Hazel Home for Seniors

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 2/8/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Caregiver, Dian Evering, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA spoke to the Administrator, Cleopatra Grant, by phone and Administrator stated that caregiver can sign report. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 6 bedrooms and 3 bathrooms for residents, common areas, kitchen, food supply, laundry room, outdoor areas, and PPE supply. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 8, 2023

Allegation investigated: Unlawful Rent Increase Facility did not provide Invoice as stated on Admission Agreement

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Cleopatra Grant, to open a complaint investigation into the allegations listed above. Licensee gave permission to have caregiver, Dian Evering, sign report. LPA wore a surgical mask. Facility staff wore masks while on the premises. During today’s visit, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Unlawful Rent Increase ** Report continued on 9099-C ** Substantiated Review of resident (R1's) file indicated that a rent increase was established via Admission Agreement signed on 12/04/2022, with a $500 increase from previous Admission Agreement signed on 7/01/2020. During inspection conducted on 12/12/2022, LPA requested a copy of the written notice used in the rate increase for R1. Facility did not provide a written notice to LPA during inspection. Interviews conducted with Licensee and facility owner indicated that the rate increase was due to a change in level of care. An LIC 602 was completed on 4/20/2022 for R1 to identify changes in care. Interviews with Licensee and facility owner indicated that no written notice was provided to R1's authorized representative prior to the change in rate or the signing of R1's Admission Agreement on 12/04/2022. Allegation: Facility did not provide invoice as stated on Admission Agreement R1's Admission Agreement (signed 7/01/2020) states "the billing and payment policies and procedures are: An invoice will be given to the resident and/or responsible party on the first of each month." R1's Admission Agreement (signed 12/04/2022) states "the billing and payment policies and procedures are: invoice will be sent to resident responsible part." During inspection conducted on 12/12/2022, LPA requested a copy of the invoices for R1's rent sent to R1's authorized representative. Interviews conducted with Licensee and facility owner indicated that an invoice for some months (exact months were not identified) were not provided to R1's authorized representative. Facility did not provide any invoice copies to LPA during 12/12/2022 inspection. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Dec 12, 2022 · control 25-AS-20221207155201

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Dec 27, 2022

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to send a written notice to R1's authorized representative regarding a rate increase due to a change in the level of R1's care, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2022

Plan of correction: Facility will send a written notice to R1's authorized representative indicating additional services provided. Facility will provide a copy of the written notice to LPA by POC due date of 12/27/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Dec 27, 2022

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to send an invoice for R1's rent every month to R1's authorized representative in agreement with R1's Admission Agreement, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2022

Plan of correction: Facility will send any missing invoices to R1's authorized representative. Facility will provide proof that the invoices were sent to R1's authorized representative to LPA by POC due date of 12/27/2022.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to obtain a signature on page 3 of complaint # 25-AS-20220412134911 for findings delivered on 7/21/2022 and also to change findings for complaint #25-AS-20220411160405 from "Unsubstantiated" to "Unfounded". . LPA met with Diane Evering, caregiver LPA spoke to Licensee, Farah Chaudhary, by phone and explained reason for inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA observed (2) residents to be eating dinner in the common area and staff Diane to be assisting one of the residents. LPA obtained the necessary signatures for the amended page and amended complaint findings. There are no deficiencies issued during today's inspection. LPA provided the facility with some PPE supplies from the Department- gloves, wipes, gowns and sanitizer. Exit interview. Copy of report provided to facility.the state’s words, verbatim · CDSS document, Jul 28, 2022

