Morningstar of Pasadena

Allegation investigated: Staff are not able to adequately care for resident due to resident needing higher level of care. Resident assaulted other residents in care.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the above allegation.The purpose of the visit was discussed with Executive Director Kevin Taliaferro. The investigation consisted of the following: A tour of the facility was conducted. Staff (S1- S6) and residents (R2- R7) were interviewed. Resident (R1) is presently hospitalized and not interviewed. Resident (R1's) file documents [Identification and Emergency Information/Face Sheet, Preplacement Appraisal, Resident Appraisals, Physician's Report, Care Plan, Medication Administration Records [MARs Sep. 2023- Oct. 2023], Admission Agreement, incident reports, and resident and staff rosters. ***Narrative continues next page.*** Unsubstantiated Allegation: Staff are not able to adequately care for resident due to resident needing higher level of care. It is alleged that Reflections Memory Care unit staff are are not able to meet the care needs of resident (R1) due to the resident's aggressive behaviors that are a danger to self and others. On 10/12/2023, facility staff called Pasadena Police Department because resident (R1) was exhibiting aggressive verbal and physical behaviors that escalated into the resident attempting to hit another resident and physically injuring staff (S2) by biting staff on the shoulder, kicking, and spitting on staff (S2's) face. A total of four (4) Reflections unit staff responded and assisted during the incident. Staff attempted to redirect resident (R1). However, the resident was combative and displayed aggressive behaviors that posed a danger to others. Based on staff interviews, staff stated that they are able to provide Activities of Daily Living (ADL) care to all residents residing in the Reflections unit, including resident (R1). Nonetheless, resident (R1) has behaviors that do not seem to be controlled with medications or redirection techniques. Per record review, resident (R1) has a diagnosis of Alzheimer's Disease/Dementia with behavioral changes. Reflections Care Plan (9/29/2023) has notation of aggressive behaviors and changes in medications. A total of 6 residents were interviewed, of which only one resident was able to recall the incident. The resident stated that they did not feel resident (R1) requires a higher level of care, because aggression is not atypical to Dementia diagnosis. Incident dated 10/12/2023 resulted in a WIC 5150-72 hour hold for being a danger to others. Prior, to the most recent incident resident (R1) still met admission criteria and behaviors were being managed through program services. As of today, resident (R1) remains hospitalized, and will be re-evaluated prior to discharge in order to determine if resident (R1) still meets admission criteria. There is insufficient evidence to corroborate the allegation. Allegation: Resident assaulted other residents in care. It is alleged that on 10/12/2023, resident (R1) who resides in the Memory Care "Reflections" unit tried to physically assault resident (R2). In addition, to last week's incident resident (R1) had a previous incident (9/20/2023) in which they became verbally and physically aggressive with resident (R3). Based on interviews conducted, resident (R1) has had several altercations with staff and residents as a result of the resident's medical diagnosis, which includes behavior disturbances exhibited through physical and verbal aggression. Staff stated that the incident dated 10/12/2023 did not result in a physical assault towards resident (R2), but confirmed that during incident (9/20/2023) R1 grabbed R3 and verbally threatened the resident. Staff intervened and separated the residents. No injuries were reported. One (1) out six (6) residents interviewed confirmed the allegation. The residents interviewed did not report safety concerns or knowledge of alleged resident altercations resulting in assaults. Per staff interviews, facility staff immediately respond to incidents. Per record review and observation, there is sufficient staffing in the facility and Reflections unit. The aforementioned incidents, were not a result of lack of supervision or insufficient staffing. Resident (R1's) behaviors are consistent with their medical diagnosis. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Kevin Taliaferro. .A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20231016185047

Allegation investigated: Staff did not prevent resident from assaulting another resident in care. Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the above allegations. LPA arrived unannounced and met with Rhonda Guzman, the Wellness Director. The reason for the visit was explained. LPA obtained copies of the staff roster, resident roster, and staff training logs. LPA also toured the memory care unit and reviewed file for Resident #1. Interviews were held with Staff, Residents, and a family member. Allegation - Staff did not prevent resident from assaulting another resident in care. It is alleged that staff saw resident (R1) walk over to another resident (R2) and punched him/her on the back, but staff did not prevent it from happening. The incident occurred in the memory care unit. Unsubstantiated LPA interviewed the administrator and 7 Staff. Staff stated they will intervene right away if they see a resident assault or try to assault another resident. They have training on dementia care and will monitor residents in memory care unit closely. They will redirect a resident as much as possible versus using any kind of restraint. For incident involving R1 and R2, staff who witnessed the incident stated that both staff tried redirecting R1 as they saw resident yelling and hitting R2. They later held R1’s hands gently to prevent resident from hitting R2 again. Staff stated R1 moved in several weeks ago and have been monitoring resident more often due to some challenging behaviors. LPA interviewed 4 residents and a family member. They stated staff are attentive and caring. 4 out of 5 individuals indicated staff supervise residents and will quickly intervene if a situation arise to protect the health and safety of residents. Allegation - Staff handled resident in a rough manner. It is alleged that 2 staff each held Resident #1’s forearm and lower part of the bicep for control while walking resident to the room. Per the administrator, they will normally redirect to calm down the resident. However, if the resident is aggressive/violent and endangering other residents, they will hold down the forearm or hands of the resident but still going along with their movement. They do not use force as they are holding their arms/hands. Staff, who dealt with the incident involving Resident #1 (R1), stated they held the arms of R1 as they attempt to calm resident down while escorting to the room but did not use force. There were no reports of any marks or bruises to the resident, as noted by the local police officer and staff. Staff interviewed indicated they have not seen other staff handling residents in a rough manner. Staff are careful with residents because they know how fragile their skins are and do not want to cause any tears or bruises. LPA interviewed 4 residents and a family member. Residents stated that staff do not handle them or others in a rough manner. The family member interviewed have not seen staff being rough with residents and only had positive feedback. 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, Sep 25, 2023 · control 28-AS-20230920112244

Allegation investigated: Staff not providing resident(s) with services that are paid for. Staff not providing resident(s) with admissions agreement. Staff not responding to resident(s) call button.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 09/02/23 regarding the above allegations. Intial 10-day visit was conducted on 8/31/2023 and needs further was required. LPA Ramirez was met by Administrator Taliaferro and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 3 interviews (S1 – S3), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Care Reports for the month of August 2023, Admissions Agreement, other pertinent documents related to this investigation and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Staff not providing resident(s) with services that are paid for. It is alleged residents are not receiving the services they are paying for. Three (3) out of the three (3) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. At 1:22 pm, LPA Ramirez reviewed and obtained copies of Resident#1 (R1) care report for the month of August 2023. LPA Ramirez reviewed R1’s Admission Agreement and payment schedule. R1 was admitted into in the facility on 11/21/22. LPA Ramirez could not find any discrepancies during review of these documents. Review of R1’s care report for August of 2023, revealed staff documented completed tasks and services that R1 pays for based on R1’s level of care. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Staff not providing resident(s) with admissions agreement. It is alleged staff are not providing resident(s) with admissions agreement. Three (3) out of the three (3) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez reviewed R1’s admission agreement. R1 was admitted into the facility on 11/21/22. LPA Ramirez obtained a copy blank facility Admissions Agreement, Schedule B -Optional Fees, and Point Assessment of Resident. 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. Staff not responding to resident(s) call button. It is alleged that staff are not responding to resident(s) call button. While touring facility on 8/31/23, at 10:36 am LPA Ramirez pressed Resident #4 (R4) bathroom call/assistance button. At 10:39 am, staff arrived to R4’s accommodation to assist R4. At 10:50 am, LPA Ramirez received permission from Resident#5 (R5) to press R5’s call pendant that was secured around R5’s neck. At 10:53 am, staff arrived near hallway on the 4th floor, where R5 and LPA Ramirez were waiting. 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 discrepancies were cited during today’s visit. Exit interview was conducted with Administrator Taliaferro and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 2, 2023 · control 28-AS-20230825143327

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent required 1- year annual on 09/02/2023. LPA was met by Administrator Taliaferro and explained the purpose of the visit. LPA Ramirez conducted staff and resident file review, staff and resident interviews during the visit. Emergency Drills: Last emergency drill was conducted on Staff Personnel Files: Six (6) staff files were reviewed, and nine (9) staff were interviewed. LPA Ramirez did not find any discrepancies in personnel files. Resident Files: Ten (10) resident files were reviewed, and nine (9) residents were interviewed. LPA Ramirez did not find any discrepancies in resident files. Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of facility Infection Control Plan and current liability insurance with an expiration date of 9/29/23. No deficiencies are being cited today. Exit interview was conducted Administrator Taliaferro and a copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Sep 2, 2023

Allegation investigated: Facility is not providing reasonable accommodations to resident in care. Facility is in disrepair.

