to staff, residents that use wheelchairs bump the doors when entering their room, therefore have damaged the doors. Staff were interviewed and acknowledged the facility needs repairs. In regards to the Dementia (1st floor) laminate flooring disrepair, a contractor evaluated the flooring issue last week, and repairs are set to begin within the next couple of weeks. A total of six (6) residents were interviewed. Three (3) out of six (6) residents reported issues with the shower water pressure and accessibility into the bathtub due to mobility issues. Staff stated that in the past a plumber evaluated the water issues. It was determined that both this facility and the SNF next door have common plumbing pipes that are occasionally getting clogged. Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D. NOTE: Civil penalties are being assessed for repeat violations within the last 12 months. Exit interview was conducted with Interim Administrator Nelida Arlante and Administrative Assistant Sau Lee. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, May 1, 2023 · control 28-AS-20230425105928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: May 5, 2023

Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement was not met evidenced by: Based on observation and interviews conducted on April 23, 2023, room # 230's bathtub water fixtures could not be turned off. Security guard shut off the water supply without notifiying Administration staff and residents. Room #230's issue was repaired the same day.the state’s words, verbatim · CDSS document, May 1, 2023

Plan of correction: Administrator shall submit written notification certifying that all resident bathrooms were inspected in order to determine the operating condition of all water fixtures in resident rooms, common bathrooms, and kitchen areas. Submit an updated LIC 610E Emergency and Disaster Plan.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: May 5, 2023

Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. On 3/31/23, incomplete Administrator change documents were submitted. The Interim Administrator appointed is not at the facility sufficient number of hours.the state’s words, verbatim · CDSS document, May 1, 2023

Plan of correction: Licensee shall submit all required Change of Administrator documents to CCL, and ensure the appointed Administrator is at the facility sufficient number of hours to permit adequate attention to the management and administration of the facility. Submit self-certification, written statement, and pending documents. *Note a civil penalty was assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 5, 2023

Maintenance and Operation. 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 evidenced by: Based on physical plant observation, the Dementia unit's laminate flooring is in disrepair, resident rooms have stained carpets, and there are room doors that need repair on the bottom half caused by wheelchairs; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 1, 2023

Plan of correction: Licensee shall ensure the facility is in good repair at all times, and areas in need of repair are addressed in a timely manner. Submit picture proof of corrections made to the Demenia unit flooring, resident room carpets, and needed door and wall repairs. NOTE: If a POC extension is needed submi a written request prior to or by the due date.

Allegation investigated: Staff are mismanaging resident's medications. Staff did not get consent from responsible party for resident to see a different doctor.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the able allegation. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Chia Demurjian is not available due to short term leave of absence. The investigation consisted of the following: Medication Administration Records (MAR) and resident (R1's) file was reviewed. Resident (R1's) medications were reviewed. Documentation errors on MARs were noted. Staff (S1-S5) and residents (R1-R5) were interviewed. Resident (R1's) medication records were reviewed. The following documents pertaining to R1 were obtained: Identification and Emergency Information, Face Sheet, Physician Report, Medication Administration Records (Aug. 2022- March 2023), Physician orders Aug 2022- to present, LIC 500 Personnel Report, and resident roster. See LIC 9099C for report continuation. Substantiated Allegation: Staff are mismanaging resident's medications. It is alleged the facility began giving resident (R1) the wrong prescription medication dosage of "Rexulti" medication in October 2022. For many years the resident has had in place a physician order for Rexulti 4 mg. The findings indicate that R1 was assessed by the facility's in-house Psychiatrist on 9/19/2021, and as a result the medication dosage was changed from 4mg to 3mg. According to staff interviews, in September 2022, the facility Administrator asked med-tech staff (S1) for a list of residents in need of Psychiatrist care. The med-tech reviewed R1's chart and noted there was no Psychiatrist listed on the form. Therefore, assumed the resident did not have a Psychiatrist in place and referred the resident to the in-house Psychiatrist. After the resident was assessed, a lower prescription dosage was ordered by the in-house doctor on October 11, 2022. The resident began taking 3mg of Rexulti until January 14, 2023. In addition, R1 was prescribed melatonin for sleep cycle regulation, but per family request it was discharged on November 18, 2022. A total of five (5) residents were interviewed; of which none had knowledge of medication mismanagement. During today's, medication review LPA observed errors in MAR's records. Staff acknowledged the documentation errors. All staff interviewed confirmed R1's medications orders were mismanaged due to incomplete file records and lack of interdisciplinary team care coordination. There is sufficient evidence to corroborate the allegation. Allegation: Staff did not get consent from responsible party for resident to see a different doctor. It is alleged that facility staff changed resident (R1's) Psychiatrist without responsible party's consent. Which resulted in medication errors due to record review oversight. Per staff interviews, a "Change of Primary Physician" form is to be completed and signed by the resident's responsible party whenever a doctor change is made. However, Administration staff did not notify and communicate with R1's responsible party, and proceeded to change R1's Psychiatrist to their in-house new Psychiatrist. All staff interviews confirmed the change was made without getting consent. Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited according to California Code of Regulations, Title 22. See LIC 9099D. NOTE: Civil penalties are being assessed for repeat violations within the last 12 months. Exit interview was conducted with Wellness Nurse Elizabeth Contreras. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Mar 24, 2023 · control 28-AS-20230321092912

