Rialto Assisted Living

Type of visit: Case Management - Incident

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living facility unannounced to conduct a Case Management Visit. The Case Management visit is being conducted in response to a Special/Unusual Incident Report, (SIR) submitted to the agency on 9/27/23. LPA met with caregiver, Bernie Escueta. LPA introduced self and stated purpose of the visit. The SIR documents that on 9/25/23, Dietary Staff, Martha Garcia, (S1) observed R1 and R2 engaged in a physical altercation with one another in the Dining Room. S1 called for assistance and physically separated the residents from one another. The Paramedics were contacted to transport to the Hospital for medical evaluations. Inquiry into this incident included conducting a facility tour to assess for any Health and Safety concerns. LPA observed no imminent health and safety concerns at the time of visit. LPA was unable to interview R1 because they have relocated to another facility. Staff informed LPA R2 was out for the day with family. LPA was able to interview staff and review the residents chart. Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Oct 10, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living facility unannounced to conduct a Case Management Visit. The Case Management visit is being conducted in response to a Special/Unusual Incident Report, (SIR) submitted to the agency on 10/5/23. LPA met with caregiver, Bernie Escueta. LPA introduced self and stated purpose of the visit. The SIR documents that on 10/3/23, Caregiver reported that R1 was not feeling very well and R1 reported feeling dizzy. Staff contacted an Ambulance to have the resident taken to the hospital to be medically evaluated. The SIR further documented that R1 reported to healthcare staff that she had a fall while attempting to get to the restroom in her room. Also, when R1 calls for assistance staff's response is delayed. Inquiry into this incident included conducting a facility tour to assess for any Health and Safety concerns. LPA observed no imminent health and safety concerns at the time of visit. LPA was unable to interview R1 because they are still admitted to the hospital. LPA was able to interview staff and review the resident's chart. All documents were in compliance. Based on the observations made during today’s visit, no deficiencies will be cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was reviewed discussed, then provided to facility representative.the state’s words, verbatim · CDSS document, Oct 10, 2023

Allegation investigated: Staff is under the influence while providing care and supervision to resident's.

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent unannounced visit to the facility to continue the complaint investigation of and deliver findings on the above allegation. LPA met with office assistant Irene Silva who was informed of the purpose of today’s visit. Ms. Silva electronically informed administrator Tae Kim of LPA's visit. The investigation consisted of resident and staff interviews and records review. The allegation is Staff (S1) is under the influence while providing care and supervision to resident's. It is alleged that S1 smoke marijuana on the job. Interviews with staff deny using any substance at work. Resident interview confirm that S1 has not worked at this facility for more than a year. LPA reviewed records confirming that S1 is no longer associated to this facility. This allegation is therefore UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with facility representative. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 16, 2023 · control 18-AS-20210412145930

Allegation investigated: Questionable Death

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit to the facility to continued the investigation of and deliver findings on the above allegation. LPA met with administrator Tae Kim who was informed of the purpose of today’s visit. The investigation consisted of witness and resident interviews and records review. The allegation is Questionable Death. It was alleged that on 12/08/2020 Resident (R1) passed away. Interviews with witness and facility residents confirmed that R1 was in isolation due to a diagnosis. LPA reviewed Department records and found that this facility reported as required active cases diagnosed between November and December of 2020. LPA reviewed R1 records and found that R1 had preexisting conditions that made R1 a higher risk for severe illness. Based on interviews conducted, and documents reviewed the allegation is therefore 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 Administrator Kim. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 7, 2023 · control 18-AS-20201208165511

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.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility to continue the investigation of the following complaints listed below and to deliver amended allegation finding for complaint number: 18-AS-20201203110823. LPA met with Tae Kim, Administrator. The following complaint allegations were fount to be UNSUBSTANTIATED. 18-AS-20201210082804 18-AS-20201208165511 Complaint control number 18-AS-20201203110823 has been amended to UNSUBSTANTIATED. Administrator Kim signed all LIC 9099 and LIC 809 during today's visit. All reports were discussed with and copies were provided to Administrator Kim at the conclusion of today’s visit.the state’s words, verbatim · CDSS document, Aug 7, 2023

Allegation investigated: Resident Sustained Multiple Falls While in Care.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living Facility to deliver the findings of the complaint investigation. LPA signed in, introduced self and stated purpose of the visit. LPA Administrator was not available. LPA spoke with Medication Technician Supervisor. It is alleged that the resident sustained multiple falls while in care. Staff interviews revealed that the resident does not have a history of falls while admitted to Rialto Assisted Living. The resident had one fall recently, which led to transport to the emergency room. The fall was self-reported by the resident themselves. Initially, the resident refused to be taken to the hospital for evaluation. They agreed to see the in-house doctor who recommended the resident go to the hospital. The resident again, refused the doctor's advice to go the emergency The following date, the resident became ill, and asked to be taken to the hospital – which was granted. LPA reviewed the resident’s Physician Report and discharge paperwork which made no mention of a history of the resident falling and sustaining injuries. Witness’s statements are consistent with one another; they support that the resident does not have a long Please see LIC9099C Unsubstantiated history of falling. During resident interviews, it was discovered that the resident does have some history of falls but these incidents occurred long before moving into Rialto Assisted Living. Resident reported having one fall, which was not reported and the second fall being 6/26/23. This fall was reported late because the pain and discomfort did not present itself until days later. Based on observations, review of documents and interviews, 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 25, 2023 · control 56-AS-20230629140718