**This is a corrected version of 9099-C dated 8/4/23.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/03/23 regarding the above allegations. LPA Ramirez was met by Administrator Kevin Taliaferro and explained the purpose of the visit. Case management Visit- Deficiencies was created on 8/4/23 stemming from this complaint investigation. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 2 interviews(S1 – S2), Resident #1 interview (R1 ), Witness #1-2 interviews (W1 – W2), Copies of Resident #1 (R1): Preplacement Appraisal Information dated 9/26/2019, Identification and Emergency Information form, Admission Agreement, Special Incident Reports (SIR) for R1, and physical plant tour. See 9099-C Substantiated The investigation revealed the following. Regarding Allegation(s): Facility is not providing reasonable accommodations to resident in care. - It is alleged that facility staff failed to provide reasonable accommodation to resident in care. R1 was admitted into the facility on 9/29/2019. Per Physician’s Report, R1 may leave the facility unassisted. Per W1, R1 is cognitive and has never required memory care assistance or accommodations. R1 was temporarily relocated to room# 212 on July 25th, 2023, due to plumbing and other general contracting issues in R1’s original accommodation (room#115). Room# 212 is in the facility Memory Care Unit. Access to the Memory Care Unit is only accessible through key code for both entry and exit. R1 was temporarily accommodated in memory care unit that did not meet R1s individual service needs. Per 87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. Based on interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Facility is in disrepair- It is alleged the facility is in disrepair. On or around July 18th, 2023, room# 115 was experiencing flooding and A/C issues. Water overflowed from kitchen sink on to kitchen counters and carpet area. Maintenance immediately began to soak up water that flooded R1’s carpet. On July 21st, 2023, plumbers came to troubleshoot cause of plumbing issues. According to Administrator Kevin, additional plumbing work and troubleshooting was required and the facility had an appointment for the plumbers to return on July 27, 2023 at 9am. On July 27, 2023, a second water intrusion occurred and water again began to flow up from the kitchen sink. Per R1, “ me and my caregiver had to get out of the room quick because it began to flood more than the last time.” Per 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 interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited. Exit interview was conducted with Kevin Taliaferro and a copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 28-AS-20230803145006

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(14) · Plan of correction due date: Aug 5, 2023

87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. This requirement is not met as evidence by: Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Licensee will certify by 8/5/23, plan to meet with R1's family and develop a plan on how R1's needs can be met while R1 is temporarily accommodated in room #212. Plan will include how the facility plans to protect R1 from memory care residents wandering into R1's room. Licensee will send minutes of meeting by 8/11/23 to LPA Ramirez via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 11, 2023

87303 Maintanance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: R1 had flooding in room coming from kitchen sink which caused plumbing issues and flooding.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Licensee will provide LPA Ramirez will timeline of repairs by 8/11/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 08/31/2023 at 8:25 am. LPA was met by Administrator Taliaferro and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents and is allowed to care for three-hundred ten (310) non-ambulatory residents of which twenty-five (25) may be bedridden residents. The facility currently has an approved hospice waiver for thirty (30) residents. LPA Ramirez requested copies and obtained of Personnel Report (LIC 500) and Resident Roster (LIC 9020). LPA OBSERVATIONS: Tour began at 8:31 am and was led by Administrator Taliaferro. The facility is low-rise 4 story building located near a residential area and several retail centers. Front Lobby: Was clean and well maintained. No hazards were observed. LPA Ramirez observed PPE supply station upon entry to the facility. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. Walk in refrigerator thermostat was observed to read 37 degrees F. LPA Ramirez observed staff preparing lunch at 10:15 am. LPA Ramirez observed staff wearing gloves while handling food. Kitchen appliances were observed to be clean and in working order. LPA Ramirez observed fully charged fire extinguishers in this area. Dining Room: Dining room was observed to be clean and contained plenty of seating. LPA Ramirez observed three (3) servers taking residents orders and bringing out their meal. Linen/Laundry/Supply Room: Contained plenty linens, towels, and hygiene products. SEE 809-C for continuation. Resident Rooms: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez selected eight (8) resident rooms at random to inspect. Bathrooms: LPA Ramirez tested water temperature in eight (8) resident bathroom sinks. Water temperatures were within 105- 120 degrees F. Bathrooms were observed to be clean and have required non-slip mats and grab bars in shower and near toilet. Centrally Stored Medications: LPA Ramirez observed several medications carts to be locked during visit. LPA Ramirez observed med techs dispensing medications during visit. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors LPA Ramirez observed posted Emergency Disaster Plan. Due to time constraints, LPA Ramirez will return to complete file reviews, conduct staff and resident interviews. No deficiencies are being cited today. Exit interview was conducted Administrator Taliaferro and a copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Aug 31, 2023

Allegation investigated: Facility is not providing reasonable accommodations to resident in care. Facility is in disrepair.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/03/23 regarding the above allegations. LPA Ramirez was met by Administrator Kevin Taliaferro and explained the purpose of the visit. Case management Visit- Deficiencies was created on 8/4/23 stemming from this complaint investigation. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 2 interviews(S1 – S2), Resident #1 interview (R1 ), Witness #1-2 interviews (W1 – W2), Copies of Resident #1 (R1): Preplacement Appraisal Information dated 9/26/2019, Identification and Emergency Information form, Admission Agreement, Special Incident Reports (SIR) for R1, and physical plant tour. See 9099-C Substantiated The investigation revealed the following. Regarding Allegation(s): Facility is not providing reasonable accommodations to resident in care. - It is alleged that facility staff failed to provide reasonable accommodation to resident in care. R1 was admitted into the facility on 9/29/2019. Per Physician’s Report, R1 may leave the facility unassisted. Per W1, R1 is cognitive and has never required memory care assistance or accommodations. R1 was temporarily relocated to room# 212 on July 25th, 2023, due to plumbing and other general contracting issues in R1’s original accommodation (room#115). Room# 212 is in the facility Memory Care Unit. Access to the Memory Care Unit is only accessible through key code for both entry and exit. R1 was temporarily accommodated in memory care unit that did not meet R1s individual service needs. Per 87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- (14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. Based on interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Facility is in disrepair- It is alleged the facility is in disrepair. On or around July 18th, 2023, room# 115 was experiencing flooding and A/C issues. Water overflowed from kitchen sink on to kitchen counters and carpet area. Maintenance immediately began to soak up water that flooded R1’s carpet. On July 21st, 2023, plumbers came to troubleshoot cause of plumbing issues. According to Administrator Kevin, additional plumbing work and troubleshooting was required and the facility had an appointment for the plumbers to return on July 27, 2023 at 9am. On July 27, 2023, a second water intrusion occurred and water again began to flow up from the kitchen sink. Per R1, “ me and my caregiver had to get out of the room quick because it began to flood more than the last time.” Per 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 interviews, observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited. Exit interview was conducted with Kevin Taliaferro and a copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 4, 2023 · control 28-AS-20230803145006