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 25, 2023

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on records review, R1 had in place a physician order for Rexulti 4 mg and it got changed to 3mg on 10/11/22 by a different unathorized doctor. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee shall submit a plan of action to correct this repeated violation. In addition, all med-tech staff shall receive in-service training by a nurse and/or pharmacy. Submit the plan by tomorrow, and provide proof of staff training by Tuesday 3/28/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Mar 27, 2023

Personal Rights of Residents in All Facilities. Residents in residential care facilities for the elderly shall have personal rights which include.....8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based on record review, facility staff did not obtain R1's responsible party's consent to change doctor; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee shall submit a written plan of correction, and conduct in-service training to all staff responsible with care plan responsibilities.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(4) · Plan of correction due date: Mar 25, 2023

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by: Based on interviews and record review, med-tech staff and Administration staff did not do their due diligence in reviewing all medication records and physician orders. In addition, MAR documentation errors were observed during today's visit; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee shall ensure that all staff are trained in job responsibilities,facility procedures, and all med-techs are adhering to company procedure. Submit plan of correction. ***Due to repeated medication errors it is advised the facility use an electronic Medication Administration Records system.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza made an unannounced Case Management-Deficiencies visit for the purpose of an unrelated complaint investigation control # 28-AS-20230321092912. LPA met with Wellness Nurse and explained the purpose of this report. During today's, complaint visit LPA was informed that Administrator Chia Demurjian is not available due to short term leave, with unknown date of return. Ms. Demurjian last worked at the facility on February 17, 2023. The Licensee did not find a temporary replacement and designate responsibility to another person in order to ensure the facility is in compliance. In addition, Community Care Licensing was not notified of the Administrator’s absence. Deficiency is cited per California Code of Regulation Title 22. See LIC809-D. Exit interview held with Wellness Nurse Elizabeth Contreras. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 24, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Mar 31, 2023

Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. Administrator last worked at the facility on Feb. 17, 2023, and no designee has been appointed, nor was CCL notified.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee shall find a temporary replacement and designate responsibility of facility management. Submit proof of correction by POC due date.

Allegation investigated: Staff failed to provide access to resident's records.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegation. LPA met with Administrator Chia Demurjian. The investigation consisted of the following: On 11/17/2020, Administratror/staff (S1) & staff (S2) were interviewed. Documents pertaining to resident (R1) were requested but not received on that date. Administrator Susana Fuentes stated that she did not get approval from the corporate office to provide to CCL the requested documents. On 11/19/2020, the following documents were received: Identification and Emergency Information/Face Sheet, Admission Agreement, Physician Report, Appraisal/Needs and Services Plan, Home Health records, Medication Administration Records [Medication Administration Records (MAR) January 2020- August 2020], Power of Attorney documents, caregiver notes, physician orders, psychiatry progress notes, skin body checks, care plan, LIC 500 Personnel Report, and resident roster. See LIC 9099C for continuation of report. Substantiated Allegation: Staff failed to provide access to resident's records. It is alleged that on October 22, 2020, the facility received via fax and U.S. mail a formal medical records request pertaining to resident (R1). A prior records request was sent via fax and U.S. mail on October 13, 2020, to the Skilled Nursing Facility (SNF) "Royal Vista Care Center" next door regarding R1. That request had the incorrect name and address listed, but had Royal Vista San Gabriel's correct fax number and resident (R1's) name. On both request dates aforementioned, the records were to be provided within two (2) business days as required by California Health and Safety Code 1569.269(21). Based on record review, the findings indicate that the initial request was addressed to the incorrect facility name/address/type, but was faxed to this Assisted Living facility with the correct resident's name. The SNF next door and this facility are owned by the same licensee. Therefore, have direct daily communication pertaining to administrative matters. Per former Administrator interview, Ms. Fuentes confirmed the records request was received on Oct. 13, 2020, and that they were provided to the facility's corporate office staff within 2 days. Former Resident Care Coordinator stated that the records were provided to the Administrator one (1) day later, and they were given to the corporate office staff. Both staff (S1 & S2) stated corporate staff were responsible in providing the resident records to the legal representative. Per staff interviews, the records were provided to the facility corporate office staff. However, as of October 28, 2020 the resident's records had not been provided to the legal representative. Therefore, based on document review there is sufficient evidence to corroborate the allegation. Based on interviews and information obtained the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22, Division 6 Health and Safety Code, Chapter 3.2 Residential Care Facilities for the Elderly Article 02.5 Resident's Bill of Rights. See LIC 9099D. Exit interview was conducted with Administrator Chia Demurjian. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 28-AS-20201109094754

