Lakewood Park Manor

Allegation investigated: Staff mismanaged resident's medication. Staff failed to safeguard resident's personal belongings. Staff failed to treat resident with dignity and respect. Staff confiscated resident's wheelchair.

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the reason for the visit. The investigation consisted of the following: During the initial visit conducted on 9/7/2022 LPA Glen Trueman conducted interview with Assistant Administrator and obtained copies of the following documents: staff and residents roster, copies of relevant documents from R#1 file were provided. Due to insufficient information available at the time the above allegations needed further investigation. (Continued on 9099-C) Unsubstantiated During subsequent visit conducted on 10/26/23 LPA Tena Herrera obtained copies of staff and resident rosters and copies the following documents for R1: Face Sheet, Physcian’s Report, Replacement Appraisal, order from doctor indicating resident needs higher level of care, Acknowledgment of Discharged signed by responsible party, Inventory of Personal Items (upon discharge) and Signed Theft and Loss Policy. Conducted 7 staff interviews and 11 resident interviews. LPA attempted to interview R1 but they are no longer a resident at the facility as of 11/1/2022, LPA left voicemail for a returned call in the am and tried again twice in the afternoon with no success in reaching R1. Investigation Revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that staff are mismanaging R1’s medication as sometimes staff fail to administer medications to R1. Interview with S7 revealed that at times R1 would return from being out in the community intoxicated and because of this sometimes medication will not be administered as R1’s doctor would instruct MedTech’s to not provide dosage since medication cannot be taken while intoxicated or with alcohol. Interviews with MedTech staff and those who held a previous position as MedTech each stated that medications are never intentionally refused to residents. Interviews with residents 10 out of 11 residents denied the above allegation and stated that they are given their medication on time, have never been denied their medication, and feel the staff are doing a good job with their medication management. During visit LPA toured medication room, reviewed MAR and 5 residents medications, no issues were observed. Allegation: Staff failed to safeguard resident's personal belongings. It is alleged that S7 entered R1’s room and went through their personal belongings and after this the personal belongings went missing. LPA interviewed S7 and it was revealed that on one occasion while R1 was at a nursing home R1’s responsible party came to collect clothing for R1 and refused to sign the Inventory for Personal Belongings log, upon return to the facility R1 claimed that they were missing clothes but couldn’t provide specifics as to what was missing just stated that they knew they had more clothing. On another occasion R1 claimed a cologne was missing, after searching for the missing item, it was found have fallen behind R1’s dresser. Based on interviews with staff 7 out of 7 staff stated they do not handle residents belongings unless the resident asks for assistance, the only staff that does handle residents belongings is the Laundry Staff. (Continued on 9099-C) Based on interview with laundry staff S4 stated they only do washing for 2 residents at a time to avoid confusion and mix up of items, there is a list they go by when doing the laundry to ensure accuracy. Based on interviews with residents, 9 out of 10 residents stated that they have never had any of their personal belongings go missing. Allegation: Staff failed to treat resident with dignity and respect. It is alleged that staff does not treat R1 with dignity and respect as R1 feels that staff have forcefully attempted to send them to Skilled Nursing Facility (SNF) in efforts to “get rid” of them. Based on interviews with staff 7 out of 7 staff stated that they have never forcefully sent residents to SNF’s. Interviews with S1 and S7 revealed that residents are not sent to SNF’s directly from facility, if they have a medical condition in which they are hospitalized the doctor at the hospital will refer them to a SNF for rehabilitation before them returning to the facility. Based on interviews with residents 10 out of 11 residents indicated that they have never forcefully been sent to the hospital or SNF. R2 indicated that they were once sent to a SNF and didn’t want to go, however, this was done through the hospital doctor after R2 suffered injuries from a fall and does not feel they were forced, understood that it was best for their recovery. Allegation: Staff confiscated resident's wheelchair. It is alleged that R1 used to have an electric chair and one day it went missing and staff put it in a room called the “beauty shop”. Based on interviews with staff 7 out of 7 staff stated that they have never taken a residents wheelchair nor have they seen/heard of another staff doing so. In interview with S7 they stated that on occasion R1 would borrow other residents electrical wheelchairs and staff would have to remind residents to not lend or borrow each others belongings to avoid any issues. Based on review of records, upon discharge from the facility R1 was given all his belongings with wheelchair included. Interviews with residents 9 out of 11 residents interviewed denied the above allegation and stated that staff has never taken their wheelchair, walker or cane from them. Based on statements and interviews conducted with staff and residents, review of R1 files and medication review, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 28-AS-20220902145555

Allegation investigated: Staff are not meeting residents needs

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced initial 10-Day complaint investigation regarding the above allegation. LPA met with Cynthia Flores who assisted with this visit. Purpose of today's visit was explained. The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters, Facility Policy of Personal Care and Admission Agreements, interviewed Assistant Administrator, Staff 1 to Staff 4 (S1 to S4), Resident 1 to Resident 7 (R1 to R7) Continue 9099C Unsubstantiated Investigation revealed the following: Regarding allegation: Staff are not meeting resident’s needs. It was alleged that facility have taken away residents’ haircuts and residents were told this week would be no more haircuts. RP stated that their concerned about residents in wheelchairs not being able to leave the facility to go get haircuts. Interviewed Assistant Administrator and staff denied the allegation. During the interview with Assistant Administrator, LPA advised that facility provided haircut services to all residents’ long time ago, before pandemic. There was a hairdresser who came to the facility for all residents’ haircuts or other cosmetology services and residents or responsible parties paid for those services. Haircut or other cosmetology services not included in the basic services plan and on the admission agreements considered as a 3rd party services. Assistant administrator and interviewed staff indicated that facility residents including residents on the wheelchair very independent and they able to leave the facility without assistance. But if they need any assistance for outside services including a haircut, staff will assist them to make an appointment, walk with them or give a ride to get to hair salon and back. Interviewed staff also indicated that sometimes family members taking residents to hair salon to get the haircut. All interviewed residents denied the allegation. they stated that facility staff always assist them with hair cut services and never heard that staff said no more haircuts this week or any other days. Interviewed residents stated that staff always make an appointment for them for haircut or other services if they need it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held. A copy of the report was provided to Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 28-AS-20231006111645

Allegation investigated: Facility neglected resident and they sustained a fracture while in care

Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit and met with Assistant Administrator Cynthia Flores and Administrator Lisa Pham arrived a short time later and assisted with the visit. The investigation consisted of interviews with seven staff members (S#1-S#7) and ten residents (R#1-R#10, reviewing and obtaining staff and resident rosters from 2022 and current, R1 LIC602A dated 03/25/2021, 02/08/2022, 02/09/2022, R1 face sheet, Appraisal/Needs and services plan for R1 dated 02/08/2022, Preplacement Appraisal Information, Hospital discharge orders dated 02/07/2022, Physicians orders for R1 dated 02/7/2022. SIR dated 02/04/2022, and Admission Agreement. The investigation revealed the following: (continued on 9099C) Unsubstantiated Allegation: Facility neglected resident and they sustained a fracture while in care Based on interviews conducted and reports reviewed, it was discovered that R1 sustained fracture at or around 7:00AM on 02/03/2022 due to unwitnessed unforeseen fall. R1 was not considered a fall hazard at the time of the fall. According to staff interviews, R1 was complaining of shoulder pain and R1 noticed a bruise on R1 upper arm near the shoulder. Med-Tech and caregiver were notified, and the facility provided observation, and medical attention by in house medical staff to assess R1. The facility immediately contacted R1 Physician and Physician ordered for R1 to be transported to Hospital. R1 was transported to Norwalk Community Hospital on 02/03/2022 at 1:25PM. Facility notified the family. R1 returned to facility on 02/07/2022 with order for half bed rails to prevent slipping from bed. R1 agreed with the order. LPA interviewed 7 staff and all 7 of 7 staff denied the allegations. All staff stated that they are required by facility policy to check on residents every 2 hours but that checks are done more frequent if needed. LPA interviewed 10 residents (R#1-R#10) and all 10 of 10 residents stated they get good attention at facility and could not collaborate the allegation. 9 of 10 residents stated staff check on them during the day and evening and ask if resident needs anything. R1 stated R1 slipped out of bed, R1 stated R1 did not fall. R1 stated R1 was sleeping when R1 slipped out of bed and that staff were not neglectful or at fault. R1 stated facility acted right away and sent R1 to the hospital. R1 stated R1 is very happy at facility and is satisfied with the care R1 receives. R1 stated staff check on R1 frequently and R1 has not slipped out of bed since incident on 02/03/2022. W1 who is family member stated W1 is very happy with the care provided to R1 and was aware of R1 incident on 02/03/2022 as facility did contact W1. Facility updated R1 LIC602A on 02/08/2022 and 02/09/2022 and Appraisal Needs and services plan on 02/08/2022.. There is no evidence that facility neglected R1 at this time. Based on interviews, observations, and records reviewed, it is determined that although the allegations 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 allegation is Unsubstantiated. An exit interview was conducted with the assistant Administrator Cynthia Flores and Administrator Lisa Pham and copy of report was provided along with appeal rights. . .the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20220204143051

Allegation investigated: Staff did not communicate with resident promptly and appropriately. Financial abuse. Facility staff failed to keep resident's rooms clean. Facility staff failed to keep facility free from insects.

** This report supersedes the original complaint investigation report dated 9/14/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.** Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit and deliver findings to the superseded reports for the allegations listed above. LPA met with Assistant Administrator Cynthia Flores and explained the purpose of today's visit. The initial investigation complaint visits were on 11/03/21 and 12/10/21. LPA Nicole Spencer took a tour of the physical plant and interviewed the Residents, Staff and reviewed residents and facility's records. During the subsequent visit on 9/14/2022, LPA Pena took a partial tour of the facility and exercised strict mitigation measures due to the most recent Coronavirus Disease 2019 (COVID-19) outbreak this facility had. LPA re-interviewed the Assistant Administrator, interviewed two (2) more residents and collected a copy of the staff roster, resident roster, housekeeping/maintenance schedule and housekeeping deep cleaning schedule (Aug-Oct. 2021). LPA also obtained copies of the pest control service invoices, surety bond, and for three (3) specified residents: account balance ledger and resident fund management authorization form. During today’s visit, LPA Pena obtained copies of the resident & staff rosters, housekeeping/maintenance schedule (Aug-Sep 2023), pest control service invoices (Aug–Sep 2023), PNI record for R1 (Feb 2021-Oct 2021) as well as random residents (Aug-Sep 2023). LPA interviewed additional residents and staff, Resident #13 (R13) – Resident #17 (R17) and Staff #4 (S4) - Staff #5 (S5). LPA also conducted a tour of the facility’s common areas and (6) random resident rooms in the 2nd and 3rd floors (Room #s 5, 17, 28, 33, 63 and 64). *****CONTINUED ON LIC9099-C***** Unsubstantiated *****This report supersedes the original complaint investigation report dated 9/14/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** Regarding allegation: Staff did not communicate with resident promptly and appropriately. It was alleged that staff will not communicate with the resident despite several attempts regarding the Social Security paperwork. An interview with the A1 revealed that she is not aware of this allegation. A1 stated that the residents’ concerns are promptly dealt with. The facility has suggestion and work order boxes that residents can use if they have concerns. Interview with A2 who denied the allegation indicated that if residents need assistance with SSI, she will do a 3-way call with the resident and SS office. A2 denied not addressing a resident promptly or appropriately and has not heard of any residents with this complaint. Interviews with staff revealed that they respond to residents’ concerns right away and have not had any complaints about the staff not responding promptly or appropriately. Staff members also stated that they deal with residents’ concerns promptly. (12) out of (17) Residents interviewed stated that staff communicate with them professionally. Other residents stated that the staff are nice, and they have no issues or concerns. LPA observed staff/ resident interactions during the visits conducted on 9/14/22 and 10/09/2023 and did not observe staff communicating inappropriately to any resident. LPA observed the interactions to be respectful. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. Regarding allegation: "Financial abuse." It is alleged that R1 has not received his PNI allowance in about 7 months. It is also alleged that R1 never received his stimulus check money, and his roommate has also had this issue. Interview with A1 revealed that A2 deals with all the residents’ finances and is not aware of any financial abuse. A2 is working with R1 and assisting with his money. A2 stated that R2 manages his own SSI money/finances. A2 also stated that she is not aware of any residents who are having this issue. A2 stated that the payees are given their allowance at the beginning of the month. S3 stated that she is not aware of this allegation, has not heard anyone complain about SSI and does not deal with SSI. (15) out of (17) residents interviewed stated that they don’t have any concerns, issues, or knowledge of financial abuse in the facility. Other residents indicated that they handle their own money, or that their SSI money is handled by a family member. (4) out of (17) residents stated that their SSI money gets deposited to their personal checking account and they have no concerns. Some residents also stated that the facility gives them their monthly allowance to spend. LPA reviewed R1's SSI PNI records (Feb 2021-Oct 2021) plus (5) random SS1 PNI records (Aug 2021-Oct 2021) and LPA did not observe any discrepancies. LPA observed that R1 received his stimulus check on 4/07/2021. All the residents SSI PNI records reviewed by LPA showed the SSI funds with corresponding debit and credit entries. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. *****CONTINUED ON LIC9099-C***** *****This report supersedes the original complaint investigation report dated 9/14/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** Regarding allegation: “Facility staff failed to keep resident's rooms clean.” It is alleged that staff used to clean R1’s room but lately in the last couple of months has only been taking out the trash and changing the sheets and that's all. Interviews with staff members revealed that housekeeping is done daily, and room checks (taking out trash, replacing paper products) are completed daily with the deep cleaning done once a week. A1 stated that if a resident has an issue with the cleaning, A1 will have housekeeping do it again. A2 stated that housekeepers clean the resident’s rooms at various times throughout the day. Staff members have not heard any residents complaining about this issue recently. Interviews with staff indicated that housekeeping staff provide housekeeping services (cleaning and room checks) daily. Deep cleaning services are done on a weekly basis. (15) out of (17) residents stated that housekeeping cleans often and does a very good job. Housekeepers check the rooms every day and do a thorough job. LPA reviewed the facility's housekeeping/maintenance schedule as well as housekeeping deep clean schedules and duties for (Aug 2021-Oct 2021) and (Aug 2023-Sep 2023). The documents revealed that they have staff assigned to clean the residents’ rooms daily and deep clean on a weekly basis. Therefore, there was not enough supportive evidence to concur with the reported allegation. Regarding allegation: “Facility staff failed to keep facility free from insects.” It is alleged that R1 has had an issue with gnats in his room for quite a while, especially in the bathroom. Interviews with staff revealed that they have not seen any bugs or heard of residents complaining about bugs. A1 stated that R1 has a plant in the room that attracts gnats. But housekeeping does maintenance sprays in the area once a week and pest control technicians come in monthly to service the facility. A2 stated that they do not have any insect problems and they take preventive measures. Interviews with staff members indicated that they have not seen any bugs in the facility and heard of anyone complaining about this issue. (13) out of (17) residents stated that they have not seen any bugs or gnats or heard anyone else about this issue. Some residents indicated that they eat in their rooms that may have attracted bugs and insects. LPAs toured the facility on 11/03/2021, 12/13/2021, 9/14/2022 and 10/09/2023. On 11/03/2021 and 12/13/2021, previous LPA observed gnats in the common areas and in (1) out of (5) rooms. However, LPA Pena did not observe bugs or gnats in the common areas and total of (11) random residents’ rooms or bathrooms during the visits on 9/14/2022 and 10/09/2023. LPA reviewed the facility's pest control invoices for (Aug-Oct 2021) and (Aug-Sep 2023) and observed that the facility continues to have regular pest control services. Therefore, there was not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview and a copy of this report was provided to Lisa Pham, Administrator and Cynthia Flores, Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 28-AS-20211027151500

