Montclair Royale Senior Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator AnnaMarie Santos and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (236) current census (129). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be at 115.8 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for client/staff files. Medications are kept inside Med-Room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator AnnaMarie Santos.the state’s words, verbatim · CDSS document, Oct 21, 2023

Allegation investigated: Illegal Eviction

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living facility unannounced to deliver the findings of the complaint investigation. LPA met with Araceli Soto, introduced self and stated purpose of the visit. It is alleged that the resident was illegally evicted from the facility. Interviews with staff revealed that R1 moved in October 2023. During the period R1 was living at the facility, R1 had a number of occasions in which he violated the rules of the facility. The violations resulted in the facility issuing two evictions. One eviction was dropped due to R1’s enrolling into and participating in the PACE program. A second eviction notice was issued on 2/17/23 for violation of facility rules. This eviction notice provided incorrect contact information for the Long Term Care Ombudsman; deeming the eviction notice invalid. However, R1 moved out of the facility before the deadline of the eviction notice which was 3/18/23. Substantiated Based on staff interviews and record reviews, we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative. Please see LIC 9099D. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 56-AS-20230420083238

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(C) · Plan of correction due date: Oct 16, 2023

87224 - Eviction Procedures (C)A statement informing residents of their right to file a complaint with the licensing agency... (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. This requirement was not met as evidenced by: Administrator failed to ensure the correct contact information for the Long Term Care Ombudsman was on the eviction notice. This posed a potential health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2023

Plan of correction: Licensee/Administrator agrees to read and review the 87224 Evictions Procedures entirely. Also, send LPA a self-certified letter that the regulation was read, understood and will demonstrated in furture evictions. This form is to be submitted to the Community Care Licensing Office within 1 business day.

Allegation investigated: Staff does not ensure resident has access to resident's wheelchair. Staff does not ensure resident's room is clean and sanitary. Staff does not ensure resident's call light works.

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced visit to the Monclair Royale Senior Living Facility to deliver the findings of the complaint investigation. LPA met with Care Coordinator, Araceli Soto and stated the purpose of the visit. The investigation included interviews with staff and residents, a review of records and observations. It is alleged that staff does not ensure the resident has access to the resident’s wheelchair. Staff interviews revealed that R3’s wheelchair is kept in R3’s closet for the purposes of safety. During LPA’s visit, LPA made observation of R3’s room. LPA observed the wheelchair inside of the room outside of the closet. LPA accessed the wheelchair, opened it, pushed it, opened the foot pedals. The wheelchair appeared to be functional and in good repair. All staff report R3 has the ability to walk on their own on the floor. Photographic evidence depicted a wheelchair next to the resident’s bed, giving the resident access to the wheelchair. **Please see LIC9099-C Unsubstantiated It is alleged that staff do not ensure the residents’ room is clean and sanitary. During interviews with housekeeping staff, it was discovered that resident rooms are cleaned several times a week. For some residents this service is optional, while other residents’ rooms are routinely cleaned. During a visit to the facility, LPA observed a refrigerator with concerns for cleanliness, a water-stained ceiling tile. LPA also observed and later confirmed that R3 does not utilize the refrigerator in the room. The stained ceiling tile was replaced. All matters of concern were addressed at the time of the visit. It is alleged that staff do not ensure the resident’s call light works. During staff interviews and observations, LPA learned that when the call light is pulled, it notifies the staff in the office. Each time this occurs, office staff document when the call light was pulled, what room and what staff responded. LPA reviewed call light response logs for 5/4/23 through 5/8/23. No entry in the log indicated that a call light in the resident’s room was triggered. According to the facility’s maintenance logs, there is no indication that the call light is not functional. Based on information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with facility representative; this report was reviewed, discussed then provided.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 56-AS-20230503082338

Allegation investigated: Resident sustained an unexplained injury while in care of the facility. Resident wandered away from the facility due to staff neglect. Staff do not provide residents with daily activities. Staff do not provide accurate information needed to ensure resident is receiving appropriate care

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale unannounced to deliver findings of the complaint investigation into the allegations listed above. LPA introduced self and stated the purpose of the visit then discussed the findings. It is alleged that a resident sustained an unexplained injury while in care of the facility. Staff interviews revealed that R1 was scheduled for a dentist appointment at 8:30am. R1 had breakfast and left the facility at 6:40am via Innovage/PACE Transportation. Staff of Montclair Royale deny the incident occurred at the facility; reporting that no injuries were observed on R1 when she left for her appointment. Staff of Innovage reported that residents who arrive early to their appointments often wait at the Innovage Center in a courtyard unattended. It is unclear whether the lip injury occurred during her dentist appointment or possibly during her time in the courtyard at Innovage. Innovage staff investigated the matter and suggested the lip injury did not occur at Innovage due to lack of any incident report being submitted on or around the date of R1’s dentist appointment. LPA unable to reach R1’s family for interviews. Unsubstantiated It is alleged that resident wandered away from the facility due to staff neglect. LPA observed that R1 resides in the facility’s Memory Care Unit. The Memory Care Unit is a restricted unit in which staff need a key to enter and leave. A key is also required to use the elevator on the unit. During staff interviews, it was discovered that the memory care unit has an adequate amount of staff to care for the number of residents in care. Staff report that R1 did leave the memory care unit floor. R1 waited by the elevator, standing along side family members leaving the floor. The family didn’t know R1 was a resident of the memory care unit and allowed R1 to enter the elevator and leave floor. By all staff accounts, R1 did not leave the facility. R1 wandered around the first floor, never leaving the facility grounds. LPA unable to gather any information from R1 or family of R1. It is alleged that staff do not provide resident with daily activities. During LPA’s walkthrough of the facility, LPA observed a Large Print Activities Calendar posted in the hallway of the memory care unit. Accessible to all residents to read and join an activity. LPA also observed the dining room with different activity materials for crafting. Across from the dining room is an Activity Room with adequate seating. Staff report the room is used for group activities such as exercising or watching television. Resident are free to go in and out of the room as they please. This room included adequate seating as well as board and card games. LPA received a copy of the Memory Care Unit’s Activities Calendar which was consistent with observations. Staff interviews revealed that staff take turns throughout the day to lead activities. Staff encourage residents to participate, but participation is not mandatory. Staff report R1 may start an activity but may get distracted get up and leave. Staff allow residents to come and go to avoid aggressive or combative behaviors. It is alleged that staff do not provide accurate information needed to ensure resident is receiving appropriate care. Staff interviews revealed that R1 was taken to the hospital on two occasions. The first occasion was to address R1 injury. On the second occasion, R1’s daughter transported R1 to the hospital. A review of medical records and incident reports reflect that this occurred. Staff report that R1’s daughter was contacted to be notified of R1’s condition and current status but received no answer or returned call. On the second occasion, R1’s daughter was present during the hospital visit. Records also reflect ongoing communication between facility staff, R1’s daughter and Innovate staff. Innovage staff and R1’s daughter worked together to find better suited housing for R1 and closer to R1’s daughter. R1 officially moved out of the facility on 8/9/23. LPA was unable to reach R1’s daughter to obtain any other information or account of what occurred. Based on the information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with facility representative and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 56-AS-20230629154129

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 13, 2023

Allegation investigated: Staff are not meeting resident's dietary needs.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint investigation into the allegation listed above. LPA met with Care Coordinator, Araceli Soto to discuss elements of the complaint. During today's visit, LPA interviewed staff and residents, collected pertinent documents and completed a walk through of the resident's room. It is alleged that staff are not meeting resident's dietary needs. Staff interviews revealed that the resident eats all of her meals. Facility staff do not maintain weight records for residents. Record reviews revealed that the resident's dietary needs are being met. Residents deny that they do not get enough food to eat. Residents also deny their dietary needs are not met. Based on information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted where this report was reviewed, discussed then provided to facility representative. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 31, 2023 · control 56-AS-20230825163400

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Amber Coleman, (LPA) conducted an unannounced visit for complaint# 56-AS-20230825163400. During this visit, LPA observed deficiencies not related to the complaint allegation. LPA completed a walk through of resident rooms on the facility's second floor. The section of the facility used for the Memory Care Unit. At approximately 11:14am, LPA observed what appeared to be human fecal in the cabinetry of a resident room. At approximately 11:15am LPA observed the resident restroom located inside the resident room. The door was not secure. LPA walked inside and observed the bathtub to have debris along the walls. The debris was dark gray in color. This debris was in bits and pieces along the walls and floor of the tub. At approximately, 11:16am LPA observed the resident window. The resident window was slightly ajar with mechanisms in place to keep the window from opening all of the way. LPA observed a screen attached to the window. The screen was weathered, damage and not secure; allowing unsecured access outside a second floor window. Based on today's inspection, observations and interviews, deficiencies will be cited to address above mentioned concerns. Deficiencies noted on LIC809, LIC809D. An exit interview was conducted where this report was discussed, reviewed, then provided to facility representative; along with the appeal rights.the state’s words, verbatim · CDSS document, Aug 31, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(f)(1) · Plan of correction due date: Aug 31, 2023

87303 Maintenance and Operation "(f)Solid waste shall be stored and disposed...(1)Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease..." This requirement is not met as evidenced by: Based on observations, the Administrator failed to uphold the requirement listed above by not properly disposing of a resident's solid waste which poses an immediate Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Administrator agreed to have the resident's room thoroughly cleaned during LPA visit Administrator agrees to have staff check on the resident and the room every 30 minutes.. POC has already been completed on 8/31/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(c) · Plan of correction due date: Aug 31, 2023

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: Based on observations, the Administrator failed to have the resident's window repaired when it became weathered and damaged causing the resident access outside a second story.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Administrator agrees to have the window screen replaced with a screen free of damage, that can be secured to the resident's window.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 1, 2023

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. This requirement was not met as evidenced by: Based on observations, the Administrator failed to keep the resident's bathroom clean, safe and sanitary. This poses a potential Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Administrator agrees to have the resident's bathroom cleaned and maintained by housekeeping staff. Administrator was able to have this completed during the visit. POC has been completed on 8/31/2023. Administrator also agrees to read and review the mentioned regulation, complete a statement of understanding by way of an LIC9098 form and submit it to the community care licensing office with in the next 7 days.