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(21) · Plan of correction due date: Jan 30, 2023

Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met evidenced by: Based on record review, the facility received a formal medical records request on 10/22/2020, and failed to provide the records within 2 business days, as required per regulation; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: Administrator agreed submit a written plan of correction addressing resident records, enumerated rights; severability, and facility procedures regarding resident records request. Submit by POC due date.

Allegation investigated: Facility is not properly managing resident's medication.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint visit to investigate the able allegation. The purpose of the visit was explained to Wellness Nurse Elizabeth Contreras. Administrator Chia Demurjian arrived later. The investigation consisted of the following: A physical plant inspection of the facility was conducted. Staff (S1-S6) and residents (R1-R6) were interviewed. A total of six (6) medication records were audited; no errors were found today. Resident (R1) file documents were obtained [ Identification and Emergency Information, Physician Report, Medication Administration Records, LIC 500 Personnel Report, resident roster, and staff schedule were obtained. Resident (R2's) Medication Administration Records were obtained. A picture of the medication that was provided in error to R1 was obtained. See LIC 9099C Substantiated Allegation: Facility is not properly managing resident's medication. It is alleged that on January 22, 2023 at 2:00 PM, resident (R1) received resident (R2's) medication in error. Resident (R1) received all it's PM medications, and was given one (1) extra medication Velphoro 500 mg medication that belonged to resident (R2). The medication error was brought to the attention of the PM med-tech staff on duty (S7) on duty. Staff (S7) apologized and stated the medications were prepared by the previous day's PM med-tech staff (S1). A total of four (4) med-techs and two (2) administration staff were interviewed. Staff (S1) confirmed that it prepared/placed the resident's medications in small plastic cups the day prior, but denied making the medication error. Staff (S1) stated that it is unlikely that R2's Velphoro medication was placed in R1's medication cup because the medication is a large brown pill that looks different than all others. However, S1 stated that cups were rearranged by alphabetical order; which may have caused the error. A total of six (6) residents were interviewed. One (1) out six (6) residents confirmed the allegation. Resident (R1) stated that med-tech staff (S7) gave the resident another resident's medication. During today's visit, LPA reviewed a total of six (6) resident's medications and found no errors. Based on record review and a picture obtained of the medication that was administered in error there is sufficient evidence to corroborate the allegation. Based on observation, record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC 9099D. Exit interview was conducted with Administrator Chia Demurjian. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 28-AS-20230124134758

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465)(c)(2) · Plan of correction due date: Jan 26, 2023

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on records review, on Jan. 22, 2023 med-tech staff gave resident (R1) resident (R2's) Velphoro 500 mg medication in error. R1 immediately reported the error, and the medication was not taken. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: Administrator agreed to provide staff training to all med-tech staff by POC due date. Submit proof by POC due date. If an extension is needed submit by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Galarza conducted a Case Management- Incident visit to follow up on an incident report submitted to the District Office on 1/22/2023. LPA met with Administrator Chia Demurjian. The purpose of today's visit is to check on the health & safety of residents in care and to issue a citation in regards to the neglect of care. On Sunday January 22, 2023 at 7:10 AM, registry caregiver staff (S1) took Dementia resident (R1) inappropriately dressed into the dining room for breakfast. Resident (R1) was sitting in it's wheelchair with briefs, and pants down around the thighs. Another registry caregiver staff (S2) on duty addressed the concern with S1, but the staff walked away and left the resident unattended. Approximately 10 minutes later staff (S1) returned and began feeding R1. Staff (S3) noticed that S1 was force feeding the resident and shoving food in it's mouth. When the feeding was completed, staff (S1) left to get a clean shirt for the resident. At that point, staff S2 observed that the resident still had food in it's mouth. Staff (S2) removed the food in the resident's mouth in order to prevent choking or food aspiration. Staff (S1) returned to put a shirt on the resident. Shortly after other staff noticed the resident had blood on it's elbow. Of note, the resident does not have teeth and does not wear dentures. The resident received first aid and Wellness Nurse sent registry staff (S1) home. Facility notified the registry staff agency, and has not worked at the facility since January 22, 2023, and staff in-services were provided to staff. The facility reported the incident to APS, Police, and Ombudsman. A deficiency was cited according to Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right 87468.1 Personal Rights of Residents in All Facilities. An exit interview was conducted with Administrator Chia Demurjian. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 26, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 26, 2023