Allegation investigated: Resident fell while in care Staff did not notify resident's authorized representative of incidents Staff did not prevent resident from engaging in inappropriate behaviors Staff did not safeguard resident's personal belongings Staff have not moved resident back to his original room

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Teresa Saavedra the receptionist of the facility and explained the reason for the visit. The Administrator Lisa Pham as well as the Assistant Administrator Cynthia Flores arrived shortly thereafter. The investigation consisted of the following: during the initial visit conducted on 05/24/2022, LPA Alberto Lopez interviewed two (2) Staff Members, two (2) Residents, and also obtained documents from Resident #1 and #2's (R1 and R2) file. During today's visit, LPA Zaragoza reobtained the FACE Sheets for Residents #3-11 (R3 - R11), and an updated Staff and Resident roster. LPA also conducted interviews with Staff #1 - 6 (S1 - S6), along with R3 - R11. LPA attempted to interview R1and R2, however they no longer live in the facility. Unsubstantiated The investigation revealed the following: In regards to the allegation that "Resident fell while in care", it is alleged that R1 fell at the facility due to a lack of supervision some time in March of 2022, however specific details were not provided. During interviews with the residents, none of them have corroborated the allegation that residents have fallen due to staff neglect. R8 explained that they once witnessed a fellow resident fall while out in the community, however paramedics were promptly contacted to assist the resident. During interviews with staff, none of them corroborated the allegation. S1 and S3 explained that if the residents cannot get up after a fall or if they hit their head then they contact paramedics immediately to take them to the hospital, and if they are able to get up after they ask one of their nurses to check on the resident to determine if any further action is required. S1 also explained it was never brought to their attention R1 fell within the facility, and also explained that they submit Serious Incident Reports to licensing whenever they do occur. In regards to the allegation that "Staff did not notify the resident's authorized representative of incidents", it is alleged that neither the passing of R2 nor a fall sustained by R1 was reported to their authorized representatives. During interviews with residents, none of them corroborated the allegation that the staff do not notify their family or authorized representative of any incidents involving them. R4, R6, R7, and R9 all explained that their families are kept informed of any incidents and updates related to them and their stay in the facility. During interviews with staff members, none of them corroborated the allegation that they do not notify responsible parties of serious incidents. S1 and S2 explained that most of the residents are self-responsible and that they do not have a responsible party, but if they do then they are contacted by phone and notified of any and all serious or unusual incidents regarding the resident immediately. Review of the resident's FACE Sheets revealed that the residents interviewed by LPA were self-responsible.. In regards to the allegation that "Staff did not prevent resident from engaging in inappropriate behaviors", it is alleged that R1 was called homophobic and racial slurs by another resident within the facility and that staff have not done anything to deescalate the situation. During interviews with the residents, eight (8) out of nine (9) residents stated that they have not encountered or witnessed any form of verbal harassment or abuse amongst the residents. R5 stated that they have been the subject of another residents harassment by the residents staring at them and bumping into R5's wheelchair intentionally, however R5 explained that they have not brought the situation up to staff because they think the harassment is petty. During interviews with staff, none of them corroborated the allegation that they do not prevent residents from engaging in inappropriate behaviors. S1 explained that in the event harassment amongst residents occurs they would first intervene to separate them and diffuse the situation, and work to set limits between the residents. S1 also explained that if one of the residents are harassing others due to behavioral issues then they will move forward with bringing in a psychiatrist to evaluate the resident. In regards to the allegation that "Staff did not safeguard resident's personal belongings", it is alleged that after R1 moved to their temporary room, their microwave, fridge, and glasses were discarded or lost and never replaced. During interviews with residents, none of them stated that that they have had any of their personal items get stolen or go missing from their rooms. During interviews with staff members, none of them corroborated the allegation that they do not safeguard the personal belongings of residents. S1 explained that if an item from the Resident's inventory list goes missing, they work to find the item and if they cannot they replace it and also possibly file a police report depending on the value of the item. S1 and S2 also explained that R1's fridge was certainly brought along with him during his move to his new room, and they were never notified of his microwave or glasses going missing during the move. In regards to the allegation that "Staff have not moved residents back to their original room", it is alleged that R1 was asked to move out of their room due to a maintenance problem into a temporary room, however they were never allowed to move back into their original room. During interviews with the residents, none of them corroborated the allegation that they were refused to move back into their room of preference. R10 and R11 explained that they have been asked to move to another room while living in the facility, however they were satisfied with the new room that they were moved into and had no complaints. During interviews with staff members, none of them corroborated the allegation. S1 explained that if a resident is ever relocated to another room temporarily due to a maintenance issue, they make sure remove any non-damaged personal items, and if the resident requests to be moved back into their original room they can. S3 explained that whenever a residents move rooms, it is by request only. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2023 · control 28-AS-20220518140116

Allegation investigated: Facility not providing residents with enough planned activities or variety of activities.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Cynthia Flores (Assistant Administrator) and Administrator Lisa Pham and explained the reason of the visit. The investigation consisted of the following: LPA requested copies of staff/resident roster, resident activity schedule for the last 3 months, toured the activity room, observed activities during visit, observed activity supplies, conducted Staff # 1-5 (S1-S5) and Resident # 1-9 (R1-R9) interviews. The investigation revealed the following: Allegation: Facility not providing residents with enough planned activities or variety of activities. It is alleged that the facility does not offer enough activities for the residents, the activities offered are available only once a week and limited to bingo. (Continued on 809-C) Unsubstantiated LPA toured the facility and observed Activity Schedule for the month of September posted throughout the halls, there is a Fitness room where the exercise activity is conducted in the mornings on the 2nd floor, an activity/family room on the 2nd floor and a Game Room on the 3rd floor. LPA observed board games and books in activity/game room that are readily available for residents. The supply for the art and crafts activities was also observed. 5 out of 5 staff interviewed stated that they have schedules with various activities for residents to engage in throughout the day/week that include, painting, jewelry making, coloring, table talk time (social engagement), exercise, going for group walks, movie afternoons (residents vote on movie), bingo, bored games, and others. Staff stated that when residents have ideas on new activities they review the activity and try to add it to the schedule. Staff stated the suggestion of residents going on field trips is difficult due to funds. LPA interviewed 9 Residents and 8 out of 9 residents denied the above allegation, some stated they do not participate in the activities as they choose not to socialize, however, they observe activities being conducted throughout the day and are announced on the intercom and in the dining area. Residents that do engage in activities stated that they have a variety of activities to choose from and feel the facility is providing as much as they can to the residents. All 9 residents stated that there are plenty of books, bored games, there is a pool table, radio, karaoke machine and TV they are able to utilize if they wish. Interviews and observation do not corroborate this allegation. Based on statements and interviews conducted with staff and residents, along with observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Administrator Lisa Pham.the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 28-AS-20230908152213

Allegation investigated: Staff make inappropriate comments towards resident's Staff are not meeting resident's hygiene needs Staff are not meeting resident's laundy needs Staff did not safeguard resident's personal belongings Facility has an expired license posted

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Teresa Saavedra the receptionist of the facility and explained the reason for the visit. The Administrator Lisa Pham arrived shortly thereafter. The investigation consisted of the following: during the initial visit conducted on 02/10/2022, LPA Joe Katrdzyhyan interviewed two (2) Staff Members, five (5) Residents, and also obtained documents from Resident #1's (R1's) file. During today's visit, LPA Zaragoza reobtained the FACE Sheet, Preplacement Apprasials information, Physician's Report, and Admission Agreement for R1, and also obtained the Inventory List of Personal Items for Resident #1 - Resident #11 (R1 - R11), along with an updated Staff and Resident Roster list. LPA Zaragoza also interviewed Staff # 1 - Staff #8 (S1 - S8), and also R2 - R11. LPA attempted to interview R1, however R1 no longer lives in the facility. Unsubstantiated The investigation revealed the following: in regards to the allegation "Staff make inappropriate comments towards resident's", it is alleged that staff at the facility yell at residents and have verbally harassed them in the past. During interviews with the residents, none of them could corroborate the allegations that they have been spoken to rudely or disrespectfully. R4 explained that the staff have been very courteous and nice to all the residents within the facility, and R7 stated that the staff treat the residents with total respect here and that they have never had any problems with the staff of the facility. During interviews with the staff members, none of them claimed to have witnessed staff at the facility verbally abusing any residents. Staff members explained that if any form of abuse were to occur then they would immediately report it to the administrator, and the Administrator stated the facility would then conduct an investigation into the allegation which would include interviewing residents and staff involved, creating and SOC341, and possible termination as well. In regards to the allegation "Staff are not meeting resident's hygiene needs", it is alleged that R1 had gone without showering for 4 weeks, and that when they did get assistance with showering R1 was given half-body showers instead of a full-body shower. During interviews with the residents, none of them corroborated the allegation that staff were not providing showering assistance to residents who need it. R7 and R9 explained that they require assistance with showering, and that they always get assistance from the staff without any issues. During interviews with the staff members, none of them corroborated the allegation that the facility does not meet the resident's hygiene needs. S1 explained that residents who require assistance with showering always receive full body showers, and S1 along with S3, S5, and S7 explained that they follow a shower schedule to help assist residents with showering at least twice per week. In regards to the allegation "Staff are not meeting resident's laundry needs", it is alleged that R1's laundry was not being done in a timely manner, and that a staff member told R1 that they did not have enough clothes to do R1's laundry. During an interviews with the residents, none of them could corroborate the allegation that their laundry needs are not being met. R4, R5, R7, R9, and R10 all explained that they get assistance with their laundry once per week, and that they have had no issues with their laundry being done in a timely manner. Interviews with staff revealed that a laundry schedule is followed to ensure all residents get assistance with their laundry, and the laundry staff S8 explained that they assist with doing the laundry for 66 out of the 80 resident rooms per week, while the other laundry staff members assist with the remaining rooms. In regards to the allegation that "Staff did not safeguard resident's personal belongings", it is alleged that some of her clothes have gone missing while living at the facility. During interviews with the residents, eight (8) out of ten (10) residents could not corroborate the allegation. R4 explained that whenever they leave the facility for an extended period of time, the facility provides R4 a "vacation lock" which ensures that R4's room remains locked and that no other caregivers or residents can enter it besides R4 in order to protect his possessions from being stolen. None of the staff members could corroborate the allegation. S1 explained that if any residents report any possession to be suspected of missing or stolen, the facility works to identify the item, attempt to locate the item or the person in possession of the item to ask them to return it to the rightful owner, and file a police report as well if necessary. S2 - S8 all explained that they would report any allegations of items being stolen from residents to management. In regards to the allegation that "Facility has an expired license posted", it is alleged that the facility's public health license had expired on 6/30/2021. During a tour of the facility, LPA observed that the administrator's certificate was posted in a prominent location near the facility's front office and was still current with an expiration date of 3/1/2024, and also noticed that the facility's license was prominently displayed as well. LPA was not able to get further clarification on which particular license was outdated at the time this complaint was field. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 7, 2023 · control 28-AS-20220202094921

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Cynthia Flores (Assistant Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. 160 non-ambulatory, of which 5 may be bedridden in Rooms 24,25, 26, 27, 28 and hospice waiver for 30. This is a three-story residential care facility for the elderly (RCFE). The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, elevator, outdoor patio, dining room, and kitchen. The 2nd floor includes 40 resident rooms, laundry room, medication room, and activity room. 3rd floor has 40 resident rooms, laundry room, maintenance/storage room, and activity room. There are (2) operable elevators. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are a total of 80 rooms in facility which each have room has its own restroom. LPA toured the common areas, 14 resident rooms, kitchen, dining area, public restrooms and outside areas. All rooms that were inspected have private restrooms. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free of obstruction. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied. Water temperature was measured throughout the resident bedrooms and temperatures ranged from 109.4-113.9 degrees F which (Continued on 809-C) is within the required range of 105-120 Degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are stored in the facility storage on the 3rd floor. The last Fire/Emergency Drill was conducted on 05/16/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers were observed to be fully charged. The facility is not equipped with delayed egress. Operational Requirements: The facility accepts bedridden residents and has proper fire clearance for up to 30 (there are currently no bedridden residents). Facility has the appropriate liability insurance. Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Lisa M. Pham has a valid administrator certificate that expires on 3/01/2024. Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid training and sufficient on-going training. Resident Rights-Information: The facility has Personal Rights Poster stationed in the main hallway. Facility provides internet and telephone access for the residents in care. Facility provides internet and telephone access to the residents. Resident Records-Incident Reports: Resident files are kept in a secured location and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Planned activities: There is a designated Activities Director that maintains and encourages participation in planned activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medications for residents are stored in the facility Medication room. All medication observed during visit were properly labeled and in their original containers. Staff designated to administer medication has the proper annual training on file. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: Facility has a hospice waiver for 30 persons there are currently no persons with hospice residing at the facility. There is proper fire clearance and signs posted for residents using oxygen. (Continued on 809-C) LPA conducted 4 staff interviews and 5 resident interviews during today’s visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on 809D. Exit interview was held and a copy of the report was provided to Administrator Lisa Pham.the state’s words, verbatim · CDSS document, Jul 14, 2023

Allegation investigated: Staff refusing to provide resident with medical/physician contact information. Staff not assisting resident with showers. Residents bed is in poor condition.