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report. (56-AS-20230818143744) LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 31, 2023

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report. (Complaint #56-AS-20230727151227) LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 31, 2023

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) made an unannounced case management visit to deliver findings and obtain signatures for an amended report complaint #56-AS-20230208105433. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report. An exit interview was conducted where this report was discussed and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 31, 2023

Allegation investigated: Resident is being physically attacked by another resident in care.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale unannounced to deliver the findings of the complaint investigation. LPA met with Araceli Soto, Care Coordinator to discuss elements of the complaint allegations. It is alleged that Resident is being physically attacked by another resident in care. Staff interviewed denied the incident happened. LPA observed resident notes dated 07/01/23 that state R1 was bit by R2. Based on LPA observation, the allegation resident is being physically attacked by another resident in care is substantiated. Substantiatedthe state’s words, verbatim · CDSS document, Aug 28, 2023 · control 56-AS-20230727151227

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87468.2(a)(4) · Plan of correction due date: Jul 1, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidenced by: Based on observations and interviews, Administrator failed to provide the level of care and supervision needed for R1 & R2, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2023

Plan of correction: The POC has already taken place, R2 was moved off of the Memory Care Unit, separating R1 from R2. Additionally, medical treatment was sought and provided to R1. LPA observed the intervention methods in place.

Allegation investigated: Staff abandoned resident at a mental health facility.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to unannounced to deliver the findings of the complaint investigation. LPA met with Care Coordinator Assistant, Gwen Galvan to discuss findings. It is alleged that the staff abandoned resident at a mental health facility. Staff interviews revealed that a resident in care began experiencing an increase in negative behaviors toward staff and residents. Medication Technicians and Administrative Staff worked within the resident's support system to make arrangements to get the resident psychiatric assistance. Included with arrangements was transportation of the resident. Record reviews indicated that the resident's admission to another facility was confirmed before the resident was transported out of the facility. Staff at the accepting facility were aware of the resident's incoming admission to their facility. Please see LIC9099-C Unsubstantiated Based on information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with a facility representative and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 56-AS-20230622102617

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to obtain a signature on an Amended Report. LPA met with Care Coordinator Asst., Gwen Galvan who signed report. No deficiencies observed during visit. An exit interview was conducted, this report was discussed, reviewed then provided to facility representative.the state’s words, verbatim · CDSS document, Aug 23, 2023

Allegation investigated: Staff is allowing resident leave the facility without staff supervision.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint allegation into the allegations listed above. LPA approached the front desk, introduced self and stated purpose of the visit. Staff informed LPA that the Administrator and Care Coordinator are out for the day, but Care Coordinator Assistant, Gwen Galvan, (GG) offered to assist LPA. LPA and GG met and discussed the complaint. Today's visit included a walk through of the facility, staff and resident interviews, file review and collection of pertinent documents. It is alleged that staff is allowing resident to leave the facility without staff supervision. LPA interviewed staff and resident. Interviews revealed that R1 can leave the facility on their own. LPA conducted a file review and observed the resident's most recent Physician’s Report which indicates the resident can leave the facility without supervision. Unsubstantiated Based interviews and LPA observation, the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with where this report was discussed, reviewed, then provided to facility representative.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 56-AS-20230818143744

Allegation investigated: Facility staff did not assure resident have hot water to shower. Resident's roof is in disrepair.

Licesning Program Analyst, Amber Coleman arrived at the Montclair Royale Senior Living Facility to unnannounced to deliver the findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Administrator, AnnaMarie Santos, to discuss elements of the complaint. It is alleged that facility staff did not insure residents had hot water to shower. During staff interviews, LPA learned that the facility's boiler stopped working properly between 1/30/23 and 2/3/23. Maintenance staff examined the boiler and determined a part was required in order to fix it. Receipts from Ferguson Enterprises indicate, new part was ordered on 2/4/23, picked up on 2/5/23 and the facility boiler was fixed by 2/6/23 restoring hot water to the facility. It is alleged that the resident's room is in disrepair. Resident and staff members statements were consistent. The resident's room had a water leak in the ceiling. LPA also observed evidence of a water leak on the resident's room ceiling. LPA observed the resident's room ceiling to have a number of brown Substantiated circular stains right above the resident's bed. According to building records, the facility's air conditioning units do leak water/fluid when in use on occasions. The maintenance staff will address these water leaks with priority when reported. Also, observed were towels on the floor, positioned under the stains seemingly to catch the fluid as it drops from the ceiling. LPA observed a white material over the stain as if it were patched. The ceiling was not actively leaking during LPA observation. Based on LPA’s interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D. An exit interview was conducted where this report was reviewed, discussed, and a copy was provided to facility representative. tray. The facility care for residents with varying ambulatory statuses. Depending on how long it takes a resident to get to the door, their food could be waiting outside their room for five to ten minutes; which allows time for the food to cool. Record reviews, LPA discovered that all dietary staff have the proper Food Service/Handling Training. The facilities laundry room houses washers and dryers that automatically dispense laundry detergent to the wash basin. This device is secure and is only serviced by maintenance staff. Staff reports that bleach isn't used in resident laundry rooms. Staff denies having knowledge of or witnessing any recent incidents involving damage to residents clothing. LPA was unable to observe any laundry said to have been damaged by facility laundry services. LPA interviewed four, (4) residents, three (3) out of 4 residents denied suffering any damage to their clothing due to facility laundry services. It is alleged that facility staff did not keep resident's room free of pests. LPA completed a walk through of the facility and observed no evidence of pests in the facility. LPA did observe that residents are permitted to keep food in their rooms. Staff advises residents to keep food containers sealed/closed to prevent pest problems. Staff reported and LPA observed that some residents have their own refrigerators and microwaves in their rooms. Housekeeping aids residents in cleaning their rooms on a weekly basis. During staff interviews, it was discovered that the facility contracts pest control services. Pest control services the facility twice a month and on call as needed. Residents are encouraged to report any pest problems to the front desk; alerting staff to contact Pest Control to book additional appointments. Based on the information recorded above, We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 56-AS-20230206124429

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Aug 22, 2023

87303 Maintenence and Operation (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Based on interviews and record reviews the Administrator did not insure the facility provided hot water to residents for personal care which poses a potential Health, Safety and Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: Plan of Correction was completed on 2/6/23 when the facility's boiler was fixed resuming hot water to residents in care.

Allegation investigated: Staff did not prevent resident from being a victim of financial abuse by an unknown perpetrator. Staff did not dispense resident's medication as prescribed Medication was falsely recorded as being refused by resident

Licensing Program Analyst, Amber Coleman (LPA) arrived to the Montclair Royale Senior Living unannounced to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator Assistant, Gwen Galvan to discuss elements of the allegations.During today's visit, LPA conducted staff and resident interviews, a walk through of the facility and collection of pertinent documents. It is alleged that staff did not prevent resident from being a victim by an unknown perpetrator. During interview, with R1, it was reported that R1 put a large sum of cash in her nightstand; approximatley, $700. This was reported to staff who contacted Law Enforcement for assistance. Staff interviews revealed that this incident occured in December 2022. The Montclair Police Department was contacted and made a visit to the facility. Police determined there was not enough evidence to make a report or pursue the theft. Please see LIC9099-C Unsubstantiated During the facility visit, LPA made three different attempts to interview R1 in her room, unsuccessfully. While doing so, LPA observed that on each occasion, residents' kept their door wide open. The room is on the bottom floor near the lobby. The door opens up to a busy hallway. Resident's use this hallway to get the court yard and dining rooms. It is alleged that staff did not dispense resident's medications as prescribed and medications are being falsely recorded as a refusal by resident. Staff interviews revealed that residents who are prescribed insulin receive their injections in the presence of a Medication Technician for the purposes of safety and security. Furthermore interview with S1 revealed that originally R1's medication was prescribed for 6am. S1 observed R1 was missing doses due to R1 being asleep at the time needed to take the medication. Record reviews revealed the prescription was modified. The time of the prescription was changed to a later time; allowing the resident to sleep in. LPA reviewed the facility's Medication Administration Record, (MARS) for R1. LPA observed no evidence indicating medications were not being administered as prescribed. Interview with R1 revealed that Medical Technician's used to bring the medications to her room, but that changed recently. Staff informed R1 she would need to go to the Medications Office to get her medications. She had no problem with the change, but a family member reported that she did not agree and expressed frustration. Based on observations, interviews and record reviews, we have determined that these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with facility representative, where this report was reviewed, discussed then provided.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 56-AS-20230818153950