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(14) · Plan of correction due date: Aug 5, 2023

87468.2(14) Additional Personal Rights of Residents in Privately Operated Facilities- To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. This requirement is not met as evidence by: Facility placed R1 in memory care unit eventhough R1 does not require memory care assistance or have a MCI diagnosis.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Licensee will certify by 8/5/23, plan to meet with R1's family and develop a plan on how R1's needs can be met while R1 is temporarily accommodated in room #212. Plan will include how the facility plans to protect R1 from memory care residents wandering into R1's room. Licensee will send minutes of meeting by 8/11/23 to LPA Ramirez via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 11, 2023

87303 Maintanance 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.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Licensee will provide LPA Ramirez will timeline of repairs by 8/11/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 8/04/23 at 10am, stemming from initial complaint investigation on 8/04/23. LPA Ramirez requested and obtained copies of Resident roster, Resident# 1’s (R1) Special Incident Report (SIR). Case Management-Deficiencies findings: · On 7/21/23 R1’s accommodation (Room #115) was flooded and R1 had to be relocated to another accommodation. Facility staff failed to provide written incident report within seven (7) days of occurrence which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. R1 had to be relocated into another accommodation on 7/25/23 due to the severity of the plumbing and A/C issues. · On 8/1/23 LPA Ramirez received two (2) death reports for Resident #2 (R2) and Resident #3 (R3). Rr passed away on 7/11/23 and R3 passed away on 7/17/23. Facility failed to provide written incident report within seven (7) days of occurrence when death of any resident. Deficiency is being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A)(D) · Plan of correction due date: Aug 11, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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. 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.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Licensee will re-train staff on 87211 Reporting Requirements. Licensee will provide staff attendance list and training material that was used for training by 8/11/23. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidence by: Facility staff did not provide written reports within seven days of such occurences.

Allegation investigated: Staff are not following proper COVID-19 mitigation guidance.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/23/23 regarding the above allegation. Pasadena Department of Public Health joined the visit. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Resident Roster, COVID-19 Pandemic Protocol, Staff #1-3 interviews (S1 – S3), Resident #1- interviews (R6), Witness #1 (W1), Witness #2 (W2) and physical plant tour. SEE 9099-C for continuation... Substantiated The investigation revealed the following. Regarding Allegation: Staff are not following proper COVID-19 mitigation guidance- It is alleged facility staff is not taking appropriate measures to isolate symptomatic residents and staff. LPA Ramirez did not observe signage at entrance of community that limits visitors to essential personnel only as stated in facility mitigation plan. LPA Ramirez and Pasadena Department of Public Health observed facility dining room to be fully open. Per facility mitigation plan, Responding to an Outbreak: Quarantine when greater than 10% of the Resident population becomes ill, or as directed to do so by local and/or state health departments. Close the dining room, bistro, activities, and any other group activities to prevent transmission of illness. The quarantine can be lifted after 48 hours of no new reported illness, or as directed by local or state health departments. LPA Ramirez observed several signs throughout the facility advertising in person social events that were taking place on 6-23-23 at various times and locations throughout the facility. LPA Ramirez observed six (6) kitchen staff not wearing masks while working in kitchen area and while serving residents in dining area. At 10: 15 am, LPA Ramirez observed S2 inside lobby entrance, not wearing a face mask, welcoming two outside vendors into the facility. Pasadena Department of Public Health had to remind S2 to wear a mask due to ongoing outbreak status. During tour, LPA Ramirez observed S1 exiting R5’s room which had signage indicating “STOP DROPLET PRECAUTIOUS”. S1 was observed not wearing gloves and was still wearing mask after exiting R5’s room. LPA Ramirez did not observe S1 was hands or sanitize hands immediately after exiting R5’s room. LPA Ramirez observed four (4) COVID-19 positive resident carts that were stationed outside the residents’ rooms to not have required alcohol-based hand sanitizer, per facility mitigation plan. Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview was conducted with Kevin Taliaferro and a copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Jun 23, 2023 · control 28-AS-20230620091221

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(c)(1)(F) · Plan of correction due date: Jun 24, 2023

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) All staff and volunteers shall perform hand hygiene. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidence by: Licesee did not adhere to mitigation plan in regards to responding to outbreak of COVID-19.the state’s words, verbatim · CDSS document, Jun 23, 2023

Plan of correction: Licensee will provide in house training to re-train staff on following facility mitigation plan. Proof of staff attendance is required to clear POC by due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Deficiencies visit on 06/23/23 at 8:30 am stemming from initial complaint visit on 06/23/23. The purpose of this visit was explained to Staff #1 (S1). LPA Ramirez requested and received copies of Personnel roster, Staff roster and COVID-19 Pandemic Protocol. Case Management Findings: LPA Ramirez discovered that from 6-3-23 through 6-17-23, twenty-two (22) residents tested positive for COVID-19. From 6-4-23 through 6-17-23, four (4) facility staff tested positive for COVID-19. From 6-17-23 through 6-23-23, thirteen (13) additional residents tested positive for COVID-19. This licensing agency did not receive any written reports within seven (7) days of occurrence in reference to this recent epidemic outbreak, which began on 6-3-23. Per Title 22 regulations, (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. 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. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. Based on records review, deficiencies are being cited. A copy of this report, 809-D and Appeals Rights were provided to Kevin Taliaferro.the state’s words, verbatim · CDSS document, Jun 23, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(2) · Plan of correction due date: Jun 24, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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. 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. (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidence by: Licensee failed to notify this licensing agency that between 6-3-23 through 6-17-23, twenty-two (22) residents tested positive for COVID-19. From 6-4-23 through 6-17-23, four (4) facility staff tested positive for COVID-19. From 6-17-23 through 6-23-23, thirteen (13) additional residents tested positive for COVID-19. This licensing agency did not receive any written reports within seven (7) days of occurrence in reference to this recent epidemic outbreak, which began on 6-3-23.the state’s words, verbatim · CDSS document, Jun 23, 2023

Plan of correction: Licensee will shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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. 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. Licensee will provide in house-training to staff on Reporting Requirements in regards to Title 22 regulations. Proof of training material and staff attendance is required to clear POC.

Allegation investigated: Residents sustained injury while in care. Residents are left in soiled diapers for extended period of time. Staff does not provide proper meal assistance to resident in care. Resident was allowed to leave the facility unsupervised. Residents do not receive proper medication assistance. Facility is unkempt. Facility is malodorous. Resident pendant calls are not answered in a timely manner.