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegations. LPA met with Cynthia Flores (Assistant Administrator) and discussed the purpose of today’s visit. During this investigation, LPA obtained a copy of the staff roster and resident roster, reviewed files for Resident #1 (R-1) through Resident #5 (R-5) and obtained relevant documentation, interviewed Assistant Administrator and Staff #1 (S-1) through Staff # 4 (S-4), interviewed Resident #1 (R-1) through Resident #10 (R-10) and conducted a facility tour. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff refusing to provide resident with medical/physician contact information. Staff interviews (4) out of (5) revealed that Residents are provided with a copy of their face sheet which includes their medical physician’s contact information along with a list of their medication upon request. Per staff interviews, R-5 has been provided with R-5’s face sheet and list of medication multiple times. Staff interviews revealed that R-5 underwent a medication change which was documented and that the new medication has been provided to R-5 as prescribed. Staff interviews revealed that R-5 is forgetful and requires reminders and redirection when requesting for medical physician’s contact information, requesting a list of medication and with medication administration. Resident interviews revealed that staff do not refuse residents the medical/physician contact information. Resident interviews revealed that they consult with their physician’s often and staff provide them with their medication daily. Resident interviews revealed that they are able to obtain their physician contact information and/or their medication list from staff. Interviewed residents do not have any concerns with retrieving their physician’s contact information and/or a list of their medication from staff. Interviews do not corroborate this allegation. Allegation: Staff not assisting resident with showers. Staff interviews revealed that staff provide assistant to residents with showers (residents that require assistance with Activities of Daily Living (ADLs)). (4) out of (5) staff interviews revealed that R-5 showers independently a couple of times per day and staff are on “standby” when R-5 is showering (in case R-5 requests for assistance). Interviewed staff indicated that residents do not go without staff assistance with showers/baths for (2) months. Resident interviews revealed that staff assist residents with showers. Interviewed residents indicated staff assist residents with showers a couple of times per week. Resident interviews revealed that staff have a “shower schedule” for residents and that staff also assist them on days not noted on the “shower schedule”. Interviewed residents do not have any concerns with staff assisting with showers. Interviews do not corroborate this allegation. Allegation: Residents bed is in poor condition. Staff interviews revealed that residents’ beds are not in poor condition. Interviewed staff indicated they have not received any concerns from residents in regards to their bed. Staff interviews revealed that R-5 requested a hospital bed versus a regular bed as R-5 was accustomed to having a hospital bed at R-5’s previous residence. Per staff interviews, there has not been any complaints in regards to beds being uncomfortable. Per staff interviews, R-5’s medical professional ordered a hospital bed and R-5 has been provided with the hospital bed. Resident interviews revealed that their beds are in good condition and are comfortable. Interviewed residents do not have any concerns in regards to the condition of their bed. Interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. An exit interview conducted, appeal rights and a copy of this report was provided to Lisa Pham.the state’s words, verbatim · CDSS document, Jun 1, 2023 · control 28-AS-20230523094907

Allegation investigated: Due to lack of supervision, resident had multiple falls Staff did not inform authorized representative of incidents Staff do not change resident timely Resident is double diapered due to staff neglect Due to staff negligence, resident was left on the toilet for an extended period of time

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Administrator, Lisa Pham, and explained the reason for today's visit. The investigation consisted of: review of resident #1's file, and obtaining copies of specific documents. LPA also interviewed Resident #1 - Resident #12, and Administrator, Staff #1 - Staff #4. Regarding the allegation that resident #1 had multiple falls due to lack of supervision. Staff interviewed denied the allegation. They stated that resident #1 has not had any falls to their knowledge. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents stated that staff provide adequate supervision, and have provided assistance to them when they have had falls. Resident #1 stated that he has fallen while at the facility, but was unable to provide details and/or dates of alleged falls. Unsubstantiated Regarding the allegation that staff did not inform authorized representative of incidents, Staff interviewed denied the allegation. They stated that staff do inform authorized representatives of incidents. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents interviewed, stated that their authorized representatives are notified of incidents, or indicated that they did not have an authorized representative. Regarding the allegation that staff do not change resident timely, Staff interviewed denied the allegation. They stated that residents who receive assistance with toileting, are provided with assistance as soon as they request it. Staff indicated that residents call staff, by using the call light in their room. Staff stated that the call light notification is received by the front desk, and the front desk notifies staff by paging them. The front desk lets staff know which resident(s) need assistance. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents indicated that they are assisted by staff in a timely manner. Regarding the allegation that resident #1 is double diapered due to staff neglect, staff interviewed stated that resident #1 requests to be double diapered. Staff interviewed indicated that resident #1 leaves the facility, on his own, and wants to be double diapered since he is often gone for extended periods of time. Residents interviewed were unable to corroborate the allegation. 8 out of 11 residents interviewed, stated that they are not double diapered. 2 out of 11 residents stated that they are double diapered at night, but they don't have a problem with it. Regarding the allegation that due to staff negligence, resident was left on the toilet for an extended period of time, staff interviewed denied the allegation. Staff interviewed stated that residents are not left on the toilet for a long period of time. Staff stated that they assist residents in transferring to the toilet, and they wait if the resident wants them to wait, or they leave and come back within 5 minutes. Residents interviewed were unable to corroborate the allegation. 10 out of 11 residents stated that they have never been left on the toilet for an extended period of time. Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Lisa Pham.the state’s words, verbatim · CDSS document, May 18, 2023 · control 28-AS-20230509152710

Allegation investigated: Unexplained death. Facility restrained resident. Facility did not get medical assistance for resident in a timely manor. Staff did not respond timely to resident pull cord due to insufficient staffing. Staff did not change residents soiled diaper timely due to lack insufficient staffing.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit to deliver findings on 04/26/2023, stemming from subsequent complaint visit dated 04/25/2023, conducted by LPA Ramirez and initial 10-day complaint visit conducted on 02/05/2021, by LPA Wesley. LPA was met by Staff 1 (S1) and explained the purpose of the visit. Allegations: • Unexplained death- It is alleged on or around January 10, 2021, Resident 1 (R1) was transported via 911 to local hospital and unexpectedly passed away four days later at local hospital. Four (4) out of four (4) staff deny having knowledge of this allegation. LPA could not confirm that R1 passed away four days later at local hospital. LPA was unable to obtain death certificate/death report. LPA was unable to contact R1’s surviving sibling due to sibling phone number being out of service. LPA was able to confirm R1's personal belongings were picked and R1 was discharged on 01/12/2021 from facility by R1's sister. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. There was no evidence, or witness statements provided at time of visit to support this allegation. SEE LIC 9099-C Unsubstantiated ·Facility restrained resident- It is alleged that on or around January 09, 2021, unknown staff restrained R1, by tying R1 to the bed, as to prevent R1 from throwing self onto floor. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. LPA toured two (2) resident accommodations at random (room 19 & 52 ), LPA did not observe restraints of any kind near bed frame or head board. LPA did not observe any hazards during tour of facility. There was no evidence, or witness statements provided at time of visit to support this allegation. · Facility did not get medical assistance for resident in a timely manner- It is alleged on or around January 10, 2021, R1 was suffering from a medical emergency and staff prolonged calling 911. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. On April 25, 2023, at 6:32 pm, LPA Ramirez contacted the Downey Police Department at 562-861-0771. LPA confirmed no service calls were made on or around January 10, 2021, to 911 requesting service at 12045 Lakewood Blvd, Downey 90242. LPA could not confirm if a private ambulance service was dispatched to facility address. LPA could not locate any SIR’s in department database however, staff provided LPA with copy of SIR dated 01/10/21, describing incident regarding R1. Facility acknowledged R1 was not at the facility between 01/11/21 through 01/12/21. Facility staff acknowledges R1 was transferred to local hosiptal. LPA was able to obtain a copy of in-house Training Sign in Sheet for staff receiving training on Emergency (911) and non-emergency calls, recognizing change of condition, and other various training's dated May 16, 2018 through March 07, 2023. There was no evidence, or witness statements provided at time of visit to support this allegation. · Staff did not respond timely to resident pull cord due to insufficient staffing- It is alleged on or around December 31, 2021, through January 10, 2021, staff did not respond to pull cord in a timely manner when R1 needed assistance. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. LPA toured random resident room 19 and tested pull cord at 12:46 pm. Staff responded to resident room 19 at 12:47 pm to assist. LPA obtained a copy of Recap Medication & other duties in-house training sign in sheet dated June 23, 2022. According to staff, when a resident pulls the emergency cord in their room, the facility signaling system will light up and make a noise to alert which room is needing assistance. Staff will assist within 5 minutes. Four (4) out of the four (4) residents interviewed confirm staff arrive no more than 5 minutes after calling for assistance. There was no evidence, or witness statements provided at time of visit to support this allegation. SEE LIC 9099-C for continuation ·Staff did not change residents soiled diaper timely due to lack insufficient staffing- It is alleged on or around December 31, 2021, through January 10, 2021, R1 was left soiled for two hours. Four (4) out of four (4) staff deny having knowledge of this allegation. Four (4) out of the four (4) residents interviewed deny having knowledge of this allegation. According to three (3) out of the four (4) staff interviewed, staff check on incontinence residents at a minimum of every two hours. If a resident request to be changed sooner, staff will assist in changing resident upon request. There was no evidence, or witness statements provided at time of visit to support this allegation. Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. Exit interview was held with Staff 1 (S1) and a copy of this report was emailed due to printer issues.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 28-AS-20210204111702

Allegation investigated: Neglect resulted in resident being physically assaulted by another resident, causing significant injuries.

Licensing Program Analysts (LPAs) Cynthia Chan and Tena Herrera conducted a subsequent visit to deliver the finding for the allegation listed above. LPA met with Administrator, Lisa Pham, and Assistant Administrator, Cynthia Flores, to explain the purpose of the visit. On 11/10/21, LPA Chan conducted the initial complaint visit with a health and safety check. LPA toured the facility, inspected random rooms, tested the hot water temperature, and reviewed food supplies. LPA did not observe any health and safety issues during the visit. LPA obtained the staff roster, resident roster, and documents pertaining to Resident #1 and #2. On 2/2/23, LPA conducted another visit to interview Staff and Residents. The allegation was further investigated by the Department of Social Services Investigations Branch (IB) Investigator Dennis Douglas. (Continue on LIC9099C) Substantiated The investigation revealed the following: Allegation - Neglect resulted in resident being physically assaulted by another resident causing significant injuries. IB investigator D. Douglas conducted interviews with the facility staff, doctors, and victim. During the investigation, it was revealed the Resident #1 (R-1) was not medication compliant prior to an initial incident that occurred on 10/1/21, which R-1 became agitated and was verbally abusive towards staff and other residents. R-1’s psychiatric doctor was notified and requested to send R-1 to the hospital for a psychiatric evaluation. R-1 was cleared to return to the facility after agreeing to comply with taking the psych medication. Upon returning from the hospital, R-1 was placed in another room with a roommate. Another incident took place on 11/6/21 in which R-1 physically assaulted the roommate (R-2). R-2 sustained injuries/lacerations to the hands and head. According to documentation gathered, R-1 was not compliant with medications after returning from the first incident. Staff indicated they tried to encourage R-1 to take the routine medications but could not force R-1 to take them. Some of the staff acknowledged the incidents and that R-1 was inconsistent with taking medication but stated that R-1 had not been physically or verbally abusive prior to the incidents. The Medication Administration Records (MAR) log showed that R-1 was inconsistently taking the psychosis medications from October 2022 – November 2022. Although the psychiatrist and primary physician were notified, the facility did not develop other plans to address R-1’s failure to comply with medications. There were no notes or updated needs and services plan provided to show that additional actions were taken after the first incident of aggressive behavior and the medication non-compliance. Therefore, the allegation of neglect resulting in physical assault of another client is substantiated. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** An exit interview was held. A copy of this report, LIC9099D, LIC421IM, and appeal rights were given to Administrator Lisa Pham.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 28-AS-20211109130625

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 3, 2023

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interviews and documents review, licensee failed to provide additional support for R-1 who failed to comply with medication which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2023

Plan of correction: Licensee will submit plan to ensure that any resident non-compliant with medication is addressed immediately to prevent any triggers of aggressive behaviors. The POC is due by 3/3/23.

Allegation investigated: Staff did not feed resident. Staff did not seek timely medical care for resident.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Assistant Cynthia Flores and explained the purpose for the visit. During today's visit, LPA obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, physician's report, Needs and Services Plan, Notice of Hospice Initiation, Hospice Care Plan, Physician's Orders for Life-Sustaining Treatment (POLST), Hospice Records/Notes, and hospital dishcarge documents. LPA also conducted interviews with Staff# 1-2 (S1-S2), the hospice case manager (CM), and hospice nurse (HN). The investigation revealed the following: (Report Continued on LIC9099-C...) Unsubstantiated Regarding allegation- Staff did not feed resident. It is alleged that facility staff did not feed R1 causing R1 to go into an altered state of consciousness. Per Hospice Initiation notice, it was discovered that R1 was admitted to hospice care on 11/20/22. S2 stated that hospice was notified on 11/21/22 that R1 was noted to not be eating well. Prior to being placed on hospice care, R1 was eating about 70% of meals. CM confirmed the information, stating that the facility also requested an order for pureed food for R1 to encourage R1 to eat. S2 stated that on 11/30/22, R1 was noted to have difficulty swallowing and did not eat breakfast or lunch after several attempts to assist with eating- hospice was notified. On 11/30/22, HN arrived at the facility and confirmed the reports of R1 not eating well due to difficulty swallowing, after completing an assessment. This allegation is unsubstantiated. Regarding allegation- Staff did not seek timely medical care for resident. It is alleged that on 12/01/22 at about 1:00PM, R1's family asked the facility to call 911 to transfer the resident to the emergency room. Per interviews conducted, 4 of 4 individuals interviewed stated on 11/30/22, hospice and R1's family member (FM) were notified of R1's health declining. Per R1's POLST, R1 was Do Not Resuscitate (DNR), which would indicate that hospice would keep R1 comfortable until expiration, in case of changes in condition. CM stated HN was sent to facility at 9:1PM for continuous care of R1. Per interviews with S2 and CM, after R1's FM was notified of changes, FM requested R1 be placed at another facility or hospital due to R1's health decline. CM coordinated a telephone call with FM and S2 to discuss requested changes. CM advised against moving R1 due to possibility of R1 expiring en route and FM not being able to visit prior to expiration. CM and S2 stated FM requested R1's POLST to be changed from DNR to Full Code, which would indicate that R1 would now receive all medical measures to try and keep R1 from expiring. At 12:38PM, HM coordinated with S2 and HN to call 911, per change in POLST. Paramedics arrived shortly after and took R1 to the hospital. Per hospital records, on 12/01/22, R1 was admitted and expired at the hospital. CM states that facility notified hospice promptly and followed all protocols for patients on hospice care. 911 was not called immediately due to initial POLST signed as DNR. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with executive assistant Cynthia Flores and copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2022 · control 28-AS-20221201150942