Type of visit: Case Management - Incident

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 8/15/23. The incident involves a resident in care who gained access to and consumed perfume. LPA met with Administrative Staff, Gwen Galvan. LPA introduced self and stated purpose of the visit. Today's visit consisted of collection of pertinent documents, a walk through the resident's floor and assigned room and staff interviews. LPA observed three to four staff members on the floor at the time of the visit. LPA asked staff to show LPA were the chemicals and toxins are kept to inspect the area. Staff escorted LPA to the floor's dining area where two white cabinets are housed. The cabinets stood approximately 4 feet tall. Each cabinet has double doors. They each have the equipment necessary to secure the cabinet. At approximately 1:25pm, LPA observed the two cabinets and observed that while the doors were shut, the locks were not engaged, making it accessible to residents in care. Based on observations and interviews, one deficiency will be cited per Title 22, Division 6, of the California Code of Regulations. An exit interview, was conducted where this report was discussed, reviewed and provided to Facility Representative.the state’s words, verbatim · CDSS document, Aug 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 17, 2023

87309 - Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observations and interviews, the Licensee failed to keep the storage of chemicals and toxins inaccessible to residents in care. Which poses an immediate Health, Safety and or personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: Licensee agrees to conduct another staff training regarding maintaining secure storage of chemicals on 8/23/23. Licensee also agrees to increase the amount of staff on the floor for additional supervision of the residents in care.

Allegation investigated: Staff did not inform resident's responsible party of incident(s).

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to initiate a complaint investigation into the allegations listed above. LPA signed in and met with Care Coordinator, Araceli Soto. It is alleged that staff did not inform resident's responsible party of incident(s). Interview with staff revealed that two (2) incidents occurred between residents and responsible party was informed. LPA observed an incident report with a notation that responsible party was notified. Interview with responsible party denies receiving any notification about the incidents. Interviews with staff, resident and responsible party revealed conflicting information regarding if incident was reported to responsible party. Due to conflicting interviews, the allegation, staff did not inform resident's responsible party of incident(s) is unsubstantiated. Unsubstantiated We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.the state’s words, verbatim · CDSS document, Jul 31, 2023 · control 56-AS-20230727151227

Allegation investigated: Staff did not properly assist resident with their medication. Facility kitchen is in disrepair. Facility has rodents. Resident's dietary records are not maintained. The water temperature is not within the required range of 105 F to 120 F.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Care Coordinator Araceli Soto. The investigation consisted of resident interviews, staff interviews, document review, and a facility tour. For allegation, Staff did not properly assist resident with their medication: It was alleged that two (2) residents (R1 & R2) did not get assistance with refilling their medication in a timely manner. Interviews with staff and document review revealed that there was an uncontrollable shipping delay with the shipping partner that the pharmacy uses to deliver medications. The pharmacy and the facility worked together to resolve the issue by using an alternative shipping company. Unsubstantiated For allegation, Facility kitchen is in disrepair: Facility tour and interviews with staff revealed that the freezer door in the kitchen was broken. The freezer door closes but it must be pushed hard to ensure the door latches correctly. The facility has been proactive and ordered a new freezer door. The facility issued payment to a company on 10/27/2022. There were issues with the company completing the work after the payment was issued. The facility had to take the company to small claims court to resolve the issue. The facility found a new company and a new freezer door was installed on 6/23/2023. Document review and interviews with staff revealed that the facility has a contract with SMC Grease Specialists. The company comes to the facility to clean and remove the grease from the oven and the stove. In between visits, the facility staff cleans the surface of the oven and stove. For allegation, Facility has rodents: Interviews with residents and staff revealed that the residents and staff have not seen rodents at the facility. Document review of pest control statements dated September 2022, October 2022, and November of 2022 revealed that the facility has monthly pest control treatments completed by Dewey Pest Control to ensure the facility prevents rodents. If there is a complaint of pest or rodents, the staff stated that they are proactive, and call Dewey Pest Control out to the facility to complete a follow-up treatment to resolve the issue. For allegation, Resident's dietary records are not maintained: Interviews with staff and document review revealed that the facility maintains dietary records in the kitchen, as well as in the facility office in the resident’s individual files. For allegation, the water temperature is not within the required range of 105 F to 120 F: During the facility tour, LPA observed the water temperature to read within the required range at 115 degrees Fahrenheit. Overall, there was not enough evidence to collaborate the allegations listed above. Based on evidence obtained during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Care Coordinator Araceli Soto, along with a copy of the appeal rights. Based on evidence obtained during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because of the preponderance of evidence the standard has been met. During today’s visit, one deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Care Coordinator Araceli Soto, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jul 28, 2023 · control 56-AS-20221228154401

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(17) · Plan of correction due date: Jul 31, 2023

87555.General Food Service Requirements. (b)The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. Based on observation, interview and document review, the licensee did not comply with the section cited above evidenced by not employing a qualified kitchen staff to ensure the residents were provided with proper food service which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2023

Plan of correction: The licensee has agreed to read regulation 87555 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee hired a qualified kitchen staff on 1/3/2023. The staff started working on 1/16/2023. The POC due date is 7/31/2023.

Allegation investigated: Staff threatens resident in care. Staff does not provide resident's clean clothing. Facility washer/dryer is in disrepair.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to the facility to continue the complaint investigation and deliver findings on the above allegation. LPA met with assistant care coordinator Gwen Galvan who was informed of the purpose of today’s visit. Administrator Annamarie Santos arrived during the visit. The investigation consisted of staff interviews, LPA observations, and records review. LPA was not able to interview Resident 1 (R1). Allegation 1: Staff threatens R1 in care. It is alleged that R1 is experiencing ongoing verbal threats. LPA reviewed records that R1 was admitted to this facility on 8/26/2022. CCL received incident reports stating that R1 was observed by staff and residents entering and leaving rooms that R1 do not occupy. Additionally, CCL visited the facility due to a report that emergency services were unable to access R1 due to clutter in their room. Staff interviews deny that they threatened R1 but rather informed them that they may be evicted for violating facility house rules. This allegation is therefore unsubstantiated Unsubstantiated Allegation 2 and 3: Staff does not provide resident's clean clothing AND Facility washer/dryer is in disrepair. Interviews with residents and staff revealed that facility washers and or dryers would break often. LPA reviewed records and found that, of the current census 92 residents are signed up for facility laundry services, which averages to 13 services per day. LPA observed four laundry rooms in the facility, three of which had two sets of washer and dryer and one with commercial units specifically used by staff. Staff interviews revealed that residents or their authorized parties purchase residents' clothing and may bring the clothing items to be washed and cleaned at their own homes. Based on the information obtained during this investigation, the allegations are unsubstantiated. A finding of UNSUBSTANTIATED means that 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. An exit interview was conducted with administrator Annamarie Santos.the state’s words, verbatim · CDSS document, Jul 24, 2023 · control 56-AS-20230412140600

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.