Allegation investigated: Not enough staff to supervise residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received by the department on 4/12/2022. LPA met with Diane Evering, caregiver LPA spoke to Administrator, Cleo Grant, andf Licensee, Farah Chaudhary, by phone. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA observed resident (R5) return from the hospital after being sent out earlier today for a fall. LIC624 to be submitted. During the investigation, LPA interviewed Licensee, the Administrator, the Ombudsman, resident (R1), resident (R1)'s representative (POA) and another resident. LPA reviewed documentation pertaining to resident (R1) including but not limited to, physician's report, pre-appraisal, copy of eviction notices, letter issued to resident for a privacy breech incident, signed Admission Agreement, and meeting minutes from 4/12/2022. LPA also reviewed residents' (R2 and R3) care plans and physician's reports. The results of the investigation are as follows: Substantiated Allegation: Not enough staff to supervise residents. Allegation refers too the incident on March 3, 2022 when resident (R3) eloped from the facility and there were not enough staff to monitor the residents. Interviews conducted in April 2022 with (2) residents confirmed that residents (R1, R2 and R4) were left alone at the facility on 3/3/22, for approximately one hour, while the only staff (S1) on duty, went to find resident (R3) after she left the facility unattended. Text message sent from one resident to a family member notes that on 3/3/22 at 2:20 pm, she and another resident were sitting outside on the porch waiting for S1 to return with resident, R3. Based on information obtained during the investigation, LPA finds the allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Because this incident occurred on 3/3/22, prior to the current license being issued on 3/9/22, this citation and any related citations and civil penalties are being issued on the prior license, #342700078. Exit interview with caregiver, Diane, which was authorized by Administrator Cleo.. Copy of report provided. Allegation: Not enough proof given for eviction. Allegation is facility did not provide enough proof to justify the eviction. Health and Safety Code §1569.683 Eviction notices; reasons for eviction contents; services (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. Eviction letters issued on 4/6/22 and on 4/8/22 both provide specific details, including the day and time for the (5) different times when R1 was assisting with feeding R2 and both times when R1 was giving R2 a massage, which would allow the incidents to be viewed on the video camera in the common areas. POA provided documentation that on 3/28/22 Licensee advised resident R1 that she would send representative a picture of R1 combing resident Mary’s hair. POA stated she never received an emailed picture. Licensee stated that these incidences are documented by video in the common area when they occurred. Administrator stated that she showed R1's POA a picture of R1 feeding R2 and combing her hair and massing her. Administrator also stated that she showed a picture to POA of her taking a picture of R5's journal. Based on documentation review and interviews conducted, LPA finds this allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff talking about residents to people who are not responsible parties. Allegation is Licensee talks about other residents’ conditions to people who are not responsible parties Interview with one resident revealed that Licensee hasn't talked to her about other residents' information. Two other residents were not able to be interviewed due to a diagnosis of Dementia,. LPA reviewed the eviction letter issued to R1 which mentions that another resident (R2) “is unable to state on her own cognitive will when to stop eating”. Based on interviews conducted throughout the investigation, residents and staff were POA was aware that R2 had cognitive challenges and needed assistance with feeding. Based on documentation review and interviews conducted, LPA finds this allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099A(C2).. Allegation: Staff having residents supervise other residents. Allegation is when resident’s responsible person arrived for a visit, she found R2 sleeping in the recliner in R1's room. LPA reviewed documentation provided by R1's POA, dated 3/8/22, which states that when R1's POA arrived to visit R1, as she does nightly, resident (R2) was asleep in R1’s recliner. When asked about it, R1 stated “they dropped her off for me to babysit”. The documented notes further states “as soon as (S1) realized I was there and R2 was still in my mom’s room, she rushed R2 to bed”. Additional documentation provided by R1's POA, specifically a text message dated 3/25/22, notes that staff (S1) asked resident (R1) to watch the other 3 residents (R2, R3 and R5) who were also sitting at the table while she went to assist another resident (R4) who was having an asthma attack. The notes further document that S1 screamed at R1, asking her to not get out of her chair and assist her in watching the other residents. A staffing schedule was provided for the third/fourth week of April 2022, as requested, and shows that 1 caregiver is scheduled to work from 7 am- 7 pm and a second caregiver is scheduled to work from 7 pm- 7 am daily. Licensee stated on 4/14/2022 that she has one staff on duty with four residents. In March 2022, there were 5 residents in care and 1 staff on duty during these noted incidents on 3/8/22 and 3/25/22. Administrator stated that when there were (5) residents in March 2022, a second, live-in staff (S1) would assist when needed. S1 stated to LPA on 4/14/22 that residents "all eat lunch together", stating "I don't ask a resident to watch another resident". They are all together for lunch and dinner". Administrator stated she is not aware of this happening and never observed any staff to ask a resident(s) to watch another resident(s). Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: POA did not receive a copy of the admission agreement. Allegation states that resident and responsible person never received a copy of the Admission Agreement. POA stated on 4/26/22 that she never received a copy of the Admissions agreement upon move in February 2022. Ombudsman stated that at the conclusion of the meeting he attended on 4/12/22 with the Licensee, Administrator, resident (R1) and resident’s representative, he requested that Licensee make a copy of the Admission Agreement for resident since she hadn’t received one upon move-in, in February 2022. Administrator and Licensee both indicated that R1 received a copy of the admission agreement upon move-in and received a second copy on 4/12/22 following the meeting held with the Ombudsman. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jul 21, 2022 · control 25-AS-20220412134911