Allegation investigated: Staff is stealing resident's medication Staff is selling resident's medication

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA met with Administrator, Tae Kim who was informed of the purpose of the visit. The department conducted interviews, documented observations, and conducted records reviews. It was alleged “Staff is stealing resident's medication”, and "staff is selling resident's medication", with allegations identify Staff #1 (S1). During today’s visit LPA conducted a random inventory of (4) resident medications who take controlled narcotics. All medications were accounted for. S1’s staff file was reviewed and found that on 4/16/2020 S1 had received a write up. Unsubstantiated The narrative stated the staff was observed taking the medication cart to the door while speak with an unidentified male outside the facility. LPA interview past administrator who gave the write up who stated they had given the write up because they had taken the cart to the door and left it unattended while speak with the male. LPA spoke with (3) staff who all stated the same version of events, including S1. Past administrator stated they did not do an inventory of medications as it was observed on the facility footage that S1 had simply left the cart unattended. LPA interviewed past administrator, current administrator, S1's supervisor who stated that they were not aware of allegations stating S1 had sold resident medication. LPA interviewed (4) facility residents, (3) of which stated they had not witnessed the S1 steal or sell medications. They stated they had no concerns about the staff, or repeated incidents of the same nature since the write up. Therefore, the allegation that staff was stealing resident medication is unsubstantiated. An exit interview was conducted with Administrator, Tae Kim where this report was reviewed and provided to them.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 18-AS-20200414084250

Allegation investigated: Staff are not meeting residents' toileting needs Staff are not assisting residents

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings on the above allegations. LPA met with Administrator, Tae Kim who was informed of the purpose of the visit. During the visit, LPA conducted interviews, documented observations, and conducted records reviews. Regarding allegation, “staff are not meeting resident’s toileting needs”, it was alleged that residents smelled of urine during lunch service due to caregivers being assigned to serve residents during this time. LPA interviewed (4) resident during the time of the visit and found that none smelled of urine. Resident stated they were changed by caregivers. LPA interviewed (5) staff who stated that residednt are changed on a regular basis. Unsubstantiated Additionally staff interviewed stated that at the time the complaint was received, the facility was not using the dining area for meal service due to COVID restrictions. Staff stated all residents were served in their room at this time and only caregivers bringing meals into the residents room. Based on the above, the allegation was found to be unsubstantiated. preponderance of the evidence standard has not been met. Regarding “staff are not assisting residents”, it was alleged that residents that were residing in room #48 were being neglected by staff. It was also alleged that staff would “goof around” instead of assisting the residents LPA spoke with administrator who stated Resident #1 (R1) was residing in room #48 at the time the complaint was received. Administrator stated they could not recall if another resident was residing in this room at the time. LPA interviewed current administrator and past administrator who stated they did not have any concerns with staff not doing their work at this time and not attending to the residents. Current administrator Kim stated that care giving staff has turned over from 2020. LPA interviewed R1 who stated no concern to the LPA. Therefore, the allegation was unable to be corroborated and found to be unsubstantiated. Findings that are unsubstantiated mean that the preponderance of the evidence standard has not been met. An exit interview was conducted where this report was reviewed and provided to Administer, Tae Kim.the state’s words, verbatim · CDSS document, Jul 13, 2023 · control 18-AS-20200330084611