Allegation investigated: Resident fell sustaining an injury while in care.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to the facility to continue the complaint investigation and deliver findings on the above allegation. LPA met with assistant care coordinator Gwen Galvan who was informed of the purpose of today’s visit. Administrator Annamarie Soto arrived during the visit. The investigation consisted of resident interviews, LPA observations, and records review. It is alleged that Resident (R1) fell sustaining an injury while in care. CCL Regional office received an incident report that on 4/6/2023 R1 was sent to the hospital after being found with a skin tear from a suspected fall. LPA reviewed records stating that R1 was admitted to this facility on 9/16/22, does not need a 1-1 assistance, and ambulates independently without any physical assistance. LPA did not find any other incidents relating to a fall. LPA attempted to interview R1 but was unsuccessuful due to R1's cognitive impairment. However, LPA observed R1 stand from sitting on their recliner and walk from their room to the hallway without wassistance. The allegation is therefore UNSUBSTANTIATED. Unsubstantiated A finding of unsubstantiated means that 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. An exit interview was conducted withthe state’s words, verbatim · CDSS document, Jul 24, 2023 · control 56-AS-20230412104719

Allegation investigated: Staff did not inform resident's authorized person of changes to resident's care/placement.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to the facility to continue the complaint investigation and deliver findings on the above allegation. LPA met with care coordinator assistant Gwen Galvan who was informed of the purpose of today’s visit. Administrator Annamarie Soto arrived during the visit. The investigation consisted of staff interviews and records review. LPA was unable to speak with Resident (R1). It is alleged that Staff did not inform resident's (R1) authorized person of changes to resident's care or placement. LPA reviewed records showing that R1 previously resided at this facility from 10/05/2021 through 06/11/2023. Records reviewed show that R1 was under the care of the San Bernardino County Office of the Public Guardian (PG). Interview with staff reveal that the facility contacted the PG as early as 06/09/23 due to R1 attempting to self admit at a medical facility for experiencing hallucinations. LPA reviewed records from 06/09/23 through 06/11/23 noting R1's aggressive and harmful behaviors and the facility contacting the PG daily. Records further revealed that on 6/11/23 R1 was taken and held at a hospital and on 6/12/23 R1's Unsubstantiated healthcare case worker notified this facility that they have been in touch with the PG about R1's hospital admission and finding an appropriate placement for R1. Based on the information obtained from records review and interview conducted, the above allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with and a copy of this report was provided to .the state’s words, verbatim · CDSS document, Jul 24, 2023 · control 56-AS-20230623110652

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Amber Coleman, (LPA) conducted an unannounced complaint visit for complaint number - 56-AS-20230717143120. During this visit, LPA observed deficiencies not related to the complaint allegations. At 11:30am, while in resident's room, LPA observed the resident room windows to be missing window shades on both the sliding window and the window adjacent to it. At approximately 11:33am, LPA observed the resident closets to be missing both sliding doors. After observing the closet, at approximately 11:35am, LPA observed three dark stains on the carpet near the foot of the resident bed. LPA entered the resident restroom. Along the wall opposite the sinks, LPA observed the towel racks missing from the wall; appearing broken off the wall. Resident interviews reveal the windows were missing shades, the broken towel rack and stained carpet were in that condition upon moving in February 2023. During staff interviews, LPA learned that there are no records indicating residents reported any maintenance issues in the residents' room. Staff deny having any knowledge of the maintenance issues in the resident rooms. Up until recently, the facility kept no records or tracked the status maintenance orders. Based on the observations and staff and resident interviews made during today’s visit, deficiencies will be cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted. A copy of this report was reviewed, discussed then provided to Facility Representative.the state’s words, verbatim · CDSS document, Jul 18, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087(a) · Plan of correction due date: Aug 18, 2023

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by: Based on observations and interviews, Administrator did not ensure the residents' room was kept in good repair at all times. Which poses poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 18, 2023

Plan of correction: Administrator and Care Coordinator agree to have the resident's window shades replaced, the resident's carpet shampooed and towel rack in the restroom repaired within the next 30 days. Administrator agrees to submit proof the repairs were made to the Community Care Licensing Office within the next 30 days.

Allegation investigated: Illegal Eviction

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to initiate a complaint investigation into the allegation listed above. LPA introduced self to staff, singed in visitor's log and stated the purpose of the visit. LPA met with Administrative Staff Member, Gwen Galvan, who informed LPA Care Coordinator, Araceli Soto and Administrator, AnnaMarie Santos-Tabila were out of the facility. During the interaction, Gwen Galvan informed Care Coordinator, of LPA's visit. During the visit, LPA met with staff and residents for interviews, collected pertinent documents, completed a walk through of the facility and delivered findings. Staff interviews and correspondence revealed that there was an attempt to evict a resident in care in 3 days; due to an increase in aggressive behaviors. Documentation collected revealed that the request to evict the resident in 3 days was not approved by the Community Care Licensing Office. Documentation further revealed that the 30 day eviction pursued afterwards was invalid. Therefore making the eviction illegal. Please see LIC(9099) Substantiated Based on LPAs observations, interviews conducted, information collected, the preponderance of evidence standard has been met, therefore; we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 56-AS-20230711095633

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87224(b) · Plan of correction due date: Aug 17, 2023

Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. This requirement was not met as evidenced by: Based on interviews, collected documentations and onservations the licensee did not acquire the approval of a 3 day eviction from Community Care Licensing. The 30 day Eviction Notice pursued after the denial was invalid as it was not complete which which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2023

Plan of correction: Administrator/Licensee agrees to complete a 30 Day Eviction correctly with applicable dates and re-issue the eviction to the resident's Power of Attorney. Administrator will also submit proof the Eviction Notice was issued to the Community Care Licensing Office. Adminstrator agrees to work with the Long Term Care Ombudsman and Innovage, Social Worker to secure suitable, licensed care and housing for the resident in care. Administrator agrees to complete a LIC9098 self-certifying that the Eviction Procedure Regulation is understood. Each task is to be completed within the next 30 days

Allegation investigated: Staff failed to provide a safe and comfortable environment for resident Staff failed to safeguard resident's personal belongings Staff failed to reimburse resident

Licensing Program Analyst, Amber Coleman, (LPA) arrived to the Montclair Royale Senior Living Facility unannounced to deliver findings of the complaint investigation. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto and stated purpose of the visit. The investigation included staff, resident, and witness interviews, collection and review of resident files/documents. It is alleged that staff failed to provide a safe environment for the resident. Witness and Resident (R1) interviews revealed that the resident moved in and was placed with another Resident (R2). The two (2) residents shared a conflict with one another that resulted in a physical altercation. Facility staff separated the two residents by finding another room for R1. The Police were called. Police determined that there was no action to be taken because both residents involved had assaulted one another. Staff interviews were consistent with the witness and R1’s interviews. According to the facility’s, “Theft and Loss Policy”, “…upon request and at the expense of the resident provide a look for the resident Please see LIC9099-C** Unsubstantiated Bedside drawer or cabinet.” Staff reported a lockbox was not provided to the resident, because R1 had not made a request for a lockbox. Additionally, the resident was not paying an extra fee for a lockbox to be provided. It is alleged that staff failed to safeguard resident’s personal belongings. While interviewing R1 and the witness, LPA learned that; after R1 was relocated to the new room, R1 was given $150 in cash. After spending an amount of the cash; it was put away in his room within his belongings. R1 left for the day and returned to find that the cash was no longer in his room. R1 brought this to the attention of staff. Staff suggested R1 contact the Police to make a report. R1 refused to call the Police with the claim that R1 would not get their money back. R1 also reported that while staff was assisting him with moving his belongings to this new room, all of belongings were not moved. Staff interviews revealed that photos were taken to catalog the relocation. During the move the resident signed and stated a statement in agreement confirming that all his personal belongings were moved to the new room. During a review of records, R1’s Personal Property/Valuables Form, the resident had “no valuables” listed. The form is not dated, therefore it is not complete. It is alleged that staff failed to reimburse the resident. After R1 informed management staff of incident, management and the Corporate Office agreed to reimburse the resident the cash that was allegedly stolen from his room in the amount of $80.00. Although, it was 2 months before management honored the request the resident was reimbursed in cash in the amount of $80.00 on 5/16/2023. Also, during this process Management had initially agreed to reimburse the R1 in the form of a check. R1 expressed that he currently had no state identification and would be unable to cash the check if given to him. Management also honored this request. Based on staff, resident and witness interviews, review of records and observation, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means 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. An exit interview was conducted with Araceli Soto, Care Coordinator, this report was reviewed, discusses and provided.the state’s words, verbatim · CDSS document, Jun 28, 2023 · control 56-AS-20230511112540

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior. Living Facility unannounced to conduct a case management visit. This case management visit was conducted to collect additional information regarding complaint #56-AS-20230413141951 and obtain signatures . LPA introduced self to staff and stated purpose of the visit. LPA met with Administrator, AnnaMarie Santos-Tabila and Care Coordinator, Araceli Soto. This visit included an interviews, collection and review of additional records and a walk through the residents room. No deficiencies were observed during this visit. An exit interview was conducted, this report was reviewed, discussed and provided to Facility Representatives.the state’s words, verbatim · CDSS document, Jun 28, 2023

Allegation investigated: . Facility did not safeguard resident's personal property.

During staff interviews, LPA learned that Resident #1, (R1) moved into the facility on August 25th, 2022. R1 and his family worked together to complete an Admissions Packet which included the facility's House Rules and a Pre Appraisal form. The documents were signed on 8/25/22 which signified that the house rules were understood and would be followed by R1. The Pre-Appraisal form indicated that R1 entered the facility with no belongings of substantial value, this document was also signed on 8/25/22. It is alleged that the facility did not safeguard the resident's personal property. LPA observed an Incident report dated on 3/15/23 which indicated R1 suffered a medical emergency and had to be taken to the Hospital. When Medical Staff arrived, they had a hard time getting to R1 due to the amount of clutter in the room. When R1 returned to the facility from the hospital, he alleged the facility had stolen his property. During interviews with staff and R1, LPA learned that the items removed from R1's room were what is considered contraband. Staff confiscated the items and put them in a secure storage room. R1's account of the items was consistent with staff's account. The facility will release R1's items at the time he Unsubstantiated The facility will release R1's items at the time he successfully moved out of the facility. Based on interviews, observations and records reviews, we have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.the state’s words, verbatim · CDSS document, May 31, 2023 · control 56-AS-20230330093256

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.683(a)(2) · Plan of correction due date: Mar 30, 2023

§1569.683 Eviction notices; reasons for eviction contents; service (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...the notice to quit shall include all of the following:(2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations. This requirement was not met as evidenced by: Based on record reviews and interviews, the Administrator illegally issued an eviction notice to the resident when the wrong contact information was given as a resource. This poses a potential health, safety and personal rights risk to persons in care,the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The plan of correction has been addressed, the Administrator re-issued a corrected eviction notice for R1. LPA observed the corrected eviction notice.