Allegation investigated: Resident is not getting showers. Resident's bed is broken. Staff did not safeguard resident's personal items. Staff are not providing resident alternative meals.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Executive Assistant Cynthia Flores and explained the purpose for the visit. On 03/19/2020, LPA B. Tao condutcted a telephonic investigation due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. During the investigation, LPA Tao interviewed Executive Assistant Cynthia Flores and requested copies of residents roster, staff roster, shower slips, picture of the bed showing the location of the bed rail, IPP, dietary menu, face sheet and phyician report, to be faxed to the LPA’s attention at the Regional Office Address listed above by 03/25/2020. (Report Continued on LIC9099-C...) Unsubstantiated During Today's visit, LPA Maldonado obtained a copy of the staff and resident roster, toured the resident's old bedroom (room#5), and conducted interviews with Staff# 2-5 (S2-S5). LPA was unable to interview Resident# 1 (R1) due to R1 no longer residing at the facility. The investigation revealed the following: Regarding allegation- Resident is not getting showers. It is alleged that R1 was receiving one shower every three weeks due to staffing issues. Per R1's physician's report, R1 requires assistance with bathing. (4) of (5) staff stated that any time R1 or any resident refuse a shower, staff would ask the resident and confirm their decision. This would then be logged and signed by the resident and a witness, unless the resident refuses to sign, then it would be signed by the staff and a witness. After review of shower logs for February-March 2020, it was confirmed that R1 did receive frequent baths, however R1 would refuse/change their scheduled days every week. The changes/refused days are reflected on the logs provided. Regarding allegation- Resident's bed is broken. It was alleged that when R1 moved into the facility, R1 had a hospital bed that moved up and down; However it stopped working and would not go up anymore. S2 states R1 requested to have the bed rails removed from the bed as it made it difficult for R1 to transfer from wheelchair to bed on their own. LPA received proof of a document signed by R1 acknowledging their request to have the rails removed. All staff interviewed stated they have no knowledge of R1 ever falling off the bed due to the removal of the bed rails. All staff interviewed stated they have no knowledge of R1's bed being broken. Regarding allegation- Staff did not safeguard resident's personal items. It is alleged that R1 had missing clothes and that other people go through R1's personal belongings. S2 stated that during R1's stay at the facility, R1 moved from the initial admissions room to another room. During the move, R1 stated a couple of shirts were missing. S2 assisted R1 to look for the shirts R1 claimed to be missing and found them with the rest of R1's clothes. (3) of (5) staff interviewed stated they have no knowledge of R1 reporting they had missing clothes or people were going through R1's personal belongings. (Report Continued on LIC9099-C...) Regarding allegation- Staff are not providing resident alternative meals. It is alleged that due to R1 going to dialysis and returning late, R1 misses meal times and is not provided a meal upon return to the facility. R1 is also diabetic and due to condition, R1 needs to eat. All staff interviewed stated that R1 and all other residents who go to dialysis are always served and saved a plate of food to be given to them upon their return. All staff stated that R1 was always prepared meals based on their special diet, however R1 was non-compliant with the special diet. All staff stated R1 always requested to have the regular meal all other residents were served, if R1 decided to eat at the facility; However, R1 would also return from dialysis with their own meal from outside restaurants or would order delivery to the facility. All staff stated that residents who go to dialysis are served a meal to eat before they leave and are served a sacked lunch, based on their special diet, to take with them and eat while they're out. Based on LPA's interviews, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Assistant Cynthia Flores and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 1, 2022 · control 28-AS-20200309155306

Allegation investigated: Illegal Eviction. Administrator retaliated against resident. Staff did not safeguard resident's personal property.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Assistant Administrator Cynthia Flores. Administrator Lisa Pham arrived shortly after. The investigation consisted of: Staff (S1-S8), resident (R1- R12), skilled nursing staff, and ALW program staff were interviewed. An interview was attempted with R1's family A tour of the interior and exterior physical plant was conducted. Resident (R1's) room, laundry rooms, and storage areas were inspected. Resident (R1's) file documents were obtained, as well as the resident and staff rosters. See LIC 9099C for report continuation. Unsubstantiated Allegation: Illegal Eviction. Based on interviews conducted and record review the findings indicate resident (R1) went to the hospital on 9/10/22 and then was discharged on 9/18/2022 to a skilled nursing facility for higher level of care. On 10/12/2022, facility staff (S7) went to the skilled nursing facility to evaluate the resident, take pictures of R1's wounds, and to inform the resident that it needs to pay October 2022 rent in order for the facility to hold the resident's room. The resident paid in full October 2022 rent fees. It is also alleged that the facility called R1's mother and asked her to pick up R1's personal belongings because the resident was being discharged due to higher level of care needs. Resident (R1) is self-responsible, and mother is only listed as a secondary contact in file documents. On 11/1/2022, the resident's mother went to the facility to pick up R1's personal belongings. It is alleged that resident (R1) was not given written notification that it was being discharged from the facility or issued an eviction notice. The resident did not sign any discharge documents and planned to pay for November 2022's rent. However, on 10/28/2022, R1 received a phone call from facility staff (S2) informing the resident that it cannot be accepted back to the facility per MD order that indicated it requires a higher level of care. One (1) resident out of 12 interviewed stated the facility illegally evicts residents. All staff interviewed denied the allegation. Staff stated that on 11/1/2022 the resident called the facility and informed staff that it's mother would be going to the facility the same day to pick up it's personal belongings. Per Physician Order dated 10/27/2022, the resident required higher level of care. Therefore, the resident was not issued an eviction notice, and the resident is still receiving care at the skilled nursing facility. There is insufficient evidence to prove the allegation. Allegation: Administrator retaliated against resident. It is alleged that facility administration staff discharged the resident without notice, with a pretense that R1 requires higher level of care. Due to the fact that several months ago R1 filed a complaint against facility staff. A total of eight (8) staff were interviewed; of which one (1) staff stated that sometimes staff have retaliatory attitude towards the residents. Five (5) out of 12 residents reported retaliatory actions against residents if and when a resident complains to facility staff or Community Care Licensing. The residents stated that they receive "lousier" service and staff get moody/mad at the residents. Based on interviews conducted, there is insufficient evidence to prove the resident was not accepted back to the facility as a retaliatory action. See LIC 9099C report continuation Allegation: Staff did not safeguard resident's personal property. According to interviews conducted facility staff called R1's mother to come to the facility to pick up the resident's belongings, and the resident's mother went to the facility and was not allowed to go into the resident's room to pack the belongings, and ensure all personal belongings were picked up. Instead, staff (S2) packed all the resident's belongings. It is alleged that R1's blood pressure monitor, clothes, elevation pedal, 3 colognes, and all personal belongings were not given to R1's mother upon pick-up. The only things that were returned were furniture items like microwave, paintings, and larger furniture pieces. Based on staff interviews, on 10/28/22 facility staff (S2) called the resident at the skilled nursing facility to inform R1 that per MD order the resident requires a higher level of care. The resident was asked if it wanted facility staff to take its personal belongings to the skilled nursing facility, or if it's mother would be picking up the items. Staff (S2) stated that the resident said that it's mother would be picking up the personal belongings. On 11/1/2022 at approximately 11:23 am, resident (R1) called the facility and gave verbal authorization to staff (S2 & S8) that it's mother would be going to the facility on the same day to pick up it's belongings. According to staff, R1's mother had previously visited the facility in September 2022 after the resident was admitted to the skilled nursing facility. R1's mother picked up clothing items, shoes, airpods, and a suitcase containing personal belongings. Per record review, the facility did not fill out an Inventory of Personal Effects form on that date. On 11/1/2022, R1's mother picked up the remaining personal belongings that were left in the resident's room. Facility staff failed to document properly which items were removed, but staff stated one of the items in question, 3 colognes were definitely provided to R1's mother. One (1) out of eight (8) staff stated that sometimes the resident's belongings are not safeguarded, and other residents take personal belongings. One (1) resident stated it's personal belongings are not safeguarded by staff. LPA inspected the R1's room, laundry areas, and storage room and did not observe R1's personal belongings. There is notation from R1's mother indicating 3 personal belongings were missing. However, those personal belongings were not documented on R1's file document Inventory of Personal Effects. There is insufficient evidence to prove the allegation. Based upon record review and interviews conducted the findings indicate that, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. Exit interview was conducted with Administrator Lisa Pham. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 4, 2022 · control 28-AS-20221102115045

Allegation investigated: Staff did not provide resident's authorized representative records in a timely manner.

Licensing Program Analyst (LPA) Bennette Pena initiated a complaint investigation for the allegation listed above. LPA Pena was greeted by Asst. Administrator Cynthia Flores and explained the purpose of today's visit. During today's visit, LPA Pena obtained copies of the Staff/Resident Roster, R1’s Identification and Emergency Information, conducted interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3) by phone, former resident #1 (R1), RP, Witness #1 (W1) and Witness #2 (W2). LPA also received copies of fax request sent by the legal services company (10/24/2022 received at 7:16am), fax confirmation receipts and R1’s records/documents sent by the facility to RP. ******CONTINUATION ON LIC 9099-C******** Substantiated Regarding the allegation: Staff did not provide resident's authorized representative records in a timely manner. It was alleged that RP requested records on behalf of R1 on 10/06/2022 and have not received anything as of complaint reporting date, 10/21/2022. Based on interviews and records review done by LPA, the investigation revealed the following: · 10/04/2022 (6:55pm) - RP sent email request via 3rd party legal services. · 10/06/2022 - legal services company received the request from RP. Witness #1 (W1) from legal services company called the facility and received information where to send/fax it to. Faxed it same day and received confirmation that it went through. · 10/21/2022 - legal services company called facility to follow up as they have not received anything. W1 stated that someone from their office spoke with Staff #3 (S3) who indicated that she would forward the information to S2. W1 called back on end of day (at 4:24pm), but no response. · 10/24/2022 - legal services company re-faxed request to facility (at 8:12am) and have not heard back from facility since. However, W1 stated that RP informed them that she will take care of it on her own. LPA spoke to R1 to confirm that he requested and authorized RP to get his personal/medical records from the facility and she responded: “Yes, I asked them to get it on my behalf, but I cannot remember when exactly.” LPA interviewed RP and stated that she received records/documents from facility on 10/24/2022 (at 4:45pm) after legal services company had called, faxed and emailed the facility multiple times. RP stated that facility should have sent the records/documents to legal services company but since she needed it, she asked the facility to fax it to her directly instead. LPA’s interview with S2 stated that she only received one (1) request and that was on 10/24/2022. S2 does not remember receiving any other request. S2 stated that she normally turns over the request the same day or following day depending if she is in the building. S3 stated that she can not recall a phone call with the specific legal services company on 10/21/2022 or at any day/time. S3 indicated that she gets a lot of calls every day. If she gets that type of call, the normal procedure is to relay it to the appropriate party. LPA interviewed S1 and stated she did not know anything about the fax request that came through on 10/06/2022 and 10/24/2022. Based on interviews and records review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency under California Code of Regulation, Title 22 is being cited on the attached LIC9099D. Exit interview conducted with Assistant Administrator, Cynthia Flores. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 28, 2022 · control 28-AS-20221021171027

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Nov 4, 2022

87468.2...Additional Personal Rights of Residents...(a) In addition.. (19) To have prompt access to review all their records ...records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidenced by: LPA Pena's interviews and records review revealed that the facility did not release and provide the resident's records to the authorized requesting party within two (2) business days as required.the state’s words, verbatim · CDSS document, Oct 28, 2022

Plan of correction: Administrator and Asst. Administrator agreed to read, review and understand Title 22 Regulation 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. And release/provide resident's records within two (2) business days. Administrator and Asst. Administrator will send a signed statement stating that they have read, reviewed and understood the regulation 87468.2 to LPA on or before POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Galarza conducted an unannounced case management visit for the purpose of amending complaint report #: 28-AS-20200304103127. The purpose of the visit was explained to Assistant Administrator Cynthia Flores. Corrections to the report were made. Exit interview conducted with Assistant Administrator Cynthia Flores. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 25, 2022

Allegation investigated: Staff do not treat residents with respect

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Assistant Administrator, Cynthia Flores. The purpose of the visit was discussed. During the visit today, LPA obtained copies of the staff roster and resident roster. Interviews were conducted with Resident's R1-R 8 from 2:00 PM to 3:00 PM. Interviews with Assistant Administrator and Staff S1 and S2 were conducted from 3:00PM to 3:30 PM. In regards to the allegation, Staff do not treat residents with respect, based on interviews conducted and information gathered 8 of 8 residents interviewed stated that staff are doing a good job and treat residents with respect. Also stated that staff act professionally and assist residents with all needs. All residents interviewed stated that there have not been any times they observed or heard of staff making negative comments toward residents. Staff interviewed stated that management wants everyone to help support residents. Stated that most important thing is customer service and they are not rude or disrespectful and have not made negative Unsubstantiated comments toward the residents. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 28-AS-20221003153013

Allegation investigated: Staff are not communicating with resident Staff do not provide adequate quantity of food Staff provide poor quality of food Staff do not provide snacks in between meals to residents Staff do not dispense medications as prescribed

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Assistant Administrator Cynthia Flores, who assisted with the visit. The investigation consisted of the following: Interview(s) with Assistant Administrator, and staff #1 -staff #4, interviews with resident #1- resident #8, review of resident medications, review of facility food supply, and facility menu. Regarding the allegation that staff are not communicating with resident(s). Staff interviewed denied the allegation. Staff stated that staff communicate with residents, and they speak to them in a respectful, polite manner. Residents interviewed were unable to corroborate the allegation. 8 out of 8 residents stated that staff communicate with them in a polite manner. Unsubstantiated Regarding the allegation that staff do not provide an adequate quantity of food, and that the food quality is poor. Staff interviewed denied the allegation. Staff stated that the food served is sufficient and of good quality. Residents interviewed were unable to corroborate the allegation. 8 out of 8 residents interviewed stated that the food served is of sufficient quantity and quality. LPA Rea observed that the facility had a sufficient amount of food during today's visit, and it was of good quality. Regarding the allegation that staff do not provide snacks in between meals to residents. Staff interviewed, denied the allegation. They stated that residents are able to have snacks in between meals. Staff stated that snacks are passed out in the kitchen to residents in between meals. Residents interviewed were unable to corroborate the allegation. 6 out of 8 residents interviewed stated that snacks are provided in between meals. Regarding the allegation that staff do not dispense medications as prescribed. Staff interviewed denied the allegation. They stated that medication is dispensed according to doctors orders. Residents interviewed were unable to corroborate the allegation. 8 out 8 residents stated that they are given their medications as prescribed. LPA reviewed medication(s) on today's visit, and observed that medications appear to be dispensed as prescribed. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Cynthia Flores.the state’s words, verbatim · CDSS document, Sep 29, 2022 · control 28-AS-20220921115307