This is a corrected verison of previous complaint report dated 05/09/2023. Verbiage was corrected on LIC 9099-C. Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit to deliver findings, stemming from subsequent complaint visit dated 05/05/23 and initial complaint visit conducted by LPA Wesley on 12/22/21. LPA was met by Executive Director Kevin Taliaferro and explained the purpose of the visit. Allegations: 1) Residents sustained injury while in care. It is alleged Resident #6 (R6) sustained an injury on or around 12/17/21 while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA reviewed R6’s physician’s report, SIRs dated on or around 12/2021 through 01/2022. LPA was unable to find any reported documentation that R6 sustained any injury on or around 12/17/21. Per staff interviewed, if staff sees any injuries or changes in condition, they report it to the Wellness Director or MedTech on duty. SEE 9099-C Unsubstantiated 2) Staff does not provide proper meal assistance to resident in care. It is alleged staff does not provide residents meal assistance while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA observed several dining room staff assisting residents with meal trays. LPA observed a facility staff member bringing a resident their lunch into their room. LPA observed the staff member place the meal on a rolling tray, towards the resident. 3) Resident was allowed to leave the facility unsupervised. It is alleged R7 was allowed to leave the facility unsupervised. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. R7 file was reviewed, and LPA could not locate any physician orders or other pertinent documentation, stating R7 could not leave the facility unattended. 4) Residents do not receive proper medication assistance. It is alleged staff do not properly give residents medication assistance while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. Staff interviewed stated “We hand them the medication in little clear cups and give them water. We can’t force them to swallow them. I have seen some pills on the floor in some rooms, and we tell the administration. I tell the MedTech.” 5) Facility is unkempt. It is alleged staff does not clean residents’ rooms. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room 107, 332, and 458. LPA observed rooms to contain the required furnishings and linens. LPA did not observe and deficiencies and health and safety concerns in toured rooms. 6) Facility is malodorous. It is alleged the residents’ rooms have strong smell due to unclean rooms. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room various resident rooms at random and shared living areas. LPA did not smell strong odors of concern. 7) Residents are left in soiled diapers for an extended period of time. It is alleged staff leaves residents soiled in their diapers for an extended period of time. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA was able to review incontinence logs for R3, R4, and R5. LPA was able to verify staff logged incontinence care for R3, R4, and R5, every 2 hours on various days for the month of April 2023. Incontinence logs for November and December for 2021 were not available. SEE 9099-C 8)Resident pendant calls are not answered in a timely manner. It is alleged staff do not answer pendant calls for assistance in a timely manner. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room 458 during visit and asked R8 to push “pendant button” at 10:40 am. At 10:46 am, staff came in to check with resident and staff used R8 room phone to ask the front to “clear” call to room 458. 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 via email.the state’s words, verbatim · CDSS document, Jun 16, 2023 · control 28-AS-20211217140336

Allegation investigated: Staff finanically abused resident in care.

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegation. On today's visit, LPA met with Administrator, Kevin Taliaferro who assisted with today's visit. Regarding the allegation that : Staff Financially abused resident in care. The investigation consisted of interview(s) with Administrator, Staff #1, resident #1, resident #1's Power of Attorney (POA), and review of resident #1's file. Administrator stated that he was aware of an incident regarding resident #1. Administrator stated that resident #1's nephew is his Power of Attorney (POA). Administrator stated that resident #1's POA called to speak to Administrator regarding some unusual activity on resident #1's account. Administrator stated that resident #1's POA came to the facility and took resident #1 to the Police Department. Administrator stated that the details of the investigation were not disclosed to the facility, as it was a private matter. Staff #1 was not aware of specific details of the allegation. Resident #1 stated that he thinks he lost his ATM card, or it was stolen. He said that a few hundred dollars was taken from his account. Resident #1 stated that the facility does not handle his finances. Unsubstantiated Resident #1 stated that he believes it may have been a private caregiver that was assisting him for a couple of months. However, he doesn't want to press charges since he doesn't have any proof. Resident #1's POA stated that the facility does not handle resident #1's finances, and stated that resident #1 had a temporary private caregiver when the ATM charges occurred. Resident #1's POA stated that he has informed the agency that the private caregiver worked for regarding this incident. 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.the state’s words, verbatim · CDSS document, Jun 12, 2023 · control 28-AS-20230602102954

Allegation investigated: Facility staff did not provide resident basic care and assistance at the facility. Facility staff did not provide resident medication on a timely basis. Facility staff did not provide resident water to be taken with their medication.

****This amended report supersedes report dated 5/18/2023 and was amended to removed identifying information only, nothing else was changed and findings remain the same**** LPA Alberto Lopez made unannounced subsequent visit to investigate the above allegations: The investigation consisted of Interviews with seven (7) staff (S1-S7), thirteen residents (R1-R13), reviewing and obtaining copies of staff roster, residents’ roster, R1 Physicians report, MAR, and other relevant medical information for R1 Allegation: Facility staff did not provide resident basic care and assistance at the facility. It is alleged that the facility failed to provide resident with basic care and assistance at the facility. Seven of seven staff interviewed denied the allegations. LPA interviewed 13 residents and 12 of 13 residents could not collaborate the allegations. Several residents stated they were very happy with the assistance they get, and several stated they require little to no assistance. (continued on 9099C) Unsubstantiated Allegation: Facility staff did not provide resident medication on a timely basis. It is alleged that the resident’s medication due between 4:00 -4:30AM was not provided to resident on 05/06/2023 between that time frame. According to the MAR review it was dispensed on time. 7 of 7 staff denied the allegations. 12/13 residents could not collaborate the allegations. One resident stated that staff can be late maybe 5 to 10 minutes but overall, most residents stated they get their medication on time. S3 stated S3 went to resident’s room at around 4:30AM to dispense R1 medication and did not see resident in R1 room, S3 Stated S3 heard water running in the bathroom and assumed R1 was in bathroom so S3 left to attend another resident. S3 stated S3 returned shortly after to R1 room but R1 was not there at the time. Shortly after that S3 got a call from S4 stating fire department was at facility. R1 stated R1 went down to the lobby to find out about R1 medications around 4:30AM and found no one at the front desk and the phone was vibrating and vibrating. R1 then called 911. At approximately 5:25 – 5:30AM incident was resolved, and resident received her medication within time frame allowed due to one hour window allowed. According to statement from R1 and S3, they missed each other. Allegation: Facility staff did not provide resident water to be taken with their medication. It is alleged that staff did not provide resident with water with her medication. 6/7 staff denied the allegations and stated that there is water in many areas of the facility. S3 stated that S3 did not have any water when she went from resident’s room down to lobby on 5/06/2023 and that S3 was asked by R1 for water and S3 stated S3 promptly went to the kitchen and grabbed an apple juice and provided it to client to take her medications. S4 collaborated this. 12 of 13 residents stated facility always has water available for them to take their medications. Although the allegations 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 allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 18, 2023 · control 28-AS-20230508091734

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(3) · Plan of correction due date: May 29, 2023

87415 (3) Night Supervision (3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes. This requirement was not met as evidenced by: Emergency Fire personnel arrived at facility and could not access the facility because there was no one at the front desk to let them in and had to contact resident via phone to allow them entry. No staff was available at that time to allow the Fire Department Entry which poses a health and safety hazard for residents in care.the state’s words, verbatim · CDSS document, May 18, 2023

Plan of correction: POC Administrator stated he will hire additional staff and train all staff to respond to emergency personnel during the overnight shift.

Allegation investigated: Residents sustained injury while in care. Residents are left in soiled diapers for extended period of time. Staff does not provide proper meal assistance to resident in care. Resident was allowed to leave the facility unsupervised. Residents do not receive proper medication assistance. Facility is unkempt. Facility is malodorous. Resident pendant calls are not answered in a timely manner.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint visit to deliver findings, stemming from subsequent complaint visit dated 05/05/23 and initial complaint visit conducted by LPA Wesley on 12/22/21. LPA was met by Executive Director Kevin Taliaferro and explained the purpose of the visit. Allegations: 1) Residents sustained injury while in care. It is alleged Resident #6 (R6) sustained an injury on or around 12/17/21 while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA reviewed R6’s physician’s report, SIRs dated on or around 12/2021 through 01/2022. LPA was unable to find any reported documentation that R6 sustained any injury on or around 12/17/21. Per staff interviewed, if staff sees any injuries or changes in condition, they report it to the Wellness Director or MedTech on duty. SEE 9099-C Unsubstantiated 2)Staff does not provide proper meal assistance to resident in care. It is alleged staff does not provide residents meal assistance while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA observed several dining room staff assisting residents with meal trays. LPA observed a facility staff member bringing a resident their lunch into their room. LPA observed the staff member place the meal on a rolling tray, towards the resident. 3) Resident was allowed to leave the facility unsupervised. It is alleged R7 was allowed to leave the facility unsupervised. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. R7 file was reviewed, and LPA could not locate any physician orders or other pertinent documentation, stating R7 could not leave the facility unattended. 4) Residents do not receive proper medication assistance. It is alleged staff do not properly give residents medication assistance while in care. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. Staff interviewed stated “We hand them the medication in little clear cups and give them water. We can’t force them to swallow them. I have seen some pills on the floor in some rooms, and we tell the administration. I tell the MedTech.” 5) Facility is unkempt. It is alleged staff does not clean residents’ rooms. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room 107, 332, and 458. LPA observed rooms to contain the required furnishings and linens. LPA did not observe and deficiencies and health and safety concerns in toured rooms. 6) Facility is malodorous. It is alleged the residents’ rooms have strong smell due to unclean rooms. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room various resident rooms at random and shared living areas. LPA did not smell strong odors of concern. SEE 9099-C 8)Resident pendant calls are not answered in a timely manner. It is alleged staff do not answer pendant calls for assistance in a timely manner. Five (5) out of six (6) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. LPA toured room 458 during visit and asked R8 to push “pendant button” at 10:40 am. At 10:46 am, staff came in to check with resident and staff used R8 room phone to ask the front to “clear” call to room 458. 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 via email.the state’s words, verbatim · CDSS document, May 9, 2023 · control 28-AS-20211217140336