Allegation investigated: Staff not providing meals as suggested by doctor.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to initiate a complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto to discuss the complaint and allegations. The investigation consisted of staff and resident interviews, record reviews and observations of the kitchen and food service. During staff interviews, LPA learned that dietary needs are discussed during the admissions process. Their dietary needs are also documented. If the dietary needs should change, the doctor sends orders directly to the facility. Doctor orders for dietary needs are given to the Dietary Staff who keeps records of these changes. Kitchen staff print a daily list of residents who require a certain diet. Kitchen staff report that meals are always prepared and provided to residents in care. Often times, resident may not like one item or another. It is a resident's choice to eat the food or not eat the food. During resident interviews, LPA learned that the resident is being provided food items as suggested by the doctor. The food may not be prepared to all residents' liking's. LPA observed no evidence that meals are not being provided based on doctors orders. Unsubstantiated We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.the state’s words, verbatim · CDSS document, May 30, 2023 · control 56-AS-20230526084728

Allegation investigated: . Staff do not ensure that resident is accorded privacy while in care. 2. Staff do not ensure that the facility is in good repair.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility unannounced to deliver findings of complaint investigation into the allegations listed above. LPA introduced self and stated purpose of the visit. LPA met with Care Coordinator, Araceli Soto. It is alleged that staff did not ensure that the resident was accorded privacy while care was being provided. Interviews with residents revealed that the blinds from their two room windows were missing. The resident's room is located on the bottom floor adjacent to the entry way to the facility patio. When it becomes dark out, the room is illuminated, allowing a view into insde the resident room. This was reported to staff on several occasions, but was never addressed. On 4/14/23, at approximately 4pm, LPA observed the window blinds missing. Staff interviews revealed, that the facility does have a work order system in place. Residents will verbally report to maintenance staff what needs to be fixed, the maintenance staff member will fix it and record it in a binder kept at the front desk. Residents will also report to front desk staff what's broken, staff will complete a work order form and give it to maintenance to be completed. At this time, the maintenance department is comprised of one staff member. Please see LIC9099-C Substantiated There are no records of when the missing window blinds were reported by the residents. There is only record of when it was fixed. Records show it was fixed on 4/14/23. There is no record of the amount of time that passed between when the item was reported broken and when it was fixed. As of today 5/30/23, at 11:15am, LPA observed the window blinds were replaced. It is alleged that staff do not ensure the facility is in good repair. During the staff interviews it was reveled that the facility has a system for work orders to be processed and addressed. At this time and for the past 6 months or more, the maintenance department is comprised of one (1) staff member. The facility maintains a Service Log which is meant to keep track of work orders being reported and when they are completed. At this time, the facility does not keep track of the progress of those work orders. For example, maybe a task requires a special part or tool in order to be fixed or addressed, there is no record of what has been done or what is needed in order to be fixed. Because progress of these work orders are not being tracked, there is only 1 maintenance staff member and there is a high volume of residents in care it is likely that some work orders do not get fixed in a timely manner. We have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with and provided to the facility representative. Please see LIC 9099D. We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.the state’s words, verbatim · CDSS document, May 30, 2023 · control 56-AS-20230413141951

From the deficiency page — Deficiency type: Type B · Section cited: HSC 80087(a) · Plan of correction due date: May 30, 2023

80087 - Buildings and Grounds- (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Observations of the residents room windows missing a number of blinds. Observations of no record of the window blinds being reported. This poses a potential Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 30, 2023

Plan of correction: Licensee/Administrator agrees to make changes to the work order system to better address how work orders are processed in order to address resident needs. Administrator/Licensee agrees to have residents or staff complete a work order form when the resident reports something to be fixed. Administrator/Licensee agrees to adopt this change from this day (5/30/23) forward. During visit, staff made changes to the way in which work orders are placed and progress can be tracked.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.2(a)(1) · Plan of correction due date: May 30, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance... This requirement was not met as evidenced by: Based on observations of the resident room and resident interviews the resident was not accorded personal privacy while care was being provided and the window shades were missing. This poses a potential Health, Safety and Personal Rights risk to persons in care,the state’s words, verbatim · CDSS document, May 30, 2023

Plan of correction: Administrator agreed to have the missing window shades replaced by the maintenance staff. As of 5/30/23, the resident's window shades have been replaced, verification submitted to Community Care Licensing. The plan of correction has been completed.

Type of visit: Case Management - Incident

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Montclair Royale Senior Living Facility to conduct a case management visit for health and safety. Specifically, following up regarding a theft and loss incident involving a resident. LPA introduced self and stated purpose of the visit. LPA met with Assistant Care Coordinator Gwen Galvan, (ACC). LPA inquired about the timeline of events on 3/13/23. ACC reported that on 3/13/23 the resident was taken to the San Antonio ER due to chronic foot pain. During the time the EMT's were preparing the resident for departure. EMT's commented, ".....That the resident's room is too cluttered making the room inaccessible to staff or medical professionals to get in and assist the resident. There was no place to put the resident to be able to access him." After the resident left staff entered the resident's room to clean it up. LPA's visit consisted of staff interview, collection and review of resident file. The incident report submitted on 3/13/23. ACC also reported that items removed from the resident's room were what the facility considers contraband. Illegal substances, open torch lighter, switchblade and powered drill were removed from the room. Also, trash items. Otherwise the room was made orderly. Items were put back in their place. Items in drawers, clothes in dresser, bathroom counter cleared. Upon the resident's return he discovered that his room had been cleaned and items removed. The resident became irate and showing aggressive behaviors. Kicking and yelling at staff, banging on the doors and glass window at the front desk. Police were contacted to make a visit due to the resident's aggressive behavior. When Police arrived, staff reported the incident and reviewed items taken from the room. The Police did not confiscate the items, they remained with the staff for storage. The resident's kicking of the facility property, resulted in a wound reopening and he was taken to the ER for medical attention. LPA was provided a Police Report No., copy of the resident's personal property list and before and after photos of the resident's room being cleaned. No deficiencies were observed during this visit. An exit interview was conducted where this report was discussed and provided to Assistant Care Coordinator,the state’s words, verbatim · CDSS document, Mar 22, 2023

Type of visit: Case Management - Other

Licensing Program Analyst, Amber Coleman (LPA) arrived at the Montclair Royale Senior Living Facility to conduct a Case Management visit for the purposes of gathering more information regarding a complaint. LPA introduced self and stated the purpose of the visit. LPA was greeted by staff and informed that the Administrator was out for the day, but LPA could speak with staff available if there were any questions. LPA's visit consisted of observation of the dining rooms, resident rooms, kitchen area, staff and resident interviews and collection of pertinent documents. No deficiencies were observed during today's visit. An exit interview was conducted where this report was discussed and provided to Araceli Soto, facility representative.the state’s words, verbatim · CDSS document, Mar 6, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Anna Bueno made an unannounced subsequent visit to this facility to conduct additional interviews for complaint control number 56-AS-20220329095154 and to discuss the requested extension for a plan of correction (POC). LPA met with administrator Annamarie Santos who was informed of the nature of today's visit. LPA interviewed four residents and one staff. LPA approved a new POC date of 2/9/23 for citation issued during 12/7/22 visit [CCR 87555(b)(8)]. No deficiencies were cited during today’s visit. An exit interview was conducted where this report was discussed with, and a copy was provided to Mrs. Santos at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 10, 2023

Allegation investigated: Residents elope due to facility door lock broken. Food service staff serve expired food and uncooked food. Facility is in disrepair.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to continue the investigation of and deliver findings on the above mentioned allegations. LPA met with care coordinator Araceli Soto who was informed of the reason for today's visit. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1 and 2: Residents elope due to facility door lock broken AND Facility is in disrepair. The Department received a special incident report of resident elopement. Staff interview revealed that the memory care door lock was broken, allowing memory care residents to leave the unit. Staff further stated that care staff assigned to temporarily guard the door quit and walked off in the middle of their shift. This allegation is substantiated. Allegation 3: Food service staff serve expired food and uncooked food. Witness interviews confirmed that food items were expired and tossed out. Interviews reveal that staff are unable to verify whether food items have been cooked thoroughly. This allegation is substantiated. Substantiated Allegation 3: Staff did not administer medication as prescribed. Staff interviews confirmed that medication is administered during usual meal times. Staff further state that medication is popped from their bubble pack before medication is given to the 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 at this time. An exit interview was conducted where this report was discussed and provided to facility representative. Allegation 3: Facility is in disrepair. On 4/7/22, LPA Bueno observed the facility front double doors with a broken left door and observed maintenance staff repair the door. LPA observed the same facility door permanently secured with a sign posted to "use other door", the right one, during a subsequent visit on 5/6/22. During today's visit, LPA Bueno reviewed documents showing that the memory care unit lock was broken as of 5/17/22 and was repaired on 6/11/22 by the same company providing security services for the memory care unit. Based on interviews and records review, the above allegations are therefore SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. These pose health and safety risks to residents in care. Refer to LIC 9099D for deficiency cited. An exit interview was conducted with Mrs. Soto and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 7, 2022 · control 56-AS-20220602102400