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. Based on interviews conducted and document review, registry staff (S1) abused resident (R1) by not dressing the resident appropriately when taking it to the dining room, and force feeding the Dementia resident without regard to choking or apiration. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: Administrator shall submit: 1. Staffing plan addressing insufficient staffing 2. Staff in-service training with Topic and staff signatures 3. Copy of S1's disciplinary action 4. Proof of incident report submitted to registry staffing agency

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza made an Unannounced Case Management- Deficiencies visit pertaining to non-reporting of COVID-19 outbreak and Administrator Changes. LPA met with Administrator Chia Demurjian and Wellness Nurse Elizabeth Contreras. A physical plant inspection was conducted today. On January 5, 2023, the Memory Care Unit had positive resident and staff cases. The COVID-19 cases were reported to Community Care Licensing (CCL) until January 10, 2023. A total of 17 Memory Care residents and 4 staff tested positive for COVID-19 virus. Administrator failed to report to CCL the COVID-19 outbreak within 24 hours, and did not notify/report any cases to LA County Department of Public Health (DPH). On January 17, 2023, CCL informed Administrator that all COVID-19 cases must be reported to the Department of Public Health. Per Title 22, Division 6, Chapter 8, Article 04. Operating Requirements 87211(a)(2) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Additionally, former Administrator Regina Guevara stopped working at the facility on October 4, 2022. Licensee and Administration staff did not report to Community Care Licensing of the change. As of January 17, 2023, the former Administrator was still listed as the Administrator on record. On January 17, 2023, CCL received incomplete Change of Administrator documents appointing Chia Demurjian as Administrator. Per Title 22, Title 22, Division 6 Chapter 8 Article 07. Personnel Administrator Recertification Requirements. 87407 (k)(1) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated. Deficiencies were cited. Exit interview was conducted with Chia Demurjian. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jan 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jan 21, 2023

Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours..... This requirement was not met evidenced by: On 1/5/2023, the facility had 21 COVID-19 positive cases that were not reported to CCL or Dep. of Public Health (DPH) within 24 hours. They were reported to CCL until 1/10/23, and to DPH until 1/17/23; which poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Jan 20, 2023

Plan of correction: Administrator shall submit a written plan of correction that includes: 1. Review/revise the Infection Control Plan and submit an updated ICP by tomorrow. 2. Conduct staff training and provide proof that all staff were trained in Infection Control

From the deficiency page — Deficiency type: Type B · Section cited: CCR87407(k)(1) · Plan of correction due date: Jan 20, 2023

Personnel Administrator Recertification Requirements. Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office ..... This requirement was not met evidenced by: On 1/17/2023, LPA was informed by current Administrator that former Administrator stopped working at the facility. The former Administrator was discharged on Aug. 1, 2022. Licensee & Administrator failed to report to CCL of the change within 30 days. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 20, 2023

Plan of correction: On 1/17/23, Administrator submitted incomplete change of Administrator documents to CCL. Administrator agreed to submit the following pending documents: 1. Licensee letter 2. LIC 503 3. LIC 308

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with med-tech Genesis Gonzalez and explained the purpose of the visit. Assistant Administrator Chia Demurjian arrived later. There are 41 residents ages 60 and above, of which 10 may be bedridden. The facility has a Memory Care Unit. A hospice waiver for 5 residents is in place. Facility is a 3- story building consisting of 66 resident rooms, 2 activity rooms, TV room, Namaste room, 3 dining rooms, laundry room, and 2 courtyard patio areas. Administrator certificate expires 2/14/2023. The following was inspected and observed during the inspection: COVID-19 Infection Control Practices were observed in main entrance, and common areas. COVID-19 infection control signs were observed in all common rooms and hallways promoting hand washing, cough/sneeze etiquette, and social distancing. Hand sanitizers throughout the facility were observed. Rooms 212 & 213 and Memory Care Unit rooms # 109, 110, & 111 are designated isolation rooms. Twenty (20) resident rooms were inspected; of which five (5) were missing curtains, had broken blinds, and/or had sheer curtains that do not afford privacy. Seven (7) centrally stored resident medication records were reviewed. SIx (6) out of seven (7) residents were missing 30-day supply of medications and/or physician ordered cycle medications. Resident (R1's) medications [total of 9] have not been filled since mid April 2022; which poses an immediate health and safety risk. Facility is responsible for ensuring that all residents get medication refills despite insurance coverage issues. Facility was provided a list of all medications that were missing. Staff responsible for direct care and supervision were observed wearing masks. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. Deficiencies were cited. See LIC809D. Exit interview was conducted with Assistant Administrator Chia Demurjian. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, May 31, 2022