Type of visit: Collateral

Licensing Program Analyst (LPA) Galarza conducted an unannounced Collateral visit to the facility. The purpose of today's visit is to interview resident (R1) regarding an unrelated complaint at another facility. Executive Director Kevin Taliaferro was explained the purpose of the visit. No deficiencies were observed during the visit. Exit interview was conducted with Business Office Manager Graciela Aquino. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 28, 2023

Allegation investigated: Staff is not properly sanitizing the facility.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Kevin Taliaferro and explained the reason for the visit. The purpose of the visit is to investigate the above allegation. At today's visit interviews were conducted with Resident's R 6 and R 7 at 10:00 AM. The initial visit was conducted on 12/08/2022 and included the following: Interview was conducted with Administrator Kevin Taliaferro at 1:15 PM. Interview was conducted with Staff S1 at 1:35 PM. Tour of the facility was conducted which included dining room area and kitchen. Interviews were conducted with Resident's R1-R5 from 1:35 PM to 2:15 PM. In regards to the allegation Staff is not properly sanitizing the facility, based on interviews conducted and information gathered facility submitted e-mail documentation dated 11/30/2022 to Department of Public Health City of Pasadena and to Licensing informing that there are GI symptoms. Special Incident Report (SIR) was also submitted to Licensing. Unsubstantiated Interviews with staff revealed that Department of Public Health had issued GI protocols that they have been adhering to. LPA observed documentation of GI protocols issued by department of Public Health. Staff stated 4 or 5 residents were affected and they were put in their room for 3 days, given a BRAT diet and dining room and chairs were disinfected after each meal. Tour of the dining room and kitchen was conducted on 12/08/2022 and LPA observed staff sanitizing the tables and in kitchen area utensils were sanitized. LPA observed the dining room and kitchen to be clean and sanitized. Interviews with residents who all stated staff are doing a good job and are professional and they clean and sanitize often. Stated when there has been an accident in the dining room staff have cleaned up promptly and have taken good care of the resident. 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 Administrator. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 28-AS-20221206115153

Allegation investigated: Facility staff did not properly supervise residents resulting in multiple falls. Facility staff did not properly store food causing residents to food poisoning. Facility staff not assisting residents in a timely manner. Facility staff not providing resident with meals in a timely manner.

Licensing Program Analyst (LPA) Bennette Pena made an unannounced visit to the facility to investigate the above allegations. LPA was greeted by the Executive Director, Kevin Taliaferro and discussed the purpose of today’s visit. The investigation consisted of the following: LPA obtained copies of the staff/resident roster, regular weekly menus/daily specials, kitchen staff weekly schedule and assignments. LPA obtained information regarding training on food handling techniques and procedures which includes set up, meal service, food preparation, universal precautions, hygiene and dietary standards with all food service staff. LPA reviewed Resident's #1-#2 (R1-R2) files (Admission Agreement, Emergency I.D. and Information, Physician's Report, Appraisal/Needs and Services Plan, Physician's orders). LPA interviewed (8) staff including the Administrator, (11) residents, toured the facility including kitchen for the ability to prepare and serve food. LPA observed that the kitchen staff were wearing masks and gloves during set up and procedure. LPA also observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Regarding allegation: Facility staff did not properly supervise residents resulting in multiple falls. During this investigation, LPA obtained relevant documentation and interviewed staff and residents. (6) out of (8) staff interviews revealed there is sufficient staff supervision. S1 stated that the staff ratio is (1) caregiver per 5-7 residents per shift. S1 indicated that facility provides balance exercises daily for free. And facility has (3) physical therapists available for residents to help with improving their health and balance. Staff interviews revealed that staff conduct rounds every (2) two hours and as needed throughout the entire day. Interviewed staff indicated rounds are documented on a chart with the resident’s names, dates, times and staff conducting the rounds. (6) out of (8) staff indicated that they have not seen any falls or slips during their shift. (7) out of (8) staff indicated that they have not received any complaints nor concerns in regards to residents falling from any resident representatives/family members, staff nor residents. LPA reviewed R1-2 documents which indicated that they both use a walker but none of them have a history or high risk of falls. Interviewed residents indicated staff conduct rounds often throughout the entire day. (2) residents interviewed stated that they had slipped because of their health condition and not because of the staff. And they did not suffer any injuries due to the fall or slip. (9) out of (11) interviewed residents indicated that they have not fallen nor they have witnessed anyone falling. Documentation reviewed and interviews conducted with staff and residents do not corroborate this 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. Regarding allegation: Facility staff did not properly store food causing residents to food poisoning. At 10:05am, LPA toured the kitchen and observed the staff wearing hair nets, masks and gloves. The food was being prepared by the chef and (1) kitchen worker cleaning the surrounding areas. There were servers delivering the food trays (wrapped) to the rooms. The food served to the residents came straight from the kitchen for those residents eating in their own room. LPA obtained a copy of the daily specials/weekly menu which included different items from each food group. Staff interviewed stated that the kitchen workers were trained in food handling, preparation, universal precautions, hygiene and dietary standards. (7) out of (8) staff indicated that they have not seen anything unusual or improper in the food preparation in the kitchen. S1 denied the allegation and stated that per their investigation, the GI outbreak they had was not from the food in the facility but elsewhere. S6 stated that the food poisoning incident started outside the facility and it started going around but not because of the food in the kitchen. S3 stated that he conducts stand up training daily to the kitchen staff regarding food handling, how to serve the food, precautionary measures and proper food storage and labeling. All (11) residents interviewed stated that they are happy with the food and had no complaints. When they order food to be delivered in their room, they get it in about 1/2 hour or so and still hot or warm when delivered. (11) Residents indicated that hot drinks, like coffee, tea are readily available in the dining area. And all (11) residents never had any illnesses due to the food they ate in the facility. Staff interviews, resident interviews and LPA's observations do not corroborate this 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. Regarding allegation: Facility staff not assisting residents in a timely manner. Interviews revealed that there are enough staff to assist with the residents needs. S1 stated that there is (1) caregiver assigned to 5-7 residents per shift. (5) out of (8) staff interviewed stated that there are (3) caregivers assisting residents per shift. S2, S4-S6 stated that the facility provided them with a company phone and when the resident press their call button/pendant, they get the call right away on their phones. They never had an issue with the phone reception so assistance is given within 5-10 mins. If one (1) of them is giving showers or unable to go to the resident when they call, the other caregivers on shift will step in to assist with the residents' calls. Staff stated that they do regular rounds, every 2 hours or less if needed. They have a system where they document the activities/incidents on a chart which was done electronically on the phone. (6) staff stated that residents want assistance at once when they call for help. They indicated that some residents think that they are waiting for a long time, but in reality, it was only 5-10 mins wait. Residents interviewed stated that they do not wait long to get assistance. Some of the residents who use the call button/pendant stated that wait times vary, between 5-30 mins which were acceptable to them. Some residents also use the phone to call the front desk for assistance. Interviews conducted with residents and staff do not corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff not providing resident with meals in a timely manner. (7) out of (8) staff interviewed denied the allegation and stated that there are enough staff working in the kitchen per shift. S1 stated that some residents complain because the facility charges extra if food is delivered to their room, except when the resident is sick. (7) out of (8) staff stated that food is delivered to the residents room in a timely manner. If food order is received by 11am, the food is delivered to them between 30-40 mins and delivered hot and fresh. S3 and S7 stated that there are (4) servers per shift, (1) server assigned per floor. They also stated that they have food runners in addition to servers and they stand as back up for servers. S7 indicated that the residents who order food to be delivered in the room are prepared first, before all the residents arrive in the dining room. The hot food is stored in hot boxes and delivered to the rooms right away. S3 and S7 stated that hot beverages are readily available in the dining area and residents can make/get their own. (11) residents interviewed stated that they do not have any issues with the meals being delivered in a timely manner. Most of them go to the dining room to eat and socialize. Some have their lunch delivered in the room and they get it on time. Based on statements and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report were provided to the Executive Director, Kevin Taliaferro.the state’s words, verbatim · CDSS document, Jan 11, 2023 · control 28-AS-20230106092955