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Dec 9, 2022

The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by: LPA observed a broken front door and LPA received a recorded video of the facility common room ceiling leaking heavily. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: As of today's visit, the facility has repaired the memory care unit and facility front doors. The facility shall submit proof of recent service for roof maintenance to the Department no later than the POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Dec 30, 2022

The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by: Witness interviews confirm that expired food items and milk were stored and sometimes served to residents in care. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: As of today's visit, the facility had a change in kitchen management and proper food handling practices are currently in place. CCL shall receive an end of year progress report from head chef on newly implemented procedures for all kitchen staff by the POC date.

Allegation investigated: Uncleared staff working at the facility. Staff have not received required training. Facility is in disrepair.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to continue the investigation of and deliver findings on the above mentioned allegations. LPA met with care coordinator Araceli Soto who was informed of the reason for today's visit. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1: Uncleared staff working at the facility. LPA reviewed records and found Staff (S1) was associated to the facility for a time. Interview with staff confirms that S1 was employed by this facility and terminated when the facility received the exemption denial letter from CBMP. Allegation 2: Staff have not received required training. LPA received and reviewed facility med tech schedule and found Staff (S2) on rotation. Staff interview revealed that S2 has not received their full medication training and is shadowing current med techs. Records show that S2 is assigned a schedule and witness interview verified that S2 has been administering resident medication. Substantiated Allegation 3: Facility not maintained clean and sanitary. LPA received and reviewed records for scheduled carpet cleaning by a third-party vendor. LPA toured the facility, including the memory care unit with newer carpet than the rest of the facility, and observed the facility as orderly. Staff interviews reveal that some residents may create more mess than other while some may purposely leave clutter and trash around the facility. This allegation is unsubstantiated. Allegation 4, 5, and 6: Facility does not meet residents' personal care needs, Staff do not groom residents, and Staff do not shower residents. LPA received and reviewed resident schedule for laundry and showers. Also, LPA toured the facility, including the memory care unit, and observed residents R1 and R2 in the memory care hallway with appropriate clothing and shoes. Interview with staff reveal that it is not unusual for memory care residents to share or forget clothing items. LPA observed a storage closet in the memory care common area with lost items and observed these items with names. These allegations are therefore unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to facility representative. Allegation 3: Facility is in disrepair. On 4/7/22, LPA Bueno observed the facility front double doors with a broken left door and observed maintenance staff repair the door. LPA observed the same facility door permanently secured with a sign posted to "use other door", the right one, during a subsequent visit on 5/6/22. Also, LPA Bueno received video recording of a leaky ceiling in a facility common room. Based on interviews and records review, the above allegations are therefore SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. These pose health and safety risks to residents in care. Refer to LIC 9099D for deficiency cited. An exit interview was conducted with Mrs. Soto and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 7, 2022 · control 56-AS-20220329095154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Nov 28, 2022

(e) All individuals subject to a criminal record review pursuant to HSC Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a CA clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by: Records review and staff interview confirm that S1 was working prior to receiving their background clearance. This poses an immediate safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: At the time of the initial visit, S1 had been separated from the facility. During today's visit, it was found that Staff1 is currently working while their clearance is still pending.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Dec 9, 2022

The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by: LPA observed a broken front door and LPA received a recorded video of the facility common room ceiling leaking heavily. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: As of today's visit, the facility has repaired the memory care unit and facility front doors. The facility shall submit proof of recent service for roof maintenance to the Department no later than the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(3)(D) · Plan of correction due date: Dec 9, 2022

Policies and procedures regarding medications, including knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection. This requirement was not met as evidenced by: Staff interview revealed that S2 has not completed their initial medication training and the facility is unable to provide proof that S2 had received such training. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 7, 2022

Plan of correction: As of today's visit, the facility has implemented a documented two full week training for all staff administering medication. As of today's visit, S2 is no longer associated to the facility.

Allegation investigated: Communications to the facility are not being answered promptly.

Licensing Program Analysts (LPA) Melody Brown and Victoria Chitgian met with Administrator Annamarie Santos-Tabila at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 10/27/2022 at 10:30 AM to deliver findings for the allegation listed above. LPAs Brown and Chitgian explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and review of pertinent documentations. Through the information gathered during the investigation, it was confirmed by documents review and interviews that Communications to the facility are not being answered promptly. It was alleged that on 07/11/2022, the facility would not answer calls from hospital staff to report Resident 1 (R1) status. LPA Brown initiated the investigation on 07/15/2022. Interviews with staffs indicated knowledge of the implemented Facility Directive to Night/NOC Shift Medical Technicians (Medtech) that *** Continuation on LIC9099 *** Substantiated “Medtechs must make sure to transfer the facility calls to their cellphone.” Interviews with staffs also confirmed that all facility calls at night is the responsibility of the Night/NOC Shift Medtech. Interview with Administrator Annamarie Santos-Tabila (S1) last 10/14/2022 also confirmed that all Medtechs were properly trained and informed of their task/responsibility of answering all calls at the facility during Night/NOC Shift. S1 also said "I am aware of what happened that night and the Medtech on duty that time no longer works at the facility." Based on interviews and records review, the allegation of Communications to the facility are not being answered promptly is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and Appeal Rights were discussed and provided to Administrator Annamarie Santos-Tabila..the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 56-AS-20220712101447

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Nov 3, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have ... (9) To have communications to the... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not having a staff answer facility telephone calls from the hospital involving R1 the night of 07/11/2022. This poses a potential Health and Safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee stated to train all Medtech staff in CCR 87468.1(a)(9) and will submit Training Log to LPA Brown by POC due date. Licensee will submit a Statement of Understanding on CCR 87468.1(a)(9) to LPA Brown by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Melody Brown and Victoria Chitgian met with Administrator Annamarie Santos-Tabila at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 10/27/2022 at 10:30 AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews and a review of pertinent documentation. During the facility visit last 07/15/2022 at 11:30 AM, LPA Brown reviewed documents and observed that Staff Six (S6) have a current criminal background clearance but S6 is not currently associated to the facility. Staff interviews and records review of Personnel Report (LIC500) and Employee Roster indicated S6 started working at the facility 06/02/2022. Civil Penalty was assessed with the amount of $500.00 during the Office Visit for failure to transfer S6 Criminal Background Clearance to the facility. In addition, LPA Brown reviewed facility's incident reports and LPA Brown did not find any Special Incident Reports (SIRs) that the facility submitted to Community Care Licensing Division (CCLD) to report R1's hospitalization and LPA Brown will issue a citation for not reporting the incident at the facility as this pose potential risk to residents in care. An exit interview was conducted where this report (LIC809), LIC80D, LIC421BG and Appeal Rights were discussed and provided to Administrator Annamarie Santos-Tabila .the state’s words, verbatim · CDSS document, Oct 27, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 28, 2022

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing...(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not transferring Staff 6 (S6) Criminal Background Clearance to the facility. This poses a potential Health and Safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee stated to trasfer and update S6 Criminal Background Clearance and submit proof to LPA Brown by POC due date. Licensee will submit a Signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Nov 3, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) of R1's hospitalization CCLD ASC. This poses a potential Health and Safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Brown by POC due date. Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Brown by POC due date.