Allegation investigated: POA not notified of incidents involving resident behavior

Allegation is resident’s representative was never notified of resident’s behaviors which were the basis of the eviction notice being issued. This allegation was inadvertently not listed on the other report page so is being listed separately. Licensee stated to LPA on 4/14/22 that resident’s POA was upset that she was not reached out to regarding resident behaviors that were not safe. Eviction letter to resident’s representative states that facility staff have only communicated with resident R1 “on multiple occasions” about her behavior from Feb-April. Documentation provided by POA notes that on 3/28/22 (5:01 pm) R1 texted her POA that she was reprimanded by staff (S2) for rubbing Mary’s back and that Licensee would send POA a picture of R1 combing R2's hair. POA stated that she never received an emailed picture of R1 combing R2’s hair. Administrator stated she discussed R1's behavior with the POA "very often" since she visited regularly. Licensee stated she also discussed by phone the issues with R1's trying to provide care to R2. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, Exit interview. Copy of report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 21, 2022 · control 25-AS-20220412134911

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

Allegation investigated: Staff unlawfully evicted a resident

**This report is being amended only to change findings from "Unsubstantiated" to "Unfounded". There are no other changes being made to the report. ** Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received by the department on 4/11/2022. LPA met with Diane Evering, caregiver LPA spoke to Administrator and Licensee by phone. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. During the investigation, LPA interviewed Licensee, the Ombudsman, resident (R1), resident (R1)'s family member. LPA reviewed documentation pertaining to resident (R1) including but not limited to, physician's report, pre-appraisal, copy of eviction notices, letter issued to resident for a privacy breech incident, Admission Agreement, and meeting minutes from 4/12/2022. LPA also reviewed resident (R2)'s care plan and physician's report. The results of the investigation are as follows: Unfounded Allegation: Staff unlawfully evicted a resident. Allegation states resident (R1) is not following safety instructions, is performing jobs meant for caregivers and is in violation of Section 87224(a) and of the Resident Care Agreement signed on 02-10-2022. Hazel Home has communicated with resident on multiple occasions of their concerns about their behavior. \ LPA was provided on 4/5/22 with an email dated 3/28/22 from Licensee to R1's responsible party/POA serving her with 30 days notice to find another facility for R1, or by 4/27/22, since she is not happy with the facility. The email does not contain all of the required elements per Regulation 87224 so is not a valid eviction notice. Licensee contacted LPA by phone on 4/5/2022 to discuss issuing an eviction notice to resident (R1). Following the call, LPA emailed Licensee a copy of Regulation 87224, as well as a sample eviction notice. Licensee provided the Department with a copy of an eviction letter, on 4/6/2022, which provides detailed information on (5) separate occasions, between 2/15/2022 and 3/13/2022, where resident was feeding another resident (R2), which posed a choking hazard to R2. Additionally, the letter notes that R1 was massaging R2's shoulders, on 2/22/2022 and on 3/27/2022, placing R1 at an increased fall risk. On 4/7/2022, LPA provided additional guidance to Licensee that an eviction letter needs to contain resources for placement agencies and a sample eviction letter was provided again. LPA received an updated eviction notice on 4/7/22 and replied on 4/8/2022 that the letter appears to contain all required elements per the regulation and so is a lawful eviction notice. An updated eviction notice was issued by email to resident's representative later on 4/8/22. On 4/12/2022, an in-person meeting was held at the facility with the Licensee, Administrator, resident (R1), R1's representative and the Ombudsman to discuss the eviction notice recently issued as well as other concerns. Copies of meeting notes were provided to the Department on 4/15/22 and note that at the conclusion of the meeting, the facility agreed to withdraw the eviction notice issued on 4/8/22 provided that 1) issues discussed at the meeting were not subsequently repeated and 2) all parties agreed to sign the meeting notes which state, in part, that any allegations previously made against the facility were false. Licensee confirmed on 4/19/22 and on 4/28/22 that the eviction notice issued on 4/8/22 had not been rescinded due to resident's responsible person not being willing to sign the meeting notes. Resident's POA indicated on 4/26/22 that she did not agree with the meeting notes, specifically about false allegations, so she was unwilling to sign and would be moving R1 to another facility. cont on 9099C(2).. 90099C(2) ..Regulation 87224 says (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(a) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). (3)Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. POA stated she never received a copy of the Admission Agreement or House Rules, as referenced in the eviction notice on 4/8/22. Licensee stated that House Rules were included in the Admission Agreement, which was signed by R1's POA upon move-in, on 2/10/2022, and that a resident can be evicted for placing him/herself in a harmful situation or another resident in a harmful situation. Admission Agreement says under Section 5(a) that a resident can be evicted for the reason of not following the written general policies of the facility. It was not anticipated that a resident would be trying to care for another resident, as in providing care like a caregiver, so it was not specifically written in until the admission policy was updated in May 2022. Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 21, 2022 · control 25-AS-20220411160405