Type of visit: Office

An informal meeting was held virtually via Microsoft Teams on 11/03/2022 @ 1:00pm PST. The attendees present during the meeting were: Licensing Program Analyst (LPA) Bennette Pena, Licensing Program Manager (LPM) David Sicairos, Pasadena Public Health Dept. (PPHD) Community Services Representative III Misael Rivera, PPHD Public Nurse Casey Cortes, PPHD Community Service Representative Adrian Griffin, MorningStar of Pasadena Executive Director Kevin Taliaferro and Wellness Director Rhonda Guzman. The purpose of this informal meeting was to discuss the facility's compliance with PPHD. CCLD's goal is to ensure that all 3 entities (CCLD, PPHD and Facility) are in agreement with Covid reporting requirements and guidelines. DISCUSSION: Facility to read PPHD’s guidance carefully and focus on submitting contact line list for covid + cases within 24-48 hrs. PPHD need to receive covid + cases and all reports in a timely manner, at least 24hrs after a covid + test result. This will allow PPHD to give the best guidance to facility and can quickly move/re-group facility back to surveillance testing. PPHD reminded facility that all staff must be tested 100%, doesn’t have to be on the same day. Tests can be split 2x a week as long as the entire staff is tested. Any labs missing for staff that are unvaccinated will be requested by PPHD in a separate email. PPHD requires daily report to be submitted everyday, weekend (Sat & Sun) reports can be submitted on Mondays. PPHD has removed testing requirement for unvaccinated staff during SURVEILLANCE, only reporting is required. Facility will be cleared after PPHD receives 3 rounds of testing and the contact line list. PPHD will then move facility to surveillance testing and will get the guidance with revision. It states that weekly reporting to be submitted every Monday is still a requirement. If not, facility will be non-compliant. K. Taliaferro and RGuzman understand all the information that needs to be reported in a timely manner and will make sure to send the information within 24 hours after a covid + case. They agree that facility need to get better with reporting and will do what they need to do to keep this reporting done and keep within PPHD guidelines. The meeting concluded with the facility requesting for testing kits. PPHD will send information to facility regarding who/where to contact at PPHD. Exit interview was conducted with Administrator, Kevin Taliaferro and a copy of this report was emailed for signature.the state’s words, verbatim · CDSS document, Nov 3, 2022