Allegation investigated: Staff is not assisting resident with hygiene needs. Facility is not safeguarding resident's belongings. Staff are not ensuring resident has clean clothes. Resident's room does not have adequate lighting. Resident's bed does not have appropriate linens. Facility not notifying responsible party about incidents.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Mikaila Tonan, receptionist. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1: Staff is not assisting resident with hygiene needs. Interviews reveal that Resident 1 (R1) is ambulatory and capable of self-care with minimal assistance. Allegation 2: Facility is not safeguarding resident's belongings. Based on observations and interviews, LPA was able to confirm that it is the facility’s policy to have residents label their belongings. Allegation 3: Staff are not ensuring resident has clean clothes. Interviews reveal that R1 always has clean clothes available however R1 may need to change clothes after meals. Allegation 4: Resident's room does not have adequate lighting. LPA was unable to find corroborating evidence relating to this allegation. Allegation 5: Resident's bed does not have appropriate linens. LPA was able to verify that the facility has a supply of clean linen labeled with the facility’s name and residents are also able to use their own linens. Allegation 6: Facility not notifying responsible party about incidents. File reviews and interviews revealed that responsible parties were notified of incidents involving R1. 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 at this time. An exit interview was conducted where this report was discussed and provided to Mrs.Tonan. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 6, 2022 · control 18-AS-20220105101235

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 did not administer resident's medication as prescribed. Staff did not provide adequate food service. Resident was not provided clean linen. Staff did not safeguard resident's personal items.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Mikaila Tonan, receptionist. The investigation consisted of file review, interviews with relevant parties, and observations of the facility. Allegation 1: Staff did not administer resident's medication as prescribed. The investigation revealed that while Resident 1 (R1) was being given medication, R1 will sometimes not take the medication. Also, it was revealed that R1 is ambulatory and self responsible. Allegation 2: Staff did not provide adequate food service. The investigation revealed that R1 does not have a special diet. This facility provides a modified menu for residents with dietary restrictions. Allegation 3: Resident was not provided clean linen. Interviews reveal that R1 had purchased their own linens. Also, LPA verified that the facility has a supply of clean linen labeled with the facility’s name and residents are also able to use their own purchased linens. Allegation 4: Staff did not safeguard resident's personal items. LPA was able to verify the facility’s policy to have residents label their belongings. LPA was unable to find corraborating evidence relative to this complaint. 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 at this time. An exit interview was conducted where this report was discussed and provided to Mrs.Tonan. Unsubstantiated The allegation of illegal eviction is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC-9099D. Refer to LIC-9099D for deficiency cited. An exit interview was conducted where this report, LIC-9099D, and Appeal Rights were discussed and provided to Mrs. Tonan.the state’s words, verbatim · CDSS document, May 6, 2022 · control 56-AS-20220318083750

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(b) · Plan of correction due date: May 9, 2022

The licensee may, upon obtaining prior written approval from licensing agency, evict the resident upon 3 days written notice to quit. The licensing agency may grant approval for eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or...others in the facility. This requirement was not met as evidenced by: The Department did not receive eviction notices until complaint #56-AS-20220318083750 was filed and investigated.the state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee and staff shall review regulation section 87224. A statement of understanding of the regulations shall be provided to CCL by end of POC due date 5/9/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst Anna Bueno conducted an unannounced visit to deliver findings for complaint numbers: 18-AS-20220105101235 and 56-AS-20220318083750. LPA met with Mikaila Tonan, receptionist, who was explained the purpose of today’s visit. During complaint investigations, the Department discovered that eviction notices were given to Resident 1 and Resident 2. Refer to LIC-809D for deficiencies cited. An exit interview was conducted where this report, LIC-809D, and appeal rights were discussed and provided to Mrs. Tonan.the state’s words, verbatim · CDSS document, May 6, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: May 9, 2022

A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: The Department did not receive notices of eviction until investigation of complaint #s 18-AS-20220105101235 and 56-AS-20220318083750.the state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee and staff shall review regulation section 87224. A statement of understanding of the regulations shall be provided to CCL by end of POC due date 5/9/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: May 20, 2022

All facilities shall have a qualified & currently certified administrator. The licensee & administrator may be...the same person. The administrator shall have sufficient freedom from other responsibilities & shall be on the premises a sufficient number of hours to permit adequate attention to the management & administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by: Based on interviews and observations, facility has not submitted an LIC308, Designation of Facility Responsibility, to the Department since Administrator went on medical leave/full time telework/on-call status onthe state’s words, verbatim · CDSS document, May 6, 2022

Plan of correction: Licensee submit to the Department an LIC308 and staff qualification and LIC507 showing Administrator's hours in the facility no later than end of POC due date 5/20/2022.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Anna Bueno and Rayshaun Nickolas conducted an unannounced visit to the facility to conduct additional interviews and gather documents pertinent to complaint control number 18-AS-20220105101235. LPAs were met by Care Coordinator Araceli Soto. LPAs toured the facility, conducted resident and staff interviews, and reviewed facility files. During this visit, LPAs did not observe imminent health & safety concerns. Ms. Soto was advised that the investigation is still open. Additional time is needed to complete this investigation. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Ms. Soto.the state’s words, verbatim · CDSS document, Mar 21, 2022

Allegation investigated: Facility mismanaging residents' funds.

Licensing Program Analysts (LPAs) Ryan Gardner and Anna Bueno arrived at the facility unannounced to commence a complaint investigation and deliver the findings for the complaint allegation. LPAs met with Care Coordinator, Araceli Soto. After interviews, record review, and gathering evidence, it was determined that the residents' money is not managed by the facility. Resident is on an Assisted Living Wavier Program that helps cover the residents monthly rent. The facility does not manage personal money for residents. Thus, the allegation was deemed to be UNFOUNDED. LPAs determined that the allegation, "Facility mismanaging residents' funds" was deemed to be UNFOUNDED. A finding of UNFOUNDED means that the allegations were false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was given to Araceli Soto. LPA did not observe any violations of Title 22 during this visit. Unfoundedthe state’s words, verbatim · CDSS document, Feb 28, 2022 · control 18-AS-20220222112449

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.

Type of visit: Case Management - Incident

On 12/22/21, Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit for the purpose of gathering details for an incident report provided to Community Care Licensing (CCL) on 12/7/21. Client 1 (C1) reported to their responsible party on 12/4/21 that staff 1 (S1) asked C1 if they wanted to be S1's girlfriend. C1 also reported that S1 lifted their shirt and licked their breast in C1's bathroom. C1 stated that S1 exposed their privates to C1 and asked C1 to have sexual relations which C1 declined. C1 informed the facility staff that this incident occurred the day before a roommate moved in with C1 on 11/30/21, some time between 11/21/21 and 11/27/21. On 12/9/21, LPA phoned care coordinator Ariceli Soto who stated that the facility interviewed C1 and terminated S1. Soto informed LPA that S1 was the facility's maintenance contractor and not an actual employee. LPA asked Soto whether S1 was fingerprinted as he was present and regularly working in this facility and Soto stated that to her knowledge, S1 was not fingerprinted because he was not an employee. During today's visit, Soto provided Montclair police department's report from 12/7/21, C1's Identification/Emergency Information sheet, Physician's report, and SOC341 completed by ALW housing program coordinator on 12/6/21, and Soto's report from 12/6/21 through 12/7/21. LPA phoned regional director Jimmy Tang who confirmed that S1 has been working in this facility since July 2021 and was offered employment but refused. Per Tang, S1 only wanted to do side jobs for this facility. Refer to LIC809D for deficiency cited. An exit interview was conducted where this report, 809D, LIC 811 and appeal rights were provided to Soto.the state’s words, verbatim · CDSS document, Dec 22, 2021

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.17(b)(2)(C) · Plan of correction due date: Dec 23, 2021

Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances - (C) A third-party contractor retained by the facility if the contractor is not left alone with clients in care. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee has retained the contractor since July 2021 and allowed the contractor to work alone with residents.the state’s words, verbatim · CDSS document, Dec 22, 2021

Plan of correction: Licensee shall circulate a facility memo to administrative staff instructing staff to assign a fingerprinted staff with third-party contractor when the contractor is present with residents. Licensee shall submit a copy to the Department no later than the end of POC date 12/23/21.

Allegation investigated: Administrator does not respond to resident's representative. Staff do not assist resident with incontinence's needs. Residents room is malodorous.

Licensing Program Analysts (LPAs) Anna Bueno and Rohit Lama conducted an unannounced visit to this facility to investigate and deliver findings on the above allegations. LPAs met with care coordinator, Araceli Soto and advised them of the purpose of today's visit. The investigation consisted of interviews and review of pertinent documents. Allegation 1: Administrator does not respond to resident's representative. Interviews revealed that resident 1 (R1) is able to communicate their needs to staff. LPAs observed R1 speaking to several staff. Allegation 2: Staff do not assist resident with incontinence needs. Interviews revealed that the facility changes diapers every two hours. LPAs interviews and observations reveal that R1 needs moderate assistance toileting while resident 2 (R2) bathing are provided by another vendor. Allegation 3: Residents room is malodorous. Interviews show that resident rooms are cleaned daily and have scheduled thorough cleaning weekly. R1 stated that they ask housekeeping staff to clean their personal items as needed. Based on today's investigation, LPAs finds that the complaints are UNSUBSTANTIATED. A finding of unsubstantiated means 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. An exit interview was conducted with and a copy of this report was provided to Ariceli Soto. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 6, 2021 · control 18-AS-20211129084328

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Cuevas met with Executive Assistant, Lindya Wenny for the purpose of amending report for complaint report (18-AS-20190917100522). LPA Cuevas went over the amended report with staff Lindya Wenny and provided copies of both the amended complaint report as well as this report. An exit interview was conducted and a copy of all reports was provided to Executive Assistant, Lindya Wenny.the state’s words, verbatim · CDSS document, Sep 30, 2021

Allegation investigated: Facility air conditioner is in disrepair

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to conduct a complaint investigation on the above allegations. LPA met with staff Makaila Tonan and Lidya Wenny and advised them of the purpose of today's visit. The investigation consisted of interviews and review of pertinent documents. The allegation states that the facility air conditioner (AC) is in disrepair. Based on document reviews and interviews, LPA was able to corroborate the allegation. LPA viewed documents confirming the facility was notified of the broken AC on 7/24/21 and an order for AC compressor dated 8/9/21. Interviews confirmed that the AC was repaired on 9/8/21. Based on today's investigation, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted with and a copy of this report was provided to Tonan. Substantiatedthe state’s words, verbatim · CDSS document, Sep 21, 2021 · control 18-AS-20210913084636

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: Sep 21, 2021

87303 (b) (1) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on interviewss and record review, this requirement is not met as evidenced by: AC unit was broker from 7/24/21-9/8/21. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 21, 2021

Plan of correction: The licensee to shall repair the AC unit.