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to request paperwork related to resident (R1) who previously lived at the facility. LPA met with Diane Evering, caregiver, who contacted Administrator, Cleo Grant, by phone and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): N95 mask. LPA obtained copies of requested paperwork (LIC602). LPA observed (3) residents to be present during today's inspection. LPA observed the facility to be clean, in good repair and to not have any bad odors. LPA observed staff to be wearing a mask. Inside temperature was 74 *F. There are no deficiencies being cited during today's inspection. Exit interview by phone with Administrator who authorized caregiver to sign today's report. Copy of report provided to caregiver.the state’s words, verbatim · CDSS document, Jun 8, 2022

Type of visit: POC

On 5/12/22, Licensing Program Analyst (LPA) arrived to conduct a POC visit of citations issued 5/2/22. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the facility. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): surgical mask. LPA was screened by caregiver at the facility. LPA found that three plans of correction due for Dementia Training 87705(c)(3), Medication Training 1569.69(a) and New staff training have not clearly been met. LPA discussed the issue with Licensee and Administrator. LPA will return to review training documentation. If not met, failure to correct civil penalties may be applied. LPA confirmed that Excluded staff are not present. LPA re-associated staff who had been disassociated. LPA advised a room change for resident in -ambulatory only room who has become non-ambulatory to move to room with 2 exits. No citations are issued at this time. Report provided.the state’s words, verbatim · CDSS document, May 12, 2022

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPA's) Sabrina Calzada and Todd Tryon arrived unannounced to conduct a case management inspection to serve an immediate exclusion to staff (S1). LPA's met with Cleopatra Grant, Administrator, and explained purpose of inspection. LPA's also met with staff (S1) , caregiver. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA's were screened per Covid-19 precautionary measures upon entering the facility. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): surgical and N95 mask. LPA's served an immediate exclusion letter to Cleopatra Grant, Administrator and S1 also. LPA's explained the letter to both individuals and also spoke to LIcensee, Farah Chaudhary, by phone. LPA's explained 15 day appeal rights. LPA's spoke briefly to (2) residents. LPA's observed the facility to be clean, safe and in good repair. LPA's observed Administrator contact another caregiver by phone during today's inspection. There are no deficiencies being cited today. Exit interview. Copy of report to be emailed to Licensee.the state’s words, verbatim · CDSS document, May 3, 2022

Type of visit: Post Licensing

On today's date around 905 am Licensing Program Analysst (LPAs) Kevin Mknelly and Mai Thao arrived at the facility unannounced to conduct a Post Licensing Inspection utilizing the CARE tool. LPA met with Cleo, Administrator. LPA explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. In addition, Staff screened LPA prior to entering the facility. LPA toured facility with staff to ensure health and safety of clients in care. Areas toured include but are not limited to: common area, 2 bathroom, 4 client bedroom, 1 staff bedroom, laundry room, garage, kitchen, and storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs reviewed resident, staff and facility records and conducted a medication audit. LPA and staff completed the infection control domain. Several deficiencies were noted as citations and technical violations. During the inspection, LPA and facility staff discussed the facility's infection control and mitigation plan, training requirements, staff and resident records, facility and medication quality assurances. Report continued... As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with Cleo . Due to technical issues LPA was unable to leave a copy of the report with the administrator. Copy of this report and appeal rights provided via email with request for the licensee to return signed copies.the state’s words, verbatim · CDSS document, May 2, 2022

The state marks this report as 37 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Office