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Bennette Pena and LPA Ashley Calderon conducted an annual continuation visit. Upon arriving at the facility, covid-19 screening was performed in the lobby. LPAs met with Executive Business Director, Kevin Taliaferro who assisted with the visit. The Wellness Director, Rhonda Guzman joined the LPAs afterwards. The initial annual visit was conducted by LPA Pena on 9/19/2022. During the initial visit the following was inspected, reviewed and toured: Entire physical plant (2 buildings) outdoor and indoor Outdoor and indoor passageways and exit doors Random residents bedrooms in assisted living and memory care units Smoke and carbon monoxide detectors COVID-19 Infection Control screening protocols and supplies Food supplies Laundry rooms Fire extinguishers CONTINUED ON LIC 809-C...... LPAs Pena and Calderon along with the Administrator and the Wellness Director checked and reviewed the following during this continuation visit: Hot water temperatures in random residents bedrooms. The hot water readings are as follows: Phase 1: Main floor - (Rm 174) - 114.8 deg F 2nd floor - (Rm 236) - 113.5 deg F 3rd floor - (Rm 354) - 114.0 deg F 4th floor - (Rm 458) - 107.5 deg F Phase 2: Main floor - (Rm 119) - 115.6 deg F 2nd floor - (Rm 215) - 115.4 deg F 3rd floor - (Rm 317) - 116.2 deg F 4th floor - (Rm 415) - 110.1 deg F Medication records for eight (8) random residents in both assisted living and memory care units Eight (8) random Staff records/files Eight (8) random Resident records/files The annual required visit is complete. Per Title 22 Regulations, there were no deficiencies observed during the initial and continuation visits. An exit interview was conducted and a copy of this report was provided to the Executive Business Director, Kevin Talafierro.the state’s words, verbatim · CDSS document, Oct 7, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1-year visit focusing on Infection Control Domain. LPA met with Business Office Manager, Graciela Aquino as the Executive Director/Administrator, Kevin Taliaferro, was not in the office. LPA explained the purpose of today’s visit. The facility is licensed as Residential Care for the Elderly (RCFE) for 310 non-ambulatories, serving age range 60 and over of which 25 may be bedridden. Hospice care waiver is approved for 30 residents. The current census is 131, 12 of which are in Memory Care unit, 9 Hospice residents and 110 are Assisted Living residents. At 11:21am, LPA spoke with Administrator on the phone to advise that he is on his way and will be in the facility in approximately 20-30 minutes. LPA explained the purpose of the Annual fees current. Updated Infection Control Plan which includes MonkeyPox is current and had been submitted to CCLD. At 11:35am, LPA and Administrator walked through the facility and observed/inspected the following: The facility is a low-rise 4-story building located near several retail centers. It consists of two (2) buildings, Phase1 and Phase 2 are connected. The main entrance (front door) is used as the central entry point for everyone. An electronic check-in station is set up by the entrance and Covid-19 symptom screening is initiated at entry, where LPA was screened. COVID-19 Infection Control screening protocols and supplies included a thermometer, PPE supplies, screening logs, and sign-in sheet were observed in the main lobby. COVID-19 signage was not posted around the building, but Administrator and staff put up the signage/posters in several areas of the facility during the visit. Administrator stated that the facility has 144 suites and offers independent living, assisted living and memory care units. Floor plans include studio; one bedroom, one bath; one-bedroom w/den, one bath; and two-bedroom, two baths. Apartments have ample lighting, wall-to-wall carpeting, and kitchenettes. Ground/First floor (1st) consists of: main lobby (central covid-19 screening area), dining room, kitchen, bistro area, library, 26 resident rooms, employee lounge/staff break room, restrooms, outdoor patio, The dining area has a separate enclosed private dining area for 20 people but it is not opened yet due to ongoing renovation. There are four (4) Administrative offices on South side of the building and another one (1) on the East side. There’s also a one (1) conference room and a discovery room used as private conference room for prospective clients or family members. CONTINUED ON LIC809-C.... LIC 809-C / PAGE 2..... The second (2nd) floor consists of 43 resident rooms of which 28 rooms are for Memory Care residents, living room (common area), dining room with a capacity for 28 residents, life enrichment room/activity area, two (2) laundry rooms – one in each side of the building (east/west), Therapy room, and Terrace. The third (3rd) floor consists of 39 resident rooms, living room (common area), Massage/Salon room, Fitness Center, Foyer, Emerald Store, two (2) laundry rooms) - one in each side of the building (east/west), Game Room, Terrace and Storage room. The fourth (4th) floor consists of 36 resident rooms, living room (common area), two (2) laundry rooms - one in each side of the building (east/west), Garden room/Art Studio, Sky Terrace North, Club Room, Music Room, Health Center, Foyer and Lounge. Facility maintained a 30-day supply of PPE located in the supply closets in the 4th and 5th floors. Staff wore face masks throughout their shift. LPA toured the kitchen and checked the food supplies. There was sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. The food supply was observed to be sufficient to meet title 22 guidelines. Kitchen counters, storage areas, refrigerators and preparation areas were clean and sanitary. Dishware, utensils, cutlery, pots and pans were sufficient for food service. Knives and sharps were locked in drawer and inaccessible to the residents. The laundry rooms are clean, chemicals and cleaning supplies were locked and inaccessible to residents. Smoke detectors were tested and are operational. Facility is equipped with a centralized sprinkler system. Fire extinguishers were last inspected on May 3, 2022. Administrator stated that the facility has 12 fire extinguishers per floor. Outdoor and indoor passageways and exit doors are free of debris and obstruction. Hand sanitizers are readily available around the facility. Disinfectants, cleaning solutions, and extra paper towels are stored and locked in a storage room. No deficiencies observed during the time of this visit. The facility is operating within compliance. Exit interview conducted with Kevin Taliaferro, Administrator and a copy of this report has been provided. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection.***the state’s words, verbatim · CDSS document, Sep 19, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cynthia Chan conducted a follow up visit for the purpose of checking the items to be corrected from the memory care unit. LPA conducted the initial inspection of the added Memory Care (Dementia) unit on 5/27/22. During the visit today, LPA measured the hot water temperature which are within the required range of 105-120 degrees Fahrenheit. The wall tiles in apartment #206's bathroom has been repaired. The smaller outdoor patio has been temporarily closed off for residents use and Executive Director stated he will inform LPA when it reopens. The larger patio is available for residents to use at this time. The Plan of Operation and Emergency and Disaster Plan were previously submitted for LPA's review. It is determined that the newly constructed Memory Care unit meets the Title 22 regulations and is ready to serve residents. An exit interview was conducted. A copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jun 10, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Cynthia Chan and Bennette Pena conducted a case management for the purpose of a memory care unit addition to the plan of operation. LPAs met with Executive Director, Kevin Taliaferro. On 5/2/2022, the fire inspector granted access control for use in the memory care unit. In addition, clients who become temporarily bedridden may continue to be housed on any story of the facility. The fire department shall be notified within 48 hours. LPAs toured the memory care unit which is located on the 2nd floor of this 4-story building. There are 28 resident bedrooms in this memory care unit. Each resident room has a large closet space. At this time, the residents’ rooms are not furnished. Per the Executive Director, the residents will bring in their own beds, chairs, lamps, and nightstand. All bathrooms have a working toilet and shower. The showers have grab bars and non-skid mats. Medication for residents in this unit will be distributed by a Med Tech and will be locked in the medication cart. The residents residing in this memory care unit will have their records kept in the nurse’s office. Laundry room is secured with washer and dryer which will be locked and inaccessible to residents. Staff will provide laundry service. Laundry supply will be secured and locked separately. Knives, chemicals products, disinfectants will be locked in a storage room. The memory care unit consists of a dining room in which food will be delivered from the kitchen downstairs. The kitchen area consists of a secured lock door to prevent residents from entering the kitchen which contains a working stove, refrigerator, and microwave. There are two outdoor space for leisure use and are enclosed by glass panels. (Continue on LIC809C) The main exit doors require a code to open the doors and can be disarmed by a fire alarm activation in case of an emergency. There is one emergency door that leads to the stairwell, which will produce an alarm sound when pushed. The door will open after 15 seconds. Each room has a fire alarm system that is hard-wired and connected to the local fire department. The fire extinguishers were last inspected on 5/3/2022. The hot water temperature was tested in each of the residents’ rooms and common bathroom. The following rooms were measured below 105 degrees: Room #212, #226, #236, #250, #252, and #254. These rooms are measured above 120 degrees: Room #210, #216, #228, #240, #258, #260, #262, #264, #266, #270, and the common bathroom by the outdoor patio. Room #220 does not have a working faucet. LPAs observed the following items that need to be corrected before this memory care unit can be licensed. 1. Hot water temperature must be adjusted to read between 105 – 120 degrees Fahrenheit. See room numbers above. 2. Room #260 bathroom tiles by the sink must be repaired. 3. The side gaps next to the walls in the outdoor patio must be secured. An exit interview was conducted and a copy of this report has been furnished to the Executive Director.the state’s words, verbatim · CDSS document, May 27, 2022

Allegation investigated: Staff are not properly trained to provide care to residents.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegation listed above. LPA met with Executive Director, Kevin Taliaferro, and explained the purpose of the visit. The investigation consisted of the following: On 1/4/2022, LPA A. Lopez conducted the initial investigation and requested a copy of the staff and resident roster, and training logs. During the visit today, LPA Chan interviewed the Executive Director, 7 Staff, and 11 Residents. LPA obtained the course completion history for the care team from January 2021 to present. The investigation revealed the following: Regarding - Staff are not properly trained to provide care to residents. LPA interviewed the Administrator and 7 staff. Per the Administrator, all his staff are fully trained and have more than the required annual hours of training. Unsubstantiated He stated Staff receive ongoing training and since the start of the Coronavirus (COVID-19) pandemic, staff has been provided with additional in-services to better assist residents. LPA obtained documentation of training hours for the care team and medtechs from 2021 to present. LPA reviewed the course completion history and observed that care and medication staff have at least 4 hours of training annually in one or more of the content areas as required in the Title 22 regulations. Staff interviewed indicated that they receive annual training such as Resident Rights, observing and reporting changes in residents’ behavior/conditions, and proper transferring of residents. They all stated they receive training monthly and feel that they are adequately trained to perform their duties. The facility utilizes the RELIAS program to monitor staff training. LPA interviewed 11 residents who believe the staff are properly trained. They are nice, respectful, and helpful. Staff assist some with their activities of daily living (ADLs) while others will occasionally press their pendants when they need assistance. 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 staff. A copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 28-AS-20211229085515

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced case management visit to this facility. During the initial 10-day complaint visit conducted on 1/19/22, the following concern was observed upon entering the facility; Upon arriving at the facility at 9AM, LPA was greeted by Staff #1 (S1) and LPA 9 was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care. The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided to Executive Director Kevin Taliaferro, along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jan 19, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.50(a)(3) · Plan of correction due date: Jan 20, 2022

a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California. This requirement is not met as evidenced by: Upon arriving at the facility at 10:30 am LPA was greeted by Staff #1 (S1) and LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 19, 2022