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Lidya Wenny and Makaila Tonan who confirmed there is 1 active Covid-19 case in the community. LPA toured the facility with Tonan. The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Single entry point to the main lobby has a sign-in policy for universal entry screening. The facility also documents daily temperature and COVID-19 symptom checks for all visitors while residents are subject to routine symptom screening and regular observations for any change in condition. Continued weekly routine testing for staff is still observed. LPA observed all staff are properly fitted with face coverings. LPA Bueno toured the facility’s common rooms and an empty private apartment currently housing Personal Protective Equipment (PPE) . Tonan stated that the COVID wing has 1 active resident and their roommate in isolation. LPA saw the COVID wing closed off by double doors and posted were necessary droplet precaution and COVID related signages. Wenny verified that the smoke and carbon monoxide detectors and fire alarms are maintained and monitored by an outside vendor. LPA viewed the maintenance log that showed the last visit was conducted on 8/29/2021. LPA observed hand sanitizer throughout the facility, mostly situated by the elevator and exit doors. Tonan also confirmed the facility has an adequate supply of cleaning and disinfectant provisions. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA Bueno gave a technical advisory regarding fit testing for staff in the Covid wing. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to Tonan at the conclusion of the inspection.the state’s words, verbatim · CDSS document, Sep 21, 2021

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility is not adequately staffed to meet resident's needs. Staff failed to keep facility free of scabies. Staff are not ensuring that resident's linens are clean. Staff are not ensuring that resident's clothing is clean.

Please Note: The following is an amended report for facility visit that occurred on 01/31/20. On 01/31/20 Licensing Program Analyst (LPA) David Cuevas conducted an unannounced visit to the facility to follow up with complaint allegations noted above. LPA identified self and was granted permission to enter. LPA met with Administrator, Annamarie Santos who was informed of the purpose of visit. During the investigation LPA Cuevas conducted: facility file review, resident record review, staff and resident(s) interviews, and documented observations. Regarding Allegation #1: Facility is not adequately staffed to meet resident's needs Information gathered from interviews indicate the facility does not have enough staff to meet the resident's needs. Interviews with 8 out of 8 staff members revealed that staffing gaps occur due to a high turnover rate from employees. Per staff’s statements this creates more workload for staff than they can handle. Substantiated While R1 was place at facility staff reported no previous fall history in records. Furthermore, facility staff reported R1 to be required to wear C-collar on his neck; however, R1 would constantly take it off and misplace it. Based on the insufficient evidence, the allegation(s) of #1 Resident sustained a fractured neck while in care and #2 Facility staff failed to safeguard residents personal belongings is UNSUBSTANTIATED. No deficiencies given during todays visit. An exit interview was conducted with Administrator, Annamarie Santos were a copy of this report was discussed and provided LPA was informed that the need for coverage in the memory care unit is constant, as a result to supplement the coverage needed medical technicians are used for both covering caregiving gaps and dispensing medication for a total of 34 resident in care. Additionally, review of staff schedule for the month of September 2019 shows that in the memory unit morning shifts had 3 staff scheduled for coverage on Sundays, Mondays, Wednesdays, Thursdays, and Fridays, and 4 staff scheduled for Tuesdays and Saturdays; However, per documents provided the coverage provided on September 19, 2019 through September 30, 2019 shows inconsistencies with staffing schedules on 9 different dates. Dates identified in which staff schedule did not match coverage needed are, September 19th 3 staff scheduled 2 covered, September 21st 4 staff scheduled 3 covered, September 22nd 3 staff scheduled 2 covered, September 24th 4 staff scheduled 3 covered, September 27th 3 staff scheduled 2 covered, September 28th 4 staff scheduled 2 covered, September 29th 3 staff scheduled 2 covered , and September 30th 3 staff scheduled 2 covered. Based on the interviews provided and review of document the allegation of facility is not adequately staffed to meet resident's needs is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Allegation #2: Staff failed to keep facility free of scabies During LPA’s resident files review, LPA identify (4) residents to have had scabies while in care at the facility, resident #1, #2, #3, and #4 (R1, R2, R3, and R4). Statements provided by staff during interviews identified that facilities first scabies outbreak in memory unit was not reported to CCL as they though a single case was not considering an outbreak. As a result, the first resident who contracted scabies then spread it to 3 additional residents within the memory unit. Based on the evidence, statements, and records review the allegation # 2 of Staff failed to keep facility free of scabies is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Allegation #3: Staff are not ensuring that resident's linens are clean During interviews with staff it was communicated that the facilities washers and dryers are constantly inoperable resulting in linens and residents personal clothing not been readily available for use. Per, service request reviewed facility endure a 6-month period in which one of the main industrial dryers used for drying residents’ linens was broken. Per statements made by staff as a result of dryer machine not being available facility was not able to keep up with the demand for residents’ clean linens. Based on the evidence, statements, and record review the allegation #3 Staff are not ensuring that resident's linens are clean is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Allegation #4: Staff are not ensuring that resident's clothing is clean During staff interviews with 4 out of 8 staff, it disclosed that facilities washing machines and dryers have been in-operable or in need of repair for a prolonged period, as a result residents clean clothing needs were not being met. Furthermore, during this investigation documents provided to LPA reflect laundry equipment for the facility to be owned by a third party, who has not been consistent with workorders and repairs needed for their equipment. Based on the evidence, statements, and record review the allegation #4 Staff are not ensuring that resident's clothing is clean is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. An exit interview was conducted with Administrator, Annamarie Santos were a copy of LIC 9099, LIC 9099D, and personal rights were discussed and provided.the state’s words, verbatim · CDSS document, Jan 31, 2020 · control 18-AS-20190917100522

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(f) · Plan of correction due date: Oct 14, 2021

87307 (3)(f) Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not being met as evidenced by Facilities washers and dryers endure a 6-month period in which one of the main industrial dryers used for drying residents’ linens was broken.the state’s words, verbatim · CDSS document, Jan 31, 2020

Plan of correction: Licensee will ensure there is enough staffing to handle the facilities laundry needs by adding additional staff to laundry department. A a new staffing schedule for laundry services must be submitted to CCL by due date before deficiency can be cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(g)(1) · Plan of correction due date: Oct 14, 2021

87307 (3)(f) Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not being met as evidenced by: Facilities washing machines and dryers been in-operable or in need of repair for a prolonged period, as a result residents clean clothing needs were not being met. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 31, 2020

Plan of correction: Licensee will purchase own laundry equipment for facility or find alternative company that will ensure laundry equipment is in good repair at all times and capable of handling facility laundry needs. Proof of correction must be sent to CCL by provided due date before deficiency can be cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 14, 2021

87411 (a) Personnel Requirements: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services This requirement was not being met as evidenced by: Interviews with staff members revealed that staffing gaps occur due to a high turnover rate from employees. Per staff’s statements this creates more workload for staff than they can handle. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 31, 2020

Plan of correction: Licensee will conduct a staffing assessment to ensure that all the departments within the facility meet the required staffing needs to provide care and supervision for residents. In addition, a plan must be develop and approved by CCL that addresses staffing gaps that occur do to high turnover rates, heavy workloads, and recruitment and retention of personnel. Plan must be submitted for review to LPA by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(2) · Plan of correction due date: Oct 14, 2021

87211(2) Reporting Requirements:(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 being met as evidenced by Facilities failing to report scabies outbreak after first case, as a result 3 other cases developed within the memory unit. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jan 31, 2020

Plan of correction: Licensee will develop a statement of understanding outlining compliance with regulation in addition to having a departmental meeting communicating reporting requirements to all department heads. Proof of correction must be submitted to CCL due date before deficiency can be cleared..

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 14, 2021

87465(a)(1) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met evidence by: Facility failed to seek timely medical attention for residents R1,R2, R3, and R4. After the first case of scabies was identified by a medical professional, this poses a potential risk to the health , safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2020

Plan of correction: Licensee will develop and implement a policy that addresses the immediate medical attention needed after a resident has been identified with a contagious condition which can affect the residents and staff at the facility by due date.