Allegation investigated: Facility did not transport resident to medical appointments.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Regina-Aguilar Guevara and explained the reason for the visit. The purpose of the visit is a subsequent visit to deliver the findings from the original complaint dated 1/7/2022. At visit 4/13/2022 at 10:05 AM Administrator Regina-Aguilar Guevara was interviewed. Resident's 1-3 were interviewed from 10:20 AM to 10:50 AM. Case Manager for Resident 1 was interviewed telephonically at 11:00 AM. At visit 1/11/2022 LPA obtained copies of; staff roster and client roster, physician report for Residents #1-2 (R1-R2), and daily notes for the months of December 2021 and January 2022 for Residents #1-4(R1-R4). LPA requested physician report for Resident #3-4 (R3-R4) to be emailed to LPA by 5 PM. on 1/12/2022. In regards to the allegation Facility did not transport resident to medical appointments, based on the interviews conducted and information gathered Client C1 stated that dialysis is 3 times a week and facility has not missed his appointments. Stated he has not missed appointments. Client's C2 and C3 said they are picked up and go all the time to dialysis. Unsubstantiated Staff interviewed stated that C1 had refused a couple of times because he said it made him tired and weak. Med- Tech interviewed stated that Caregiver had alerted her that C1 had refused to go to dialysis and it was documented. Case Worker for C1 confirmed that dialysis would not let C1 return until he visited a cardiologist. Daily Screening Log For Residents, Visitors and Medical Providers notates the following: On 12/27/2021 at 11:37 AM C1 back from dialysis. On 12/29/2021 at 11:45 AM C1 back from dialysis. On 12/30/2021 at 7:52 AM C1 left to dialysis. On 12/31/2021 at 10:00 AM C1 back from dialysis. There are also numerous entries for C2 and C 3 going and coming back from dialysis. Daily Notes from the facility document the following: C 1 on 1/7/2022 went to dialysis at 4:30 AM. C 1 on 1/6/2022 back from dialysis. C 1 on 1/4/2022 back from dialysis at 9:10 AM. C 1 on 1/3/2022 went to dialysis at 4:30 AM C 1 on 12/31/2021 back from dialysis at 10:00 AM. C 1 on 12/28/2021 refused dialysis and primary care provider notified of C1's refusal. Based upon interviews conducted, and observations made the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Administrator.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 28-AS-20220107134705

Allegation investigated: Staff are failing to administer resident's medications.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with Administrator Regina Guevara. The investigation consisted of: LPA toured the interior of the facility, Memory Care Unit, and audited resident's medications. Staff (S1-S5), residents (R1-R7), and R1's pharmacy were interviewed. The following documents were obtained: resident (R1's) Face Sheet, Physician Report, Medication Administration Reports [Jan 2022- March 2022], LIC 500 Personnel Report, and resident roster]. LPA requested copies of the Plan of Operation and staff job descriptions, but did not obtain the documents because Administrator does not have copies. As a result, a case management deficiencies report was created. See LIC 9099C for report continuation. Substantiated Allegation: "Staff are failing to administer resident's medications." Based on record review and interviews conducted the findings indicate that Memory Care unit resident (R1) has not been administered 13 medications ordered by physician since March 1, 2022; a total of 4 days. The facility failed to obtain refill medications from the resident’s pharmacy. According to staff interviews, cycle medications are automatically refilled by the pharmacy on a monthly basis, and/or more often when there is new physician orders. LPA spoke to R1's pharmacy and was informed that the medications were not delivered as a result of non-payment of $ $528.55 since September 2021.The findings indicate that the pharmacy provided the facility a 10-day notice of discharge on February 17, 2022, and spoke to facility staff on February 28, 2022 regarding non-receipt of payment. Facility was informed that medications would not be filled for the month March unless payment was received. The pharmacy has not been paid as of today. A total of 7 residents were interviewed; of which one (1) resident stated that it ran out of one medication last week, and was filled 1 day late. Resident (R1) is a Dementia resident without a public guardian or family. However, R1 confirmed that it has not received medications this week. Therefore, it is the facility's responsibility to ensure that R1's medications are filled in a timely manner, so there is no lapse in medication administration, and that the medications are paid for. Medications were audited during today's visit, and none of R1's medications were at the facility. Resident (R1) has hypertension and is diabetic. Which poses an immediate health, safety or personal rights risk to persons in care. Per Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right. 87465(a)(4) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. Based on record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 08. See LIC 9099D. An exit interview was conducted with Administrator Regina Guevara. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 4, 2022 · control 28-AS-20220303150219