Allegation investigated: Staff did not communicate with resident promptly and appropriately Financial abuse Facility staff failed to keep resident's rooms clean Facility staff failed to keep facility free from insects

Licensing Program Analyst (LPA) Bennette Pena conducted a follow up complaint visit to render findings on the above allegations. LPA met with Assistant Administrator Cynthia Flores and explained the purpose of today's visit. The initial investigation complaint visits were on 11/3/21 and 12/10/21. LPA Nicole Spencer took a tour of the physical plant and interviewed the Residents, Staff and reviewed residents and facility's records. During today's visit, LPA took a partial tour of the facility and exercised strict mitigation measures due to the most recent Coronavirus Disease 2019 (COVID-19) outbreak this facility had. LPA re-interviewed the Assistant Administrator, interviewed two (2) more residents and collected a copy of the staff roster, resident roster, housekeeping/maintenance schedule and housekeeping deep cleaning schedule (Aug-Oct. 2021). LPA also obtained copies of the pest control service invoices, surety bond, and for three (3) specified residents: account balance ledger and resident fund management authorization form. Continued on LIC 9099-C....... Unsubstantiated · Regarding allegation: Staff did not communicate with resident promptly and appropriately. It was alleged that Administrator (A1) will not communicate with RP despite several attempts regarding RP's Social Security paperwork. Interview with Administrator revealed that residents’ concerns are promptly dealt with. Facility has suggestion and work order boxes that residents can use if they have concerns. A1 is not aware of this allegation. Asst. Administrator (A2) stated that if residents need assistance with SSI, she will do a 3-way call with the resident and SS office. A2 denied the allegation that she did not address a resident promptly or appropriately and has not heard of any residents with this complaint. Interviews with S1-3 revealed that they respond to residents’ concerns right away and have not had any complaints. They have not heard complaints about the staff not responding promptly or appropriately. Interview with S3 revealed that they deal with residents’ concerns promptly. S3 does not deal with SSI so she refers them to the Asst. Administrator and has not heard anyone complain about SSI. Seven (7) out of 12 Residents (R2, R4, R6-7, R9, R11-12) interviewed stated that Staff communicate with them professionally. Staff are nice and they have no issues or concerns. LPA observed staff/ resident interactions during the visit conducted on 9/14/22 and did not observe staff communicating inappropriately to any resident. LPA observed the interactions to be respectful. Therefore, there was insufficient evidence to corroborate with this allegation. Based on LPA's observations and interviews, investigation revealed: Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. · Regarding allegation: Financial abuse Administrator stated that A2 deals with all the residents finances and is not aware of any financial abuse. A2 is working with RP and assisting with his money. A2 stated that she is not aware of any residents who are having this issue. A2 stated that the payees are given their allowance in the beginning of the month. S3 stated that A2 deals with all the finances and not aware of this allegation. Nine (9) residents (R2-6, R9-12) out of 12 residents revealed that they either handle their own money. Some also stated that their SSI money are handled by a family member and they have no issues or knowledge of financial abuse in the facility. R2 and R10-12 stated that their SSI money get deposited to their checking account and have no concerns about that. R3 stated that facility gives him $138/mo. for spending. LPA reviewed some resident's records and did not find any discrepancies. Based on LPA's observations and interviews, investigation revealed: Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. CONTINUED ON LIC 90999-C........ · Regarding allegation: Facility staff failed to keep resident's rooms clean Interview with Administrator (A1) and Asst. Administrator (A2) revealed that housekeeping is done daily, and room checks (taking out trash, replacing paper products) are completed daily with the deep cleaning done once a week. A1 stated that if resident has an issue with the cleaning, A1 will have housekeeping do it again. A2 stated that housekeepers clean the resident’s rooms at various times throughout the day. A1 and A2 have not heard of any residents complain about this issue recently. Interviews with Staff 1-3 indicated that housekeeping staff are providing housekeeping services (cleaning and rooms checks) daily. Deep cleaning services are done on a weekly basis. Interviews with nine (9) out of 12 residents stated that housekeeping cleans and do a very good job. Housekeeping checks the rooms every day and do a thorough job. LPA reviewed the facility's housekeeping/maintenance schedule and housekeeping deep clean schedules and duties for Aug-Oct 2021 and revealed that they have staff assigned to clean the resident's rooms daily and deep clean on a weekly basis. Therefore, there was not enough supportive evidence to concur with the reported allegation. Based on LPA's observations, interviews and record reviews, investigation revealed: Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. · Regarding allegation: Facility staff failed to keep facility free from insects Interview with Administrator (A1) and Asst. Administrator (A2) revealed that they have not seen any bugs or heard of residents complain about bugs. A1 stated that RP has a plant in the room that attracts gnats. But housekeeping do maintenance sprays in the area once a week and pest control technicians come in monthly to service the facility. A2 stated that they do not have any insect problem and they take preventive measures. Some residents eat in their room that have attracted bugs and insects. Interviews with S1-3 indicated that they have not seen any bugs in the facility and heard of anyone complain of this issue. Interviews with eight (8) out of 12 residents (R2-7, R11-12), stated that they have not seen any bugs or gnats or heard anyone else with this issue. R3 stated that he used to see bugs about a year ago but not anymore. LPA Spencer toured the facility on 12/13/2021. LPA checked the common areas and five (5) resident rooms and observed that four (4) out of the five (5) resident rooms checked did not have bugs or gnats. During today's visit, LPA Pena inspected three (3) rooms and common areas and did not observe bugs or gnats in their rooms or bathrooms, including shower curtains. LPA reviewed the facility's pest control invoices and revealed that the pest control company serviced the facility in Aug, Sep and Oct. 2021. Based on LPA's observations, interviews and record reviews, investigation revealed: Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted and copy of the reports were provided to Asst. Administrator, Cynthia Flores.the state’s words, verbatim · CDSS document, Sep 14, 2022 · control 28-AS-20211027151500

Allegation investigated: Staff stole resident's money.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Cynthis Flores); as Administrator (A1: Lisa Pham) was unavailable at the time of this visit. LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff members have symptoms. The purpose of today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation. Initial 10-Day visit was conducted by LPA Nicol Wesley on 12/23/21. LPA/RA Ceniceros interviewed (between 8:30 a.m. - 9:15 a.m.) one (1) staff and one (1) former staff. Resident #1 was not interviewed as the resident moved out on 03/05/20; and, LPA Nicol Wesley conducted pre-investigation. LPA/RA reviewed (between 9:00 a.m. – 9:45 a.m.) pertinent documents: Admissions Agreement (dated 08/09/18), Emergency I.D. and Information (dated 08/09/18), Physician’s Report (dated 01/07/19), Unsubstantiated Pre-placement Appraisal (dated 08/09/18), Resident Appraisal (dated 11/22/19), Personal Rights (08/09/18),P & I Ledger/Trust Fund Account (dated 01/05/20 - 04/07/20), reimbursement Check #002926 to sister facility (Le Bleu Chateau) dated 04/16/20 for Resident #1's relocation; SSA Letter (dated 05/13/20) addressed to facility regarding Resident #1's stopped payments; current Facility Staff and Residents rosters. Regarding Allegation #1: this investigation revealed that Resident #1 moved out of the facility on 03/05/20. Administrator (A3: Adam Zenou) was the former administrator at the facility and did not handle Resident #1's P & I monies. The facility contracts with a Resident Fund Management Service company who rendered services for Resident #1's trust fund account. A review of Resident #1's P & I Ledger and payment history from the trust fund account was opened on 01/06/20 and closed on 04/07/20. A direct deposit entry was made on 03/03/20 by SSA Treasury funds in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00); and, an automatic withdrawal (for care cost) in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00) - showed a resident cash advance in the amount of One-hundred Thirty-seven Dollars and No Cents ($137.00) - leaving a zero ($0) balance. On 04/01/20, a direct deposit was made by SSI Treasury funds in the amount of Five-hundred Sixty Four Dollars and Thirty-seven Cents ($564.37); and, an automatic withdrawal (for care cost) in the amount of Four- hundred Twenty-seven Dollars and Thirty-seven Cents ($427.37) - leaving a balance of One-hundred and Thirty-seven Dollars and no Cents ($137.00). On 04/03/20, a direct deposit entry was made by SSA Treasury funds in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00); and, an automatic withdrawal (for care cost) in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00); and, a charge of One-hundred Thirty-seven Dollars and No Cents ($137.00) was charged on 04/07/20 to close account - showed a zero ($0) balance to Resident #1's account. Last direct deposit entry was made on 05/01/20 by SSA Treasury funds in the amount of Six-hundred Sixty-two Dollars and No Cents ($662.00) were rejected because there was no account for this direct deposit. On 05/28/20 IRS Treasury funds in the amount of Twelve-hundred Dollars and No Cents ($1,200.00) were also rejected because there was no account for this direct deposit. Interviews conducted corroborated that a follow-up letter addressed to the facility (dated 05/13/20) from Social Security Administration documented payments stopped for Resident #1 due to no correct address, effective 05/01/20. Facility staff issued reimbursement Check #002926 to sister facility (Le Bleu Chateau) dated 04/16/20 in the amount of One-thousand Eighty-nine Dollars and Thirty-seven Cents ($1,089.37) for Resident #1's relocation to their sister facility; therefore, Resident #1's P & I Ledger/Trust Fund Account showed a zero ($0) balance. Based on the evidence gathered and interview(s) conducted and records reviewed, although the allegationmay have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Staff stole resident's money is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to the Asst. Administrator (Cynthia Flores).the state’s words, verbatim · CDSS document, Sep 13, 2022 · control 28-AS-20211214111934

Allegation investigated: Resident was illegally evicted. Licensee violated the terms of the admission agreement regarding refunds. Staff did not provide an inventory of resident's personal items upon request.

***AMENDED REPORT***Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Cynthis Flores); as Administrator (A1: Lisa Pham) was unavailable at the time of this visit. LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff members have symptoms. The purpose of today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Nina Galarza on 01/14/22. LPA/RA Ceniceros interviewed (between 10:30 a.m. - 11:30 a.m.) three (3) staff members; however, Resident #1 was not interviewed as the resident moved out of the facility on 12/28/21; however, LPA Nina Galarza conducted the pre-investigation. LPA/RA Ceniceros reviewed (between 12:30 p.m. – 1:30 p.m.) pertinent documents: Admissions Agreement (dated 12/22/21), Emergency I.D. and Information (dated 12/22/21), Safeguard for Property Valuables (dated 12/22/21), Acknowledgement of Discharge (signed 12/28/21), and Unsubstantiated Inventory of Residents Personal Property (signed 01/03/22) for Resident #1; and Staff & Residents rosters. Regarding Allegation #1: this investigation revealed that Resident #1 is own responsible person. Resident #1 shows a daughter as a secondary contact person based upon the resident's Emergency I.D. & Information Face Sheet (dated 12/22/21). On 12/28/21, the only incident that occurred was that Resident #1 signed an "Acknowledgement of Discharge" vacating the facility and removed all personal belongings without providing a 30-Day advance notice of intent to move or vacate the premises. When hospital staff contacted the facility on 12/29/21 and spoke to Staff #1 (S1: Olga Morales, Med Tech - A.M.) to advise that Resident #1 was being discharged from the hospital, Staff #1 advised hospital staff that the resident no longer resided at the facility; as Resident #1 discharged from the facility on 12/28/21. A review of Resident #1's "Admission Agreement" (signed on 12/22/21) documented, "The facility will refund the pre-admission fee under the following circumstances: (1) if the applicant decides not to enter the facility (prior to the facility's completion of a pre-admission appraisal)"; of which, a "Pre-placement Appraisal" was completed on 12/22/21 and "Physician's Report" completed on 12/15/21. This one time Pre-admission Fee in the amount of Five-hundred Dollars ($500) covers: resident appraisal, room preparation, arrange and/or review physician's assessment, cost of admission forms and materials, staff time, inventory of personal belongings, employee training, dietary provisions, medication set up, and other admission-related expenses. This Five-hundred ($500) fee is collected - prior to admission and prior to the required facility assessment; of which, the latter two (2) had been completed on 12/15/21 and 12/22/21. Interviews conducted corroborated that Resident #1 signed an "Acknowledgement of Discharge" and vacated the facility and removed all personal belongings on 12/28/21 without providing a 30-Day advance notice of intent to move or vacate the premises. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of EVICTION/DISCHARGE: Resident was illegally evicted is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed that a review of Resident #1's "Admission Agreement" (signed on 12/22/21) documented: "The facility will refund the pre-admission fee under the following circumstances: (1) if the applicant decides not to enter the facility (prior to the facility's completion of a pre-admission appraisal)"; of which, a "Pre-placement Appraisal" was completed on 12/22/21. This one time pre-admission fee in the amount of Five-hundred Dollars ($500) covers: resident appraisal, room preparation, arrange and/or review physician's assessment (cost incurred by resident), cost of admission forms and materials, staff time, inventory of personal belongings, employee training, dietary provisions, medication set up, and other admission-related expenses. This fee is collected - prior to admission and prior to the required facility assessment; of which, the latter two (2) had been done on 12/15/21 and 12/22/21. LPA/RA Ceniceros re-interviewed reporting party/family member who indicated that facility should have reimbursed some monies from the $2,300 rent and $500 pre-admission fee during Resident #1's seven (7) day stay at the facility (from 12/22/21 thru 12/28/21. Interviews conducted corroborated that Resident #1 failed to give the facility a 30-Day Notice to Move as agreed upon per "Admission Agreement" (signed on 12/22/21); rather, Resident #1 signed an "Acknowledgement of Discharge" on 12/28/21 and vacated the facility and removed all personal belongings. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of ADMISSION AGREEMENT: Licensee violated the terms of the admission agreement regarding refunds is found to be UNSUBSTANTIATED. Regarding Allegation #3: this investigation revealed interviews conducted corroborated that Resident #1 had "removed all personal belongings from Room #3", signed and dated on 12/28/21. LPA/RA Ceniceros reviewed Resident #1's records which documented the resident's "Safeguard for Property Valuables" (dated 12/22/21) and "Acknowledgement of Discharge" (dated 12/28/21) were both signed by Resident #1. LPA/RA Ceniceros observed the "Inventory of Residents Personal Property" and "Certification of Receipt" signed and dated by Resident #1's relative on 01/03/22 and witnessed by Assistant Administrator (Cynthia Flores). Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Staff did not provide an inventory of resident's personal items upon request is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator (Cynthia Flores).the state’s words, verbatim · CDSS document, Sep 13, 2022 · control 28-AS-20220105161023