A tele-visit meeting was held on 4/25/2022. Present in the meeting were Farah Chaudhary, Licensee, Harjot Singh, Business Partner, Cleopatra Grant, Administrator and AZ Chaudhary, Licensee's spouse and owner of propety of Hazel Home for Seniors, Regional Manager, Alycia Berryman, Licensing Program Manager, Maribeth Senty, and Licensing Program Analyst, Sabrina Calzada. The office meeting process was explained during the meeting: Today's meeting was to address the following issues: Eviction notice issued 4/8/22- email sent to Licensee on 4/8/22 that notice was approved Audio and video surveillance being used in the common areas- Reporting requirements Provide technical assistance The Facility agrees to do the following: Immediately cease using video and audio surveillance at the facility due to personal rights violation Submit a waiver to the Department requesting approval of video surveillance only Update Plan of Operations in the facility Admission Agreement explaining use of video surveillance and submit to the Department for approval Review Regulation 87209- Program Flexibility; 87405- Administrator Qualifications; 87507- Admission Agreement- in Evaluator Manual at DSS website. Licensee was advised of the responsibility to ensure staff is fully trained and provide training opportunities Training links available- can access from Evaluator Manual Update resident paperwork to reflect new license name Discussed working relationship with DSS- LPA is the first line of contact. Items discussed were summarized at the conclusion of the virtual meeting and Licensee was informed a copy of this report would be emailed to her following the meeting for signature. There are no deficiencies cited during this report.the state’s words, verbatim · CDSS document, Apr 25, 2022

Type of visit: Case Management - COVID-19

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual inspection on prior license, #342700708 as annual was showing as overdue in the system. LPA met with Farah Aslam who stated that she is the new Licensee for the facility and a new license was just issued. LPA observed copy of license # 345002868, issued on 3/9/2022 under current Licensee. Facility name remains Hazel Home for Seniors. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE): KN95 mask. LPA and Licensee toured the facility to ensure the health and safety of residents in care. Currently, there are (5) residents and no residents are receiving hospice services. LPA observed the facility to be in clean, in good repair and to pose no health and safety risk. LPA observed paper towels, sanitizer, trash can with lid and hand-washing poster in the bathrooms. LPA observed sufficient food supply. Inside temp was 74*. Fire extinguisher last serviced August 2021. LPA provided copy of PIN 22-07. Discussed staff and resident vaccination status and visitation protocols. LPA observed Administrator, Cleopatra Grant, on site also. LPA and Licensee discussed the process of increasing the capacity from (6) to (12) residents. LPA stated an LIC200 needs to be completed and submitted to local fire department along with an STD850 with a request for increase. There are no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Licensee.the state’s words, verbatim · CDSS document, Mar 28, 2022

Type of visit: Prelicensing

On 2/9/2022 at 1:40 pm, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Pre-licensing inspection for change of ownership referencing the infection control domain. LPA met with Caregiver, Leah Cummingham, and explained the purpose of the visit. Prior to initiating the inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. Administrator arrived to the facility shortly afterwards. LPA toured the interior and exterior of the facility together with Administrator to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, staff office, and backyard. In the areas toured, no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control recommendations and facility was found to be in substantial compliance at this time. LPA confirmed that masks were worn by staff. LPA observed a more robust lock on the knife drawer and kitchen sink cabinet, all toxins and chemicals be secured from residents. LPA observed medication to be stored in a secured office. LPA completed the Component III Orientation with Administrator. No deficiencies are being cited as a result of today's inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 9, 2022

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Change in ownership (CHOW) Capacity: 6 Census (if any clients in care): 3 COMP II Participants: Farah Aslam, Applicant Cleopatra Grant, Administrator Interview Method: Telephone interview On February 7, 2022 at 10:00 AM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed the understanding of the California Code Title 22 Regulations. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness Exit interview conducted with Applicant and Administrator. COMP II report sent via emal pdf and informed Applicant and Administrator to return signed copy to Analyst.the state’s words, verbatim · CDSS document, Feb 7, 2022

Type of visit: Office

Component II completion: Unsuccessful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 6 Census (if any clients in care): 3 COMP II Participants: Harjot Singh, Applicant Farah Aslam, Applicant Cleopatra Grant, Administrator Interview Method: Telephone interview On January 21, 2022 at 10:30 AM, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID and other identifying personal information. Applicant and Administrator did not provide sufficient knowledge the program and the California Code Title 22 Regulations. Component II will be rescheduled. Exit interview conducted with Applicants and Administrator. Report sent via email pdf and informed to return signed copy to Analyst.the state’s words, verbatim · CDSS document, Jan 21, 2022