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 5, 2022

Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement was not met evidenced by: Based on record review, R1's Medication Administration Record showed evidence of no medication administration beginning March 1, 2022, due to non-payment. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator shall obtain R1's medications immediately (no later than 24 hours) from the pharmacy. In addition, all med-tech staff shall be trained in their job responsibilities, and medication administration procedures. Submit proof of correction by tomorrow.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza initiated a case management visit due to deficiencies found during a complaint investigation (Control #: 28-AS-20220303150219). The purpose of the visit was explained to Administrator Regina Guevara. During the complaint investigation, LPA requested a copy of the Plan of Operation and staff job descriptions. Administrator was not able to find copies of the documents. Administrator started working at the facility on August 2021, and has not been able to find copies of the Plan of Operation in facility records since then. Title 22, Division 6 Chapter 8 Article 04. Operating Requirements. 87208(a) Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. LPA reviewed the file at the Regional Office and noticed the Plan of Operation and other documents have the old facility name "Vista Cove" that was owned by a different company. Licensee shall update the Plan of Operation and all applicable facility documents that list the old facility name. The documents shall be submitted to Community Care Licensing by plan of correction date. Deficiency was cited. See LIC 809D. An exit interview was conducted with Administrator Regina Guevara. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Mar 4, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Mar 18, 2022

Plan of Operation. Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility..... This requirement was not met evidenced by: Based on record review during complaint control #: 28-AS-20220303150219, LPA requested a copy of the Plan of Operation and staff job descriptions, but Administrator was not able to find copies in facility record files. This poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator shall obtain from Licensee "Royal Vista San Gabriel LLC" copies of the Plan of Operation and staff job descriptions. Submit proof of correction and a written statement by POC due date.

Type of visit: Case Management - Deficiencies

1/11/2022 Licensing Program Analyst (LPA) , Nina Galarza conducted an unannounced Case Management visit. Purpose of the visit was to address deficiencies observed on 1/11/2022 during a complaint investigation. LPA met with administrator, Regina Aguilar-Guevara and stated the purpose of the visit. During the visit the following deficiency was observed: 1/11/2022 11:20 a.m. LPA was not screened for COVID-19 symptoms or temperature check by security guard or staff. This is a repeat violation from 5/12/2021. Civil Penalties assessed in the amount of $250 for repeated violation. Deficiencies cited under California Code of Regulations, refer 809-D Exit Interview conducted, copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 11, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 12, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities...personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: 1/11/2022 11:20 a.m. LPA was not screened for COVID-19 symptoms or temperature check by security guard or staff. This is a repeat violation from 5/12/2021. Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2022

Plan of correction: Administrator will provide proof of visitor log for temperature check and symptom check for COVID 19 and proof of staff training of how to screen visitors and residents for COVID-19 to LPA by POC date

Allegation investigated: Facility staff is falsifying documents

Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint investigation about the above allegation and deliver the finding. LPA met with Administrator, Regina Aguilar-Guevara and explained the reason of the visit. The investigation consisted of the following: On 3/23/20, LPA Irra conducted the initial 10 days visit and LPA conducted a telephone interview with the prior administrator and requested copies of: resident and staff rosters (note: Facility Administrator indicated there are no LVNs nor RNs working at this facility). LPA Irra also obtained copies of the Job Descriptions/Duties for caregivers and med techs via email. On 09/28/2021, LPA Wong conducted a follow up visit and interviewed two (2) staff (S1-S2) and three residents (R1-R3), reviewed four residents' record and requested the four previous employee job application. On today's date, LPA interviewed one additional resident (R4). (See LIC9099C for continuation) Unsubstantiated The investigation revealed of the following: Allegation: “Facility staff is falsifying documents.” LPA interviewed four residents, and all denied the allegation and reported they are not aware of anything about staff falsified documents or they have no idea what is it about.. LPA interviewed staff and they all denied, and they never heard any staff falsified documents in the facility and they had no knowledge about that. LPA also interviewed the Prior and current administrator both reported Med-Tech can only pass the medication and cannot sign anything on behalf of any licensed staff or residents. Based on the record review and interviews conducted, 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 allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report and appeal right was provided to Administrator Regina Aguilar-Guevara.the state’s words, verbatim · CDSS document, Oct 20, 2021 · control 28-AS-20200311103919