Allegation investigated: Staff failed to treat residents with dignity and respect Staff failed to meet resident’s diapering needs Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Nune Margaryan conducted a complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and Administrator Lisa Pham and explained the reason for the visit. The investigation consisted of the following: LPA Margaryan conducted interviews with Administrator, Assistant Administrator, Staff 1 to Staff 4 (S1 to S4) and Resident 1 to Resident 5 (R1 to R5). The following documents were requested: staff and residents roster, Staff schedule (with staff names) for the month of August, copies of relevant documents from R#1 file were provided. S1 and R1 were interviewed over the phone. S1 was off and R1 was out of the facility at the time of visit. Continue 9099C Unsubstantiated Regarding allegations: Staff failed to treat residents with dignity and respect and Staff handled resident in a rough manner. It was alleged that one resident (name unknown) was confused and kept getting up in his / her wheelchair. S1 grabbed his/her shoulders in a rough manner and made him /her sit in his chair and told him, “You have to do what I am asking you to do” and then took the resident away.,and S1 is disrespectful to R1 and other residents. and for R1 call to get assistance to change the diaper S1 told R1 in a rough manner “I said I would be back”. R1 not feels safe around S1. 5 out of 5 residents said that staff has never handled them in a rough manner and failed to treat residents with dignity. 4 of 5 residents said they have never witnessed staff handling other residents in a rough manner. They stated that staff nice and respectful. R1 stated that S1 treat him /her with dignity and respect. During interviews with Administrator , Assistant Administrator and staff, they advised that they have never handled residents in a rough manner and failed to treat residents with dignity and respect. Interviewed Administrator advised that he/she has never witnessed or received any complaints from residents that staff has handled them in a rough manner or failed to treat residents with dignity and respect. Never heard that R1 complains that R1 not feels safe around S1. S1 was interviewed over the phone and S1 denied that he/she failed to treat residents with dignity and respect and handled R1 or other resident in a rough manner. S1 stated he/she never grabbed any resident shoulders and made him/her to sit in the chair in a rough manner. S1 denied that he/she handled R1 in a rough manner during the assistance to change the diaper. S1 stated that R1 prefer to get an assistance for diaper change from woman staff. S1 never assist R1 for diaper change. R1 stated he/she prefer woman staff assistance and S1 never assist him / her for diaper change. Continue 9099C Regarding allegation: Staff failed to meet resident’s diapering needs. It was alleged that on 08/20/22 S1 didn’t assisted R1 for diaper change. R1 called S1 twice for help. All interviewed staff including S1 stated that they do not refuse to assist the residents with diapering needs. S1 mentioned that some woman residents prefer to get assistance for diaper change from woman staff. R1 is one of them. R1 always get assistance from women staff for diaper change as she prefer. S1 stated that on 8/20/22 like other days he /she didn't refuse to assist R1 but any time that he/she is going to change R1's diaper R1 requesting to get assistance from woman staff. It will take a few minutes until woman staff will come to substitute S1 but R1 always will get an assistance with diaper change. S1 never refuse to assist R1 or other residents. R1 stated that S1 is nice with him/ her and when R1 called for assistance and it's S1 shift , S1 will call woman staff to assist R1. Interviewed Administrator and Assistant Administrator stated that facility always make an arrangements to meet residents needs, also diapering needs. They stated that staff change diapers for incontinent residents every 2 hours and as needed. Interviewed residents stated that staff always available to assist them with their needs if they require assistance. Staff comes and check on their incontinent needs too often, but understands they have a job to do. Based on statements and interviews conducted with staff, residents there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 1, 2022 · control 28-AS-20220822142735

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Cynthia Flores (Assistant Administrator) and explained the purpose of the visit. The facility is licensed to serve age range 60 and over. 160 non-ambulatory, of which 5 may be bedridden in Rooms 24,25, 26, 27, 28. Hospice waiver for 30. During today's inspection, LPA observed the following: Facilities maintains in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Facility is not operating over capacity or beyond any conditions and limitation on the license. There are no pools and bodies of water on the premises. No ammunition or firearms on the premises. Facility maintains a comfortable temperature for residents. All outdoor and indoor passageways are free of obstruction. Hot water temperature measured between 105 degrees F and 120 degrees F throughout the facility. The presence of grab bars for each toilet, bathtub and shower used by residents was observed. Bathtub or shower have non-skid mats or strips. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bed spreads. Facilities have a signal system that operates from each resident’s living unit. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Smoke and Carbon Monoxide detectors are operable. The facility has sufficient and competent staff to provide the services needed to meet resident needs. A first aid kit has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, first aid manual available for staff use but inaccessible for residents. Staff assisting residents with ADLs have required training. Criminal Record Clearance for required persons is associated to the license. Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. LPA was allowed to enter the facility to conduct inspections. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications is given per the physician’s directions. Centrally stored medicines is kept in a safe and locked place. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided to Lisa Pham (Administrator).the state’s words, verbatim · CDSS document, Aug 29, 2022

Allegation investigated: Staff are not assisting residents with bathing. Facility is not assisting resident with obtaining health care services. Animals allowed in facility present health risks to residents in care.

Licensing Program Analyst (LPA) Nune Margaryan conducted a subsequent complaint visit to complete the investigation and deliver findings for the allegations listed above. LPA met with Assistant Administrator Cynthia Flores and explain the purpose for today’s visit. The initial visit was conducted by LPA Nune Margaryan on 12/28/21. During the initial visit LPA interviewed the Assistant Administrator, Administrator, Staff #1-4 (S1-S4 ), and Residents #1-10 (R1-R10). LPA collected a copies of the staff roster, resident roster, showering schedule and other relevant documents. Continue 9099C Unsubstantiated The investigation revealed the following: Staff are not assisting residents with bathing. It was alleged that Resident #1 is not showered or bathed and feels very dirty. Interviewed Administrator and staff denied the allegation. The facility provides shower assistance to residents twice a week and as needed. On the days that residents do not receive a shower they are sponge bathe by staff and if residents miss scheduled bathing times or staff is unable to bathe residents, residents are bathe during the next shift or the following day. Staff indicated that sometimes it took more than 2 hours to convince residents to take a shower or bathe. Staff stated that family members getting involved too if needed. The residents interviewed stated Staff showers them twice a week and as needed and they feel clean. LPA observed resident shower dates were documented and signed by residents. Staff stated that R1 never happy with staff who assisted R1 for any services. R1 always giving attitude to staff and called names. Administrator spoke about this with R1’s daughter and she apologize for her mom that R1 doing. Facility is not assisting resident with obtaining health care services. It was alleged that R1 would offer physical therapy/rehabilitation but R1 was left in the bed the whole time. During the investigation, LPA learned that R1 admitted to the facility on 08/09/2021 without an order for Home Health / Physical Therapy. R1 was self responsible including medical decisions. Administrator and staff indicated that they tried to assist R1 with obtaining health care services but R1 always rejected to get help from the facility staff to arrange health care services / physical therapy through other health care agencies (Home Health Care). Interviewed staff stated that facility staff always help residents to obtain health care services. Interviewed residents stated that staff very helpful and they always get assistance with health care services. Residents understand that it is a process and staff will do their best to enrolled or change the health insurance to get the necessary services. Administrator and interviewed staff indicated that R1 get assistance from the staff and didn’t left in the bed the whole time. LPA interviewed R1 in the conference room which was located on the 1st floor. LPA observed that R1 was in wheelchair and was able to ambulate by their self. Continue 9099C Animals allowed in facility present health risks to residents in care. It was alleged that there are cats that live on the premises which R1 is allergic to. The LPA interviewed Administrator, staff and residents who all stated that there were no cats or other animals on the premise. Administrator and staff indicated that there are cats outside of facility and sometimes residents feeding them even staff told them do not do it. They stated that residents didn’t bring them inside. They didn’t hear any complaints from residents or others that there are cats at the facility. Interviewed residents stated that there are cats outside of facility but they never coming inside. They stated that have not seen the cats come into the facility, in the common areas or their rooms. Facility not allow cats or any animals at the facility. At the time of visit LPA didn’t observed any cats or other animals at the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, a copy of the report and appeal rights were provided to Assistant Administrator Cynthia Floresthe state’s words, verbatim · CDSS document, Jun 18, 2022 · control 28-AS-20211220092042

Allegation investigated: Staff unlawfully evicted a resident while in care.

Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and Administrator Lisa Pham and explained the reason for the visit. The investigation consisted of the following: Interviews were conducted with R1 conservator, 5 staff and 3 residents. Resident #1's (R1's) file was reviewed, and facility was toured. The investigation revealed the following: Allegation: Staff unlawfully evicted a resident while in care. All 5 staff denied that resident was evicted from facility. 3/3 residents could not collaborate the allegations. R1 tested positive for Covid-19 on May 31 and facility staff instructed R1 to follow Covid prevention protocols by wearing a mask. S3 stated that R1 kept leaving her room without a mask and S3 told her to put on a mask and R1 slapped S3 on her thigh in response on 6/01/22 Continue on 9099C Unsubstantiated . On same day R1 slapped Administrator on face as she was attempting to assist resident with her face mask. S1 stated that R1 also slapped her on the face on 5/30/22 because staff did not provide cigarettes that she didn’t have yet. All three times police were called. Administrator stated that resident was not happy at facility and R1 called 911 and police arrived and told facility staff that resident had rights and could leave without anyone’s consent. She asked to get her stuff from her room and S1 went with her and when R1 and S1 arrived, R1 threw herself on the floor and stated that she was in a lot of pain and could not get up. R1 called 911 and told them she was in a lot of pain and She was then taken to hospital (Downey PIH). Administrator stated that R1 was not evicted but requires higher level of care and decided to make arrangements to have her admitted next door at Lakewood Park Healthcare. LPA spoke with R1 conservator and she agreed with facility assessment that resident required higher level of care and agreed to have her moved to Lakewood Park Healthcare by the end of today. Based on record review and interviews conducted the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 14, 2022 · control 28-AS-20220606155118

Allegation investigated: Facility is not communicating with resident's responsible party. Facility did not seek resident timely medical attention. Electrical wires unsafe in resident's room. Facility failed to safeguard resident's belongings. Resident touched inappropriately by another resident. Residents are not treated with dignity or respect.

Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the reason for the visit. Administrator, Lisa Pham was called and notified of the allegations. The investigation consisted of the following: Interviews were conducted with 4 staff and 3 residents. Resident #1's (R1's) file was reviewed and facility was toured. The investigation revealed the following: Allegation: Facility is not communicating with resident's responsible party. Staff interviewed were well informed on R1's needs and medical appointments. Staff indicated they are in regular contact with R1's family and keep them updated through phone calls and text messages. R1 was interviewed and could not confirm if the allegation was true. There was no evidence to prove this allegation occurred. This allegation is unsubstantiated. Continued on 9099C. Unsubstantiated Allegation: Facility did not seek resident timely medical attention. Allegedly R1 has missed several medical appointments due to facility staff. Staff interviewed included management and caregiver. Staff indicated the reason some medical appointments are missed is because R1 or R1's family wants them cancelled. The medical appointment calendar was reviewed. R1 went to appointments on 3/17/22, 4/25/22, and 6/7/22. Facility incident reports from January 2022 indicate medical appointments were rescheduled 4 times because R1 had family plans. R1 was interviewed and did not confirm any medical appointments were missed, but were rescheduled. R1 indicated he/she recently saw a doctor. There was no other evidence that medical appointments have been missed. This allegation is unsubstantiated. Allegation: Electrical wires unsafe in resident's room. Allegedly there are exposed wires in R1's room. R1's room was toured. There were no exposed electrical wires observed. R1's previous room was also toured. That room also did not have any exposed electrical wires. Based on the information obtained, the allegation is unsubstantiated. Allegation: Facility failed to safeguard resident's belongings. Allegedly R1's electric wheelchair was broken at the facility. Staff interviewed stated that the seat on R1's electric wheelchair was torn when R1 was out in the community. Staff indicated electric wheelchairs are not allowed inside the facility. The facility repaired the seat even though they feel it was not damaged at the facility. R1 indicated the electric wheelchair is working fine and indicated it was scratched out in the community. R1 said the electric wheelchair is only used out in the community and has a manual wheelchair inside the facility. Other residents reported seeing R1 in the electric wheelchair and didn't know if it was ever damaged. Based on the information obtained, the allegation is unsubstantiated. Allegation: Resident touched inappropriately by another resident. Allegedly R1 was touched and kissed by a male resident at the facility. Staff reported sometime last year R1 reported that a male friend walked into his/her room and attempted to kiss him/her. Staff spoke with the male resident and called the police. Incident report dated 7/25/21 documents what was reported by R1 and indicates Downey Police Department arrived to interview both parties. Families were notified of the incident. The male resident moved out a short time later. Other facility residents were interviewed. They did not have any information about the alleged incident. There is insufficient evidence to prove the alleged incident occurred. Therefore, the allegation is unsubstantiated. Continued on 9099C. Allegation: Residents are not treated with dignity or respect. Allegedly facility staff accused R1 of stealing from the store and made a scene in front of other residents. Staff confirmed there were some incidents with R1 brining in clothing from the stores nearby without bags, but never accused R1 of stealing. An incident report dated 11/2/21 documents that on 11/2/21, a man from a nearby store entered the facility and reported that R1 was seen putting items in his/her electric wheelchair and leaving the store without paying. The man indicated he would be calling the police. R1 was asked to provide receipts for the purchases, but R1 could not provide the receipts. Later that day police arrived to interview R1, but R1 was asleep. R1 was interviewed today and denied stealing anything. R1 did confirm that he/she was interviewed by someone about stolen items from a store. Residents interviewed reported never witnessing staff accusing R1 of anything. There were no other witnesses to the alleged incident. Based on the information obtained, the allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2022 · control 28-AS-20220608110027

Allegation investigated: Facility has not provided resident their requested copy of contract.