Plan of correction: Executive Director will ensure that all facility staff are following California Dept of Public Health and CCLD requirements by conducting an in-service training with the staff on the importance of COVID screening for all visitors, staff and residents. Executive Director will submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Allegation investigated: Facility is not complying with local public health department's COVID-19 requirements.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint visit to gather information for the allegation of facility is not complying with local public health department’s Coronavirus (COVID-19) requirements. LPA arrived unannounced and met with Executive Director, Kevin Taliaferro. The purpose of the visit was explained. During the visit today, LPA obtained the staff roster, resident roster, interviewed the Executive Director and the Wellness Director. LPA also interviewed the Pasadena Public Health Department (PPHD) Nurse on a different date. Regarding allegation, facility is not complying with local public health department’s COVID-19 requirements. It is alleged that the facility failed to submit required documentation on a weekly basis which PPHD sent out to all Pasadena Long Term Care Facilities via email on 9/17/21 informing the standard document submission requirements. (Continue on the LIC9099C) Substantiated The Pasadena Public Health Nurse confirmed that the facility failed to submit completed lab reports for twice weekly testing for unvaccinated employees from 9/18/21-11/29/21 and unvaccinated residents from 10/21/21-11/19/21. According to Executive Director (ED) Taliaferro, he acknowledged the test results were not submitted on time weekly for all unvaccinated individuals of the facility for some of the weeks during the months of September to November. He understood the PPHD COVID-19 requirements of testing unvaccinated staff twice a week and unvaccinated residents once per week. He acknowledges the importance of following the guidelines to ensure the health and safety of the residents as well as staff. Per ED Taliaferro, he has delegated a team of staff to prevent this oversight and to ensure the weekly reports for unvaccinated individuals are submitted to PPHD every Monday by 12pm. The Wellness Director also indicated that the required weekly reports for the unvaccinated individuals were not submitted timely to PPHD for about a month, but stated the weekly reports are now being turned in on time. 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. A copy of this report, LIC9099D, and appeal rights were provided to the Executive Director.the state’s words, verbatim · CDSS document, Dec 10, 2021 · control 28-AS-20211202125114

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Dec 17, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require,...: (2) Occurrences, such as epidemic outbreaks,... or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported... to the licensing agency and to the local health officer when appropriate. Based on interviews, the Executive Director did not ensure that the Pasadena Public Health Department receives their weekly required lab reports for unvaccinated staff and residents which poses a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2021

Plan of correction: The Executive Director has delegated staff members to oversee the lab reports for unvaccinated individuals and ensure the lab reports are provided to PPHD weekly. Executive Director will submit a statement adhering to the reporting requirements by POC due date 12/17/21.

Type of visit: Office

An informal conference was held via Microsoft Teams on 12/07/2021. The purpose of this informal meeting was to discuss the facility not complying with the Pasadena Public Health Departments' Guidance for the unvaccinated individuals at the facility. Present in this meeting were: Araceli Ramirez (Regional Manager), Lisa Hicks (Licensing Program Manager), Cynthia Chan (Licensing Program Analyst), Whitney Frame (Pasadena Public Health Department Nurse), Lani Hashimoto-Raju (Pasadena Health Nurse), Kevin Taliaferro (Administrator), and Rhonda Guzman (Wellness Director). Per Pasadena Public Health Department (PPHD) guidelines effective 9/17/21, the facility is required to submit a fully updated weekly report to the Pasadena Public Health Department every Monday. The facility must test all unvaccinated staff twice a week and unvaccinated residents once a week. The facility has not been compliant with the PPHD Guidance for weekly reports of unvaccinated employees. The facility has stated they will do the following to achieve continued and substantial compliance: * Kevin Taliferro will ensure that his staff will submit the weekly reports for unvaccinated staff and residents to PPHD every Monday. * He has appointed backup staff to collect data and submit to PPHD on time if Staff in charge is absent. Community Care Licensing (CCL) reminded Administrator that PPHD Guidelines must be followed as well CCL's regulations to remain in compliance otherwise citations may be warranted. No deficiency was issued during today's meeting. An exit interview was conducted and a copy of this report was emailed to Administrator for signature.the state’s words, verbatim · CDSS document, Dec 7, 2021

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to continue the Pre-licensing visit with Executive Director, Kevin Taliaferro and Wellness Director, Rhonda Guzman. The initial Pre-licensing inspection was conducted on 9/9/2021 and which all residents' rooms were inspected on that date. The fire clearance has been approved for a capacity of 310 residents, which 285 may be non-ambulatory and 25 may be bedridden. The facility has an approved hospice waiver for 30 residents. There are no rooms set aside for bedridden residents. Residents that become bedridden remain in their suite. There are currently 102 residents residing at the facility. Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are available in the hallways and by the elevators. The menu is posted in the kitchen and also given to the residents in their rooms weekly. The fire extinguishers were last inspected on 5/7/21. Smoke Detectors: The facility has smoke/carbon monoxide combo detectors in each of the resident rooms. Appliances: All appliances in the facility are in good repair. The laundry equipment on each floor are operable. Medications, First Aid Kit & Book: Medications are stored and locked in the Wellness Office located on the 4th floor. LPA Chan randomly selected 12 residents' medication logs to review and all medications are being administered as prescribed. The first aid kit contains all the required supplies along with the current first aid manual which are located in the Wellness Office. (LIC9099C) The facility had submitted proof of corrections to correct the hot water temperature, freezer and refrigerator temperature deficiencies which was issued on 9/9/21. Component III: LPA Chan conducted the component III during today's visit to provide information on how to operate the facility within substantial compliance. Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted and this report has been provided to the Executive Director.the state’s words, verbatim · CDSS document, Sep 15, 2021

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Cynthia Chan, Mary Flores, and Jewel Baptiste conducted an announced visit to the facility for the purpose of a prelicensing evaluation. LPAs met with Kevin Taliaferro, Executive Director, and Rhonda Guzman, Wellness Director, who provided assistance with the tour of the physical plant. An application was submitted to CCLD on 10/28/2020 for a Change of Ownership for a Residential Care Facility for the Elderly for ages 60 years and older. The fire clearance has been approved for a capacity of 310 residents, which 285 may be non-ambulatory and 25 may be bedridden. There are currently 102 residents residing at the facility. LPAs inspected and observed the following: Structure: Facility is a 4-story building. The first floor consists of the lobby, Administrative rooms, beauty salon, activity room, dining room, kitchen, common area, commercial laundry room, and 27 resident rooms. The second floor consists of 44 resident rooms, massage room, spa room, family room, Country Kitchen/recreation room, fitness room, Physical therapy room and residential laundry room. The third floor consists of 44 resident rooms, California Kitchen/dining room, game room, residential laundry room, and spa room. The fourth floor consists of 36 resident rooms, Country Kitchen/dining room, family room, medication room and doctor’s office. There are no obstructions to the walkways and/or driveways. There are no pools or bodies of water at the facility. Bedrooms for Residents: Bedrooms are equipped with a bed, nightstand, recliner, and adequate closet space. There is adequate lighting throughout the room. Bathrooms: Each resident room has a private bathroom. The bathtub has a grab bar and a non-skid mat. Staff and Residents files: Staff and Residents files are stored and maintained at the facility. LPAs randomly selected 12 residents and 7 staff files to ensure all required forms are in their files. The Administrator's certificate expires on 9/3/2022. Linens & Hygiene supplies: Extra supplies of linens and hygiene were observed in storage rooms. Food service: Adequate supplies of 2-day perishable and a week of nonperishable are observed. Food in refrigerators were properly covered to avoid contamination. Dishes, cups and flat ware are stored in the kitchen area. The following items must be corrected and submit the proof of corrections to LPA by 9/10/21. * The freezer should be maintained at 0 degrees F. * The Refrigerator should be maintained at 40 degrees F. * The hot water temperature is measured between 105-120 degree F. LPA will return to complete the remainder of the inspection and conduct the Component III at a later date. An exit interview was conducted. A copy of this report was given to Executive Director, Kevin Taliaferro.the state’s words, verbatim · CDSS document, Sep 9, 2021