Type of visit: Office

An Informal meeting was held via tele conference. The purpose of the meeting is to address staffing shortages and operational changes. Attendees present during the meeting were: Community Care Licensing, Assistant Program Administrator Claire Matsushita, Licensing Program Manager (LPM) Lisa Hicks, Licensing Program Analyst (LPA) Noemi Galarza, and Royal Vista San Gabriel LLC corporate staff, Board Representative Kevin Chen, Nurse Consultant Francis Largoza, and Nursing Home Administrator/Consultant Chia Demurjian. On July 22, 2021, Community Care Licensing (CCL) obtained information there was staff shortages at the facility that resulted in lack of adequate care and supervision of residents. Only one (1) caregiver worked the PM shift. The caregiver provided care for residents in the Memory Care Unit, resulting in the 2nd and 3rd floor Assisted Living residents being unattended and without supervision. The following was discussed: Staffing shortages and excess work hours of current staff. Recent staffing changes and corporate hiring plan to address staffing issues. Staffing update of Registered Dietician and new Administrator. Staff responsibilities and duties. Clarification of facility security guard role and responsibilities. Corporate team acknowledged understanding of the seriousness of staffing shortages and health and safety issues. Operational changes resulting in lack of facility leadership by an Administrator or designated substitute. Medication management errors and staff training. Lack of corporate oversight during COVID-19 pandemic and recent operational changes and issues during the past several months. Future unannounced compliance case management visits. CCL requested the following: 1. Submit revised staffing plan and update Personnel Report list 2. Submit updated License Administrative Organization form 3 Special Incident Reporting 4. Reassessment of all residents in order to determine facility care needs. Exit interview conducted with Francis Largoza, Kevin Chen, and Chia Demurjian. A copy of the report was emailed to Nurse Consultant Francis Largoza.the state’s words, verbatim · CDSS document, Jul 27, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Galarza and Wong conducted an unannounced case management visit to the facility to perform a health and safety check of facility and residents in care. Upon arrival, LPA met with Marina Galaviz explained the purpose of the visit. The facility is licensed to serve 100 residents over the age of 60 (100 Non-Ambulatory & 10 bedridden). The facility has a Dementia Waiver and an approved Hospice Waiver. Administrator on file Susana Fuentes has been on leave since May 10, 2021. Ms. Fuentes resigned on July 18, 2021. Corporate staff Brenda Nicolas arrived at the end of the visit. OBSERVATIONS: At 12:00 PM, LPAs and Administrator toured the interior and exterior physical plant. LPA inspected: Assisted living floors and Memory Care unit were toured. LPA conducted a random tour of resident rooms. Residents were interviewed. Kitchen/dining room & food supply. Sufficient supply of perishable food was observed, but non-perishable food supply was not sufficient. NOTE: Facility does not have registered dietician or a dietary director. Medication room was locked and inaccessible to residents. Interior physical plant was inspected. The flooring in the 1st floor Memory Care Unit is need of repairs. The laminate flooring is lifting posing a tripping hazard for residents in care. Staff schedules were observed. Staff were interviewed and staffing shortages were confirmed. LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats. One (1) caregiver was observed in Assisted Living floors and 2 caregivers in the Memory Care Unit were observed during the AM shift. Today's PM shift will have 2 Assisted Living caregivers, and 2 Memory Care Unit caregivers and one Activity Assistant. On 7/22/2021, the facility only had one (1) caregiver and one (1) med-tech staff for the entire building during the PM shift. Security guard had to assist with resident supervision. Marina Galaviz stated that two new staff are scheduled to start working tomorrow, and registry staff will work on Sunday. See LIC 809C for continuation of report. Documents obtained: 1. LIC 500 Personnel Report, weekly staff schedules for July 2021, and July 23- July 25 weekend schedule. 2. Resident Roster NOTE: One Heart registry staffing agency was contacted. On Sunday July 25, 2021 two (2) registry staff will be working. Names of staff were not obtained. Deficiencies were cited according to California Code of Regulations, Title 22. See LIC 809D. Exit interview held with Resident Care Coordinator Marina Galaviz. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 24, 2021

87411(a) Personnel Requirements - General.(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation and interviews conducted the facility failed to ensure there is sufficient personnel to meet the needs of residents in care. On 7/22/2021 only 1 caregiver staff worked in the PM shift [memory care]. No caregiver was available for Assisted living residents. Staffing shortages have not been addressed by Licensee. This poses and immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licensee shall: 1. Contact registry staffing agency to obtain immediate staff assistance. 2. Submit a written plan addressing staffing shortages and plan of action. 3. Submit a copy of registry staffing contract and list of staff that will be working at the facility. ***POC due tomorrow.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jul 30, 2021