Licensing Program Analyst (LPA) Cynthia Chan conducted the complaint investigation for the allegation listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the purpose of the visit. Administrator, Lisa Pham, arrived shortly thereafter. The investigation consisted of the following: LPA obtained a copy of the staff and resident roster, food menu for the month, and reviewed medications for 9 residents. LPA also toured the facility, interviewed the Administrator, 6 Staff, and a total of 11 Residents. The investigation revealed the following: Regarding - Facility has not provided resident their requested copy of contract. It is alleged that Resident #1 has been requesting for a copy of the Admission Agreement but has not been provided with one. Administrator Pham stated a resident signs the Admission Agreement upon admission and a copy of the agreement is offered to them. She stated a copy is given to residents even though some may not want it. Substantiated LPA interviewed a total of 11 residents. 6 out of the 11 residents stated they did not receive a copy of the Admission Agreement when they moved in, or they were not asked if they wanted a copy, or that a copy was given when requested. According to Title 22 regulation 87507(e), The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with the Administrator. A copy of this report and appeal rights were provided. The Med Techs pass out medication starting as early as 6am (morning time), 12pm (afternoon), 4pm (evening), and 7pm (bedtime). The Med Techs will go to the residents' rooms or pass out the medications during the meal time in the dining room. For residents with PRN, they will need to request from the med tech. 10 out of 11 residents interviewed stated that they take medications daily and on time. LPA also reviewed medications for 9 Residents and compared the medications to the MAR log. It is determined the routine medications are being administered as prescribed. Regarding allegation - Facility toilets are clogged. The administrator stated that the toilets sometimes get clogged due to residents throwing in baby wipes, however, they will get it fix right away. The maintenance staff stated that the toilets get clogged at times, but he or the housekeepers, will get it unclogged the same day. 10 out of 11 stated either there are no issues with the toilet or the toilet gets clogged but the staff will get it unclogged once they are notified. LPA toured the facility and observed toilets working properly. Regarding allegation - Facility not providing adequate food service to resident. It is alleged that the food are served cold. During the visit today, LPA toured the dining room and kitchen area during lunch time. LPA observed the kitchen staff preparing the plates to serve the residents. The foods were kept in a steamer to keep the food hot. The plates being delivered to the residents in the rooms were wrapped. Staff interviewed did not hear of any residents complaining their foods are served cold. 10 Residents interviewed stated that the food are served hot or warm but not cold. Regarding allegation - Elevator floor numbers do not light up. During the tour of the facility, LPA tested the elevators buttons which were working properly. The staff stated there are no issues with the elevators recently. 10 out of 11 Residents interviewed stated that the elevator buttons light up when they press them. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with the Administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, May 17, 2022 · control 28-AS-20220509114229

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: May 24, 2022

87507 Admission Agreement (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification... This requirement is not met as evidenced by: Based on interviews, 6 out of 11 residents did not obtain a copy of the Admission Agreement upon signing the agreement or provided another copy when requested which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: The Administrator shall review regulation 87507 Admission Agreement and provide a copy of the Admission Agreement to all residents and representative. The Administrator shall submit a statement acknowledging this regulation by POC due date 5/24/22.

Allegation investigated: Facility is understaffed Staff failed to meet residents' needs Facility is in disrepair

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Assistant Administrator Cynthia Flores and explained the reason for the visit. The purpose of the visit is to investigate the above allegations. At today's visit Resident's 1-8 were interviewed from 9:30 AM to 11:30 A.M. LPA toured the facility and both elevators were operable and the facility was observed to be in good repair. In regards to Facility is understaffed based on interviews conducted and information gathered residents interviewed stated that there is sufficient staff and they do a good job and help with any needs they may have. Staff interviewed stated there are 4- AM staff, and 3-PM staff and the LIC 500 submitted at visit lists the same staff numbers. In addition the Administrator, Assistant Administrator and Resident Director are also available for AM and PM shifts. Based on interviews, observations, and records reviewed, it is determined that although the allegations 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 Unsubstantiated In regards to the allegation Staff failed to meet residents' needs, based on interviews conducted and information gathered residents interviewed stated that staff does a good job assisting with showers 2x a week. Staff interviewed stated that showers are given 2x a week and if resident refuses they will notate it. Facility submitted to LPA documents of a shower log with resident names and when resident is given shower it is checked off. Based on interviews, observations, and records reviewed, it is determined that although the allegations 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 In regards to the allegation facility is in disrepair, LPA toured facility on 12/23/2021 and today 4/5/2022 and both elevators were operable. Previous complaint report 12/09/2021 28-AS-20211209101633 addressed the allegation elevator is in disrepair. Deficiency issued 12/15/2021. Deficiency cleared 12/15/2021. Based on interviews with staff and residents there was no evidence revealed to support flooding having occurred in the facility. Based on interviews, observations, and records reviewed, it is determined that although the allegations 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 Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 5, 2022 · control 28-AS-20211214101414

Allegation investigated: Neglect and lack of supervision resulting in fracture.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegations.The purpose of the visit was discussed with Assistant Administrator Cynthia Flores. Administrator Lisa Pham was explained the purpose of the visit and interviewed telephonically. The investigation consisted of: Staff (S1-S7) and residents (R2 - R10) were interviewed. An interview was attempted with resident (R1). Family (F1) was interviewed. Resident (R1's) file was reviewed. The following documents were obtained: Identification and Emergency Information/Residents Face Sheet, Physician Reports, Appraisals, Individual Service Plan (ISP), Incident report dated 1/27/2022, Admission Agreement, resident roster, and LIC 500 Personnel Report were obtained. See LIC 9099C for report continuation. Unsubstantiated Allegation: "Neglect and lack of supervision resulting in fracture." Based on record review and interviews conducted the findings indicate that on January 27, 2022 at approximately 9:00 AM, 98 year-old resident (R1) had an un-witnessed fall in the room. It is unknown how long the resident was on the floor. Staff (S4) found the resident on the floor next to the night stand. A body check was conducted, and at first the resident did not report major pain or discomfort. Caregiver checked on the resident approximately 2 hours later, and the resident then reported knee pain and discomfort. The resident was then transported to Norwalk Community Hospital approximately 4 hours later. Resident (R1) sustained a knee fracture and is presently recuperating at a Skilled Nursing Facility. Staff stated R1 is overall independent, uses a walker, and requires minimal assistance. However, per Individual Service Plan (ISP) resident (R1) is at fall risk. Staff reported caregivers perform room checks every 2 hours. All staff interviewed denied negligence or lack of supervision in regards to R1's fall incident. Three (3) out of nine (9) residents stated staff do not perform regular room checks and there is not enough staff supervision. Family has not had any concerns with resident (R1's) care. There is insufficient evidence to support the allegation. Based on record review and interviews conducted the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Assistant Administrator Cynthia Flores. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 4, 2022 · control 28-AS-20220128150605

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza conducted a Case Management -Deficiencies visit due to observation made while investigating complaint control #: 28-AS-20220128150605 visit. The purpose of the visit was explained to Assistant Administrator Cynthia Flores. On 1/26/2022, resident (R1) sustained a fall that resulted in a knee fracture. The facility failed to report the incident within reporting requirements time frame. In addition, during the course of the complaint investigation LPA requested a copy of the incident report. The incident report obtained had incorrect date and was missing time of incident. NOTE: The facility has not faxed any incident reports since November 16, 2021. Ms. Flores presented LPA a copy of a FAX Transmission Verification Report with time stamp 1/31/2022. However, the fax # the incident reports were sent to was incorrect. Ms. Flores acknowledged the fax # on the Transmission report is incorrect. LPA provided Ms. Flores the correct fax number. Per Title 22, Division 6, Chapter 8, Article 04. Operating Requirements 87211(a)(1) "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...." Deficiency is cited. See LIC 809D. Exit interview conducted with Assistant Administrator Cynthia Flores. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Feb 4, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 15, 2022

Reporting Requirements. 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. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on observation during record review for complaint #: 28-AS-20220128150605; resident (R1) sustained a fall on 1/26/22 that resulted in a knee fracture. The incident report was not faxed to Community Care Licensing (CCL). The last incident report received at CCL was 11/16/21. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 4, 2022

Plan of correction: Licensee shall submit a written statement that states how this deficiency was corrected. FAX all incident reports that were faxed the wrong number. In addition, submit proof of staff training and attach the training materials.

Allegation investigated: Elevator is in disrepair.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation of elevator is in disrepair. LPA met with Cynthia Flores, the Assistant Adminstrator, and explained the reason for the visit. During the visit, LPA obtained the Staff and Resident rosters, elevator repair statement. LPA also toured the facility and interviewed the Administrator, Assistant Administrator, 3 Staff, and 10 Residents. In regards to allegation, elevator is in disrepair. It is determined that a second elevator has been non-operable for several months. The Assistant Administrator stated there are 2 elevators and the second elevator is currently not working. The part has been ordered and waiting for it to arrive. Administrator and Assistant Administrator both indicated they have been following up regularly with the elevator company to achieve repair date. LPA observed 2 elevators side by side on the first floor and a sign indicating "Elevator is out of service" on the elevator to the left. (Continue on LIC9099C) Substantiated Interviews with Staff indicated that one of the elevators has been down on and off for a few months. The maintenance staff stated that parts have been ordered in July 2021, but the elevator company has not been able to secure all parts for the repair due to the Coronavirus pandemic; thus delaying the repair. Seven (7) out of ten (10) residents interviewed indicated one of the elevators has not been working and sometimes they have to wait a long time, which causes an inconvenience in reaching their destination. Per Administrator, the resident may utilize the stairs or the ramp in addition to the elevator. Although there is one working elevator for use, there is evidence of the other elevator in disrepair. Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Dec 15, 2021 · control 28-AS-20211209101633

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 31, 2021

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. Based on observation, interviews, and record review, one of the elevators is currently not working which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 15, 2021

Plan of correction: The licensee shall ensure that elevators are in good repair at all times and will follow up with the elevator service company to obtain time frame for repair. The licensee shall provide LPA a statement with estimated elevator repair date or receipt of completed repair by POC due date 12/31/21. The correction will not be cleared until elevator is repaired.

Allegation investigated: Residents bathroom is not properly cleaned Staff did not change resident's bed linens in a timely manner Resident was put on a 72 hour hold without cause

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent complaint visit for the allegations listed above. LPA Spencer met with assistant administrator Cynthia Flores and explained the purpose of today's visit. The investigation consisted of the following: During the initial visit on 10/13/21, LPA conducted a tour of the physical plant including a sample of resident rooms and observed meal service. LPA Spencer interviewed the assistant administrator, staff #1-4 (S1-S4), and residents #1-11 (R1-R11). During the course of the investigation, LPA interviewed staff #5-6 (S5-S6). LPA collected a copy of the staff roster, resident roster, menu, cleaning schedule and housekeeping duties. For R1, LPA collected incident reports, police report, physician's report, and admissions agreement. ***See LIC9099C for continuation of this narrative.*** Unsubstantiated The investigation revealed the following: Regarding the allegation, "residents bathroom is not properly cleaned" it was alleged that resident bathrooms are not thoroughly cleaned due to housekeeping not mopping floors and cleaning the toilets. Interviews with residents revealed: nine (9) out of eleven (11) residents stated that bathrooms are thoroughly cleaned including cleaning sinks, toilets, showers, and mopping. Two (2) out of eleven (11) residents stated that bathrooms are not thoroughly cleaned. Interviews with staff reveal that housekeeping staff cleans the toilets, take out the trash, mop, sweep, wipe sinks, and clean the tubs. Housekeeping staff stated that if residents request something to be cleaned again the staff will do it. They stated that resident rooms and bathrooms are checked daily and cleaned at least once a week. The assistant administrator stated that she hasn't heard of any residents complaining about this issue. A review of the housekeeping duties list reveal that housekeepers are required to mop floors and clean fixtures in the restroom. During the tour of the physical plant on 10/13/21, LPA observed that all resident's bathrooms appeared clean including floors, toilets, showers, and sinks. Regarding the allegation, "Staff did not change resident's bed linens in a timely manner," interviews with residents revealed: ten (10) out of eleven (11) residents interviewed stated bed linens are changed in a timely manner and that housekeeping changes the sheets several times per week and as needed when they are soiled. One (1) out of eleven (11) residents interviewed stated that bedding Is changed too late in the day. Housekeeping staff interviewed stated that bedding is changed at least 1-2 a week and whenever it is soiled. Bedding is checked daily during housekeeping rounds and are changed more frequently if needed. Staff denied the allegation. During the tour of the physical plant on 10/13/21, LPA observed that all resident's bedding was clean. Regarding the allegation, “Resident was put on a 72 hour hold without cause” it was alleged that a resident was forced to leave the facility on a psychiatric hold for no legitimate reason. Interviews with the S5-S6 who were involved in the incident indicated that the resident was a danger to himself and others which is why a 72-hour hold was placed. S5 stated that R1 was had been drinking and was being aggressive with staff and residents and refusing to take psychiatric medications. S5 called the psychiatrist who approved the 72-hour hold and the Downey Police Department were called to assist. LPA obtained the police incident report dated 9/14/21 which stated that R1 was upset with roommate and was “non-compliant and being aggressive towards staff.” R2 stated that, during the incident, R1 was arguing and yelling at staff and refusing to take his medications. There were no other resident witnesses involved and all other residents interviewed did not have details about the incident. Other staff interviewed did not have knowledge of the incident. A review of incident report dated 9/15/21 states that R1 was being non-compliant and aggressive towards staff and facility staff called psychiatrist who ordered the 72-hour hold. The psychiatrist was unable to reached by LPA for interview. ***Continued on LIC9099C*** Based on interviews, observations, and records reviewed, it is determined that although the allegations 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 the assistant administrator Cynthia Flores and copy of report was provided. The investigation revealed the following: Regarding the allegation, “staff did not safeguard resident’s personal belongings,” interviews with residents revealed: eight (8) out of eleven (11) residents stated that they have items missing or stolen from their room. Three (3) out of eleven (11) residents stated that they have not had anything missing or heard of any other residents with this issue. Residents with missing items stated that when they informed the staff, nothing was done about it. Staff interviewed stated that they have not heard of any residents complain about stolen or missing items. The assistant administrator stated that resident inventory is taken upon admission unless they opt out. She stated all resident rooms are locked unless they leave the door open. A review of the admissions agreement theft and loss policy states that items reported lost or stolen will be replaced or reimbursed. A review of R1’s inventory list reveals that the items allegedly missing were not listed on the form. Staff notes indicated that facility staff packed up resident’s items upon move out but R1 refused to sign the move-out inventory list. During the physical plant tour on 10/13/21, LPA observed that R1’s antennae was found under the bed. The other missing items were not found during the tour. Regarding the allegation, “staff did not provide adequate food service,” it was alleged that hot meals are served to residents cold/luke warm and service takes too long. Interviews with residents revealed: nine (9) out of eleven (11) residents interviewed stated that meals are served luke warm or cold and the wait times for meals are at least one (1) hour. Two (2) out of eleven (11) residents interviewed stated that the food is served at an adequate temperature and wait times are not too long. Dietary staff interviewed stated that meals are served to residents right away and those who get foods delivered to their room have their food saran-wrapped to keep it warm. The assistant administrator stated that she has had no complaints regarding food service. A review of the menu reveals that residents are served with a variety of foods. LPA Spencer observed meal service during the visit on 10/13/21. LPA observed that residents with tray service had their food plated at 11:37 a.m. and the last resident received their plate at 12:27 p.m. (50 minute wait time). During lunch time in the dining room, LPA observed that residents were seated in the dining room at 12 p.m. and the first table was served their food at 12:45 p.m. (45 minute wait) while the last table was served their food at 1:13 p.m. (73 minute wait time). ***See LIC9099C for continuation of this narrative*** Regarding the allegation, “staff withheld residents mail” it was alleged that staff do not provide residents with their mail in a timely manner. All residents interviewed stated that they must inquire about their mail and are not informed when mail comes for them. The assistant administrator stated that mail is sorted by herself or the front desk staff and they put in a file folder. She stated that residents usually call or come down to pick up their mail. LPA observed the file folder located in the front office which had mail still placed in it. In R1’s file, a copy of a UPS letter marked “return to sender” was observed. Assistant administrator stated that residents are not delivered the mail to their rooms but will call to inquire about their mail or come down to get it. Other staff interviewed were not aware of this issue. Based on observation, interviews, and records reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22, deficiencies cited on the attached 9099D. An exit interview was conducted with the assistant administrator and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 8, 2021 · control 28-AS-20211006120622

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(a) · Plan of correction due date: Dec 13, 2021

87218(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety code section 1569.153. This requirement was not met as evidenced by... Based on interviews, the licensee did not ensure that 8 out of 11 residents interviewed had valuables that were adequately safeguarded. This poses a potential risk to the personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2021

Plan of correction: The administrator stated that they will ensure that the inventory list is accurate, and once a month, the staff will send notice to residents to update their inventory. Administrator stated that she will send a copy of the letter to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(5) · Plan of correction due date: Dec 13, 2021

87468.2(a)(5) Residents in RCFE's shall have personal rights which include...to be served food of the quality and quantity necessary to meet their nutritional needs. This requirement was not met as evidenced by... Based on observation and interview, the licensee did not ensure that residents were served the quality temperature of food in a timely manner. This poses a potential risk to the health of persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2021

Plan of correction: The administrator stated they will divide the serving staff so that some are doing tray delivery and others will do in the dining room. The administrator will create a new policy that states that residents will have no longer than a 30 minute wait for meals.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Dec 13, 2021

87468.1(a)(15) (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that all residents were informed about and received their mail in a timely manner. This poses a potential risk to the personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2021

Plan of correction: The administrator stated that she will create a self-certified letter that mail will be sorted and residents will be delivered the mail to their room at least once a day on the same day that their mail arrives.