87405(a) Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator....there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. Based on interviews, observation, and record review the facility failed to appoint an Administrator after Administrator on record's extended absence. Designee Marina Galaviz assummed Administrator responsibilities in May 2021.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licensee shall appoint a qualified Administrator and submit all required documentation to licensing by POC due date. Submit a written plan and required documents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Aug 13, 2021

87555 General Food Service Requirements. In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian ... shall be made for regular consultation from a person so qualified. Based on observation and interviews conducted the facility has not had a dietary supervisor or dietician consultant in years. Currently the dishwasher is is responsible for creating the food menu, cooking, ordering food inventory supplies, cleaning, and serving. There are residents that require special diets. Staff confirmed no special diets are being cooked.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licensee shall hire a facility dietary supervisor and dietician are required per Title 22. Submit a written plan of correction and proof that staff were hired.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Aug 13, 2021

87303(a) Maintenance and Operation. 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 by evidence of: Based on observation during physical plant inspection in the Memory Care Unit the laminate flooring was observed to be in major disrepair. The laminate flooring was raised and sticking out. The floors has a temporary fix of duct tape in some areas. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2021

Plan of correction: Licensee shall repair and/or replace the flooring in the Memory Care Unit. Submit picture proof of corrections by POC due date.

Allegation investigated: Staff mismanaged resident's medication. Inadequate staff resulting in resident's needs not being met.

On the above date, Licensing Program Analyst (LPAs) Chrstine Wong and Alberto Lopez conducted the initial 10 day complaint investivation. LPAs met with Marina Galaviz-Resident Care Coordinator and explained the reason the visit, she also assisted with the visit. The investigation consisted of the following: On today's visit, LPAs interviewed six (6) residents (R1-R6)and four (4) staff (S1-S4) and reviewed five residents file, medication and medication administrative record (MAR). The investigation revealed of the following: Allegation#1 "Staff mismanaged resident's medication." LPA interviewed six (6) residents, they reported medication was not given on time or sometimes staff forgot to give them medicaton. LPA reviewed the MARs and all five (5) residents' MARs were missing staff initials. LPA also reviewed R1's medication and observed all her morning medicationa for day 15th in the bubble pack was taken out in error and then put it back into the original package. (See LIC 9099C for continuation) Substantiated Besides that, while the staff put R1's medication into the original package and one of the medication (Potassium 10meg) was missing. In addition, LPA also observed all R2's medication which included Zinc 50mg, Multinvitamin, Sertraline HCL 50mg and Omerprazole Dr 20mg. was missing on the day 15th due to staff put the medication in the cup and accidentally dropped all the medication and staff needs to reorder all the medication for R2 for day 15th. For the PRN medication, the staff was not able to locate R1, R2 and R3's PRN medication in the facility and it was not there since July 1, 2021. For R4, three of her medications (Amlodipine, Rourvastain Calcium 5mg and Montelukast Sodium 10mg) did not dispense for the day 12th and 13th and were still in the bubble pack. Allegation#2 " Inadequate staff resulting in resident's needs not being met." LPA interviewed six (6) residents, one of them refused to be interviewed, three of them reported the facility has inadequate staffing. It took very long for staff to come and assist them. Staff sometimes would forget their needs like showering or giving them medication and would assist them next day or next week for showering or give the medication to them later time or even forget sometimes. LPA also interviewed staff and all admitted they are under staff at the present time and they are in the process of hiring more staff. The staff also reported the inadequate staffing had been an ongoing issues and they only have two caregivers for memory care unit at night shift and one caregivers for assisted living unit. Based on document review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Resident Care Coordinator Marina Galaviz A copy of the report an appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 14, 2021 · control 28-AS-20210709153106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 15, 2021

87465(c)(2)Incidental Medical and Dental Care if the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. The requirement is not met as evidenced by reviewing record, LPA observed all R1's morning medication on the bubble pack on day 15th was taken out in error and then put them back on the original package. Also R2's day 15th medication was missing due to staff accidently dropped which posed an immediate risk to residentsthe state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Licensee shall submit a copy of written medication administration protocols, and a plan that addresses the medications errors. In addition, all med-tech staff shall obtain medication training from a pharmacy.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 28, 2021

87411(a)Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care The requirement is not met as evidenced by conducting interiew. Staff reported they are currently under staffing and residents reported they did not get their medication sometimes or showering due to short staff which impose a potenital risk to resident in carethe state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Licensee shall submit a plan for how to able to provide the services necessary to meet residents needs or provide the hiring plan for the insufficient number of staff.