Allegation investigated: Staff refused to provide resident's medical records. Resident was provided the wrong medication. Staff refused to provide necessary medical treatment.

Licensing Program Analysts (LPA) Nicole Spencer and Joseph Hanna conducted a subsequent complaint investigation for the allegations listed above. LPA Spencer met with assistant administrator Cynthia Flores and explained the purpose of today's visit. The investigation consisted of the following: During the initial visit on 8/3/21, LPA Spencer conducted interviews with the assistant administrator, staff #1 (S1), and resident #1 (R1). LPA Spencer obtained a copy of the staff roster, resident roster, resident face sheet, physician's report, and physician's orders. During today's visit on 12/6/21, LPA 's interviewed resident #2-11 (R2-R11), staff #2 (S2), R1's physician (P1), and R1's home health agency worker (HH1). Regarding the allegation, "staff refused to provide resident's medical record," it was alleged that the facility refused to provide a resident with their medical records upon request. ***See LIC9099C for continuation of the narrative*** Unsubstantiated Interviews with residents revealed: One (1) out of eleven (11) residents stated that they requested medical records from the facility but have not received it. This resident stated that they wanted medical records regarding an injury that took place in the facility. The assistant administrator stated that there are no records of such injury and that the facility can only provide the records that they have on file. Ten (10) out of eleven (11) residents interviewed stated that they have not had any trouble receiving their medical records upon request and have not heard of any other residents having this issue. All others interviewed stated that they were not aware of this issue. Regarding the allegation, "Resident was provided the wrong medication," all staff interviewed denied the allegation and stated that residents are only given medications prescribed by the resident's physician. One (1) out of eleven (11) residents interviewed stated that they were given the wrong medication, "Seroquel." A review of the resident's current physician's orders shows that medication "Seroquel" is not listed. A review of the resident's physician report reveals other medications are provided but "Seroquel" is not listed. Ten (10) out of eleven (11) residents interviewed stated that they have never been provided the wrong medication and have not heard of other residents with this issue. R1's physician stated that he has no information regarding this. Regarding the allegation, "Staff refused to provide necessary medical treatment," it was alleged that staff refused to treat a resident's toe blister. All staff interviewed denied the allegation and stated that all resident's receive necessary medical treatment. Ten (10) out of eleven (11) residents stated that the facility provides necessary medical treatment, while one (1) out of eleven (11) residents interviewed stated that they did not receive proper treatment for their toe. Staff interviewed stated that home health was treating the resident's toe but the resident was not complying with home health's recommended treatment plan. The home health agency worker (HH1) interviewed stated that the resident had a callous wound that was treated by home health and it was healed prior to discontinuing the treatment. HH1 noted that the resident was non-compliant with treatment. Based on interviews and records reviewed, it is determined that although the allegations 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 allegation is Unsubstantiated. An exit interview was conducted with the assistant administrator Cynthia Flores and copy of report was provided.the state’s words, verbatim · CDSS document, Dec 6, 2021 · control 28-AS-20210729115524

Allegation investigated: Wrongful Eviction

Licensing Program Analyst (LPA) Angelica Rea initiated the complaint investigation regarding the allegation listed above. LPA met with Cynthia Flores, the Assistant Administrator, and explained the purpose of the visit. Regarding the allegation that resident #1 has been wrongfully evicted, the investigation consisted of interview with Administrator, Staff #1, Staff #2, and review of Resident #1's file. LPA obtained the following from resident #1's file: copy of admission agreement dated 7/26/19, resident appraisal dated 12/26/20, physician's report and copies of special incident report(s). Per interviews with Administrator, and Staff #1- Staff #2, resident #1 attacked resident #2 on 11/6/21. Resident #1 was placed on a 51/50 hold and was admitted to the hospital for evaluation. Per Reporting Party, resident #1 was evaluated on 11/8/21, and the incident was determined to be "situational", and resident #1 needs to follow up with his psychiatrist for possible medication adjustments. According to hospital, resident #1 is able to be discharged and can return to the facility. However per reporting party, the facility is refusing to allow resident #1 to return. Substantiated Administrator, and Staff #1- Staff #2 stated that resident #1 has not been issued an eviction notice by the facility. Administrator and Staff #1 - Staff #2 stated that they are not allowing resident #1 to return to the facility based on the incident that occurred on 11/6/21. Administrator, and Staff #1- Staff #2, resident #1's primary care doctor, and psych doctor stated that resident #1 needs a higher level of care and can not return to the facility. Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22, Division 6. An exit interview was conducted with Administrator Lisa Pham. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 15, 2021 · control 28-AS-20211112101724

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224 · Plan of correction due date: Nov 16, 2021

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. This requirement is not being met as evidenced by: Administrator, and staff #1-staff #2 stated that resident #1 has not been issued an eviction notice. Administrator, and Staff #1- Staff #2 stated that the facility is not allowing resident #1 to return to the facility, even though he is ready to be discharged from the hospital.the state’s words, verbatim · CDSS document, Nov 15, 2021

Plan of correction: Administrator shall abide by Title 22 regulation, 87224 Eviction Procedures. Administrator stated that she will request a 3 day eviction for resident #1.

Allegation investigated: Black mold at the facility. Resident was injured while in care.

***Please note: this LIC9099 report supercedes LIC9099 report dated 7/2/21. Additional interviews were conducted but the findings remain the same.*** Licensing Program Analyst (LPA) Spencer conducted a visit to supercede the report dated 7/2/21 for the allegations listed above. LPA Spencer was met by assistant administrator Cynthia Flores and explained the purpose of today's visit. The investigation consisted of the following: On 4/21/21, LPA Spencer conducted the initial investigation, took a tour of the physical plant, and conducted interviews with assistant administrator Cynthia Flores, staff #1 (S1), and residents #2-5 (R2-R5). On 7/2/21, LPA Spencer interviewed the facility's elevator service repair company (W1), staff #2 (S2), resident #1 (R1) and residents #6-11 (R6-R11). R4-R5 declined to be interviewed so a total of 9 resident interviews were conducted. On today's visit, LPA interviewed staff #3-staff #4 (S3-S4) and a follow-up interview with the assistant administrator. ***See LIC9099C for continuation of this narrative. Unsubstantiated LPA Spencer collected a copy of the staff roster, resident roster, elevator service invoices from 12/2019-6/2020 and R1's needs and services plan. Per assistant administrator, there were no hospital records or incident reports regarding R1. The investigation revealed the following: Black mold at the facility: It was alleged that there was black mold throughout the facility that lead to residents hospitalizations/deaths. During LPA Spencer's tour of the physical plant on 4/21/21 and 7/2/21, LPA did not observe any signs of black mold in the kitchen, dining rooms, common areas, bathrooms, or resident rooms. In interviews, the assistant administrator denied the allegation of black mold and hospitalizations/deaths due to black mold. Three (3) out of four (4) staff interviewed denied that the facility has been treated for black mold and have not observed any black mold at the facility. One (1) out of four (4) staff stated that they have observed black mold in a couple of resident bathrooms but that it was immediately treated with bleach. Staff interviewed had no knowledge of any resident hospitalization/death due to black mold. Eight (8) out of nine (9) residents interviewed stated that they have never noticed black mold or heard of any resident hospitalizations/deaths due to black mold. Resident was injured while in care: It was alleged that a resident was injured by a fallen elevator ceiling that was damaged by an earthquake that occurred in 2019. During LPA Spencer's observation of the two facility elevators on 4/21/21 and 7/2/21, LPA did not observe any signs of damage to the elevators. During interviews, all staff denied the allegation that a resident was injured by the elevators. Staff stated that regular maintenance is conducted on elevators on a monthly basis. A review of elevator service invoices from 12/2019-6/2020 show that standard maintenance was completed on the elevators monthly. In interview with the elevator service repair company, W1 stated that only regular maintenance was completed and the system doesn't show that any ceiling damage was documented. 8 out of 9 residents interviewed stated that they had no knowledge of a resident being injured by the elevators and do not recall an earthquake causing damage to the elevators. Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. An exit interview was conducted with assistant administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 13, 2021 · control 28-AS-20210416111501

Allegation investigated: Facility staff did not submit paperwork needed for resident's prescribed wheelchair Resident sustained a stage four pressure injury while in care

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer met with assistant administrators Cynthia Flores and Elizabeth Martinez and explained the purpose of today's visit. The investigation consisted of the following: On 3/18/21, LPA Spencer conducted the initial visit and a 24-hour health and safety check was completed. During the course of the investigation, LPA interviewed assistant administrator Elizabeth Martinez, resident #1 (R1), staff #1 (S1), wheelchair vendor (W1), case worker (W2). LPA Spencer obtained a copy of the staff roster, resident roster, census of residents sent out to skilled nursing, and medical records for R1. For 3 specified residents, LPA obtained face sheet, physician's report, medication log, and physician's orders. ***See LIC9099C for continuation of this narrative. Unsubstantiated The investigation revealed the following: Facility staff did not submit paperwork needed for resident's prescribed wheelchair In interviews, R1, W1, and W2 stated that they sent multiple requests to S1 to send the paperwork needed to order a wheelchair and cushion for R1. S1 confirmed that an electric wheelchair and cushion was requested by R1, but that the vendor took a long time to come to the facility to do the face-to-face evaluation, which is required prior to ordering. After the evaluation was completed in March, S1 stated that the vendor requested a physician's signature on the completed evaluation form. Per S1, the facility sent the paperwork to R1's physician in April. S1 stated that there was a delay because the vendor said they never received the paperwork and the facility had to contact the physician to re-send it. W1 stated that process takes from 4-6 weeks from start to finish but they could not move forward without physician's signature on the evaluation form. On 3/31/21, R1 was sent out to a skilled nurse facility for almost two months. S1 stated that the physician signed and submitted the paperwork, but the vendor would not deliver the wheelchair/cushion to facility while R1 was out. S1 followed up with the vendor when R1 returned and confirmed that they could deliver the items within 7 business days. In follow-up interview, R1 stated the problem was resolved and that the wheelchair and cushion arrived about 2 weeks ago, and was observed by LPA during the subsequent visit on 8/3/21. Resident sustained a stage four pressure injury while in care Staff interviewed stated that residents with pressure injuries are treated by a home health agency or are sent out to a skilled nursing facility. Assistant administrator stated that R1 had a stage three pressure injury when R1 was sent out in March. A review of R1's physician's report and medical records shows that R1 has a history of skin breakdown and is being monitored by home health. R1 stated that due to a previous skin flap surgery, any subsequent pressure injuries in the same area are automatically staged at a stage 3 or 4. According to R1's medical records, R1 was evaluated for a stage 3 pressure injury and has a wound care plan in place. Staff and R1 stated that R1 did not want to be treated by home health at the time, so R1 was sent out to skilled nursing. Medical records revealed that R1 was admitted to the skilled nursing facility on 3/31/21 and was discharged on 5/9/21. R1 stated that the pressure injury was minor and had healed within two weeks, but had to stay longer in the skilled nursing due to another medical issue. Based on interviews, observations and records reviewed, the findings indicate that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with the assistant administrator and copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 3, 2021 · control 28-AS-20210317094246

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nicole Spencer conducted an unannounced annual inspection visit focusing on the Infection Control Domain. LPA Spencer met with assistant administrator Cynthia Flores and administrator Lisa Pham and explained the purpose of today's visit. This three-story residential care facility for the elderly (RCFE) is licensed at a capacity of 160. LPA conducted a physical plant tour and inspected the entrance screening area, dining room, kitchen, ten (10) resident rooms/bathrooms, two (2) isolation/quarantine rooms, medication room, and PPE supply closet. The following was observed: A universal screening area consisted of thermometer, screening log, and hand sanitizer was present. COVID-19 signage was placed in the entrance lobby and several areas of the facility. There was a sufficient supply of 2-day perishable and 7-day non-perishable foods. Sharps and chemicals were stored in kitchen and inaccessible to residents. Facility maintained a 30-day supply of PPE. Ten (10) resident bedrooms were observed and had all required furniture including bed, dresser, chair, lamp, night stand and covered trash can. Hot water temperature was measured and was between the required 105-120 degrees Fahrenheit. Centrally stored and locked medications were reviewed. Facility maintained 30-day supply of meds. Smoke detectors/carbon monoxide detectors were tested on each floor and were functional. All fire extinguishers fully charged and recently serviced in March 2021. Five (5) resident files were reviewed and physician/dentist contact information was missing for three (3) out of five (5) residents. Five (5) staff files were reviewed and all files contained health screening, criminal record clearances, and required trainings. There were no deficiencies were cited at this time. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 23, 2021

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.