Type of visit: Required - 1 Year

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living Facility unannounced to conduct an Annual Inspection. LPA introduced self to staff and stated purpose of the visit. Staff informed Administrator, Tae Kim of LPA's visit and came to the front to meet with LPA. LPA discussed the purpose of the visit. LPA signed in and was provided a space to work. During today's visit, LPA completed a walk through of the facility with the Administrator, conducted staff and resident interviews and review of staff and resident files. LPA observed the following: Physical Plant: LPA observed the facility's temperatures to be comfortable and measured the hot water temperature in the kitchen at within regulation. LPA observed bathrooms and found that showers and toilets are operable. Each bathroom contained adequate amounts of hand hygiene and paper products. The facility houses a laundry room ran by housekeeping staff. LPA observed that linens and hygiene items are enough for residents in care. Each resident room included lamps, night-lights and appropriate lighting to ensure residents comfort and safety. The facility is equipped with smoke alarms and carbon monoxide detectors. The facility maintains a contract with a third party company who conducts fire/disaster drills on a monthly basis. Last drill completed on 6/16/23. No abnormal notes made. Fire Extinguishers were observed throughout the facility. Fir Extinguishers were last inspected October of 2022. Food Service: Nonperishable and perishable food items observed were sufficient for number of residents in care. Food is being prepared and stored properly. Facility offers a variety of food options and snacks for residents. Kitchen Staff maintain a food menu which is updated on a monthly basis. Care & Supervision: Facility has sufficient care staff; toxic items are inaccessible to residents in care and stored and kept secure in closets throughout the facility. Record Review and Resident/Staff Files: LPA reviewed records for all five (5) residents currently living at the facility. Resident records are complete with updated physician reports and Needs and Services Plans. LPA additionally reviewed all five (5) staff files and four (4) out of (5) staff records reflect current CPR/First Aid Certification and Criminal Record Clearance. Administration: Disaster Plan, Ombudsman poster, Administrator Certificate, and facility license are posted in a prominent place. Emergency Disaster Plan is current. Facility files are maintained in secure locations throughout the facility. Medication/Medical Related Services: LPA observed that the residents' medication is centrally stored and locked in a Medications Room; managed by Medication Technicians. Based on observations, a deficiency will be cited per Title 22, California Code of Regulations. An exit interview conducted and copy of this report reviewed and discussed, then provided to Administrator, Tae Kimthe state’s words, verbatim · CDSS document, Jun 20, 2023

Allegation investigated: Facility has bug infestation.

Licensing Porgram Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed above. LPA met with Tae Kim, Administrator and explained the purpose of the visit. The allegation listed above were investigated. The investigation consisted of observation, interviews and record review. Regarding the allegation facility has a bug infestation. It was reported that in July 2020, that the facility had a bug infestation particulary in rooms # 33 and 35. Per interviews conducted with mutltiple staff and residents confrimed that there was in fact a bed bug problem/infestation at the facility. Information from an interview revealed that had been at minimum of seven bed bugs observed/found on the bed inside room #33. A bed bug was reported to have been found inside of the mop buckets, which were to believe to have gotten in there after cleaning one of the rooms noted to have bed bugs inside. Additionally, an interview conducted with the previous Administrator Kyong Suk Lee "Clara", whom admitted that the facility had a bed bug problem which resulted in the baseboards having to be removed, and the exterminator having to come out to treat the room. ****Continued on 9099C Substantiated LPA was unable to obtain supporting evidence to corroborate what was alleged with the resident not being provided with a reasonable accommodation. Based on observation, interviews and record review the allegation is 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, and a copy of this report was reviewed and provided to Tae Kim, Administrator. Based on interviews the allegation of facility has bug infestation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Tae Kim, Administrator.the state’s words, verbatim · CDSS document, May 11, 2023 · control 18-AS-20200707151257

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 12, 2023

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 interviews and observations, the Licensee failed to ensure that at least 1 out of 48 rooms were kept clean and sanitary at all times. This is poses an immediate health risk to residents.the state’s words, verbatim · CDSS document, May 11, 2023

Plan of correction: There is POC due as the facility there is no longer a bed bug infestation. A copy of treatment invoices were provided to LPA.

Allegation investigated: . Facility Staff denied resident food.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Rialto Assisted Living Facility to initiate a complaint investigation regarding the allegation listed above. LPA was greeted by office staff, LPA introduced self and stated the purpose of the visit. Staff notified the Administrator, Tae Kim of LPA visit and came to meet LPA. Today's visit consisted of a review of resident charts, staff and resident interviews and a walk through of the facility's dining room. According to staff interviews, breakfast, lunch and dinner are served 7 days a week. Breakfast served at 8am, Lunch at 12pm and dinner at 5pm. Snacks are offered between those meals as well. Food items such as fresh fruit, graham crackers, cheese, any leftovers from meals prior. An announcement is made over the PA system 15 minutes. prior. Ambulatory residents come in on their own, staff will bring residents and bedridden residents are delivered their meals. In the event, a resident does not care for what is offered on any day, alternative meals are offered. Its recommended that residents sign up for the alternative meal ahead of time so that it can be prepared in a timely manner, but if that doesn't happen residents can ask staff. Unsubstantiated By staff and resident's accounts no meal has ever been denied to a resident in care. Staff interviews reflected that there is an abundance of food made available to residents. LPA walked through the dining rooms and kitchen area and observed that the weekly food menu is posted across the hall. A print version is posted and then written on a white board in large font. Posted to the right of the menu is an alternative menu sign up sheet. Written above is what the alternative meal is, and below are spaces available for residents to sign up up for the alternative meal. Kitchen staff reported that there is assigned seating in the dining room. Kitchen staff serve the meals to residents on a cart. Odd number dates, staff serve meals in a clockwise rotation. On even numbered dates, meals are served in a counterclockwise rotation. Certain days a resident may be the first to be served, while other days he may be the last served. During the review of resident records, it was discovered that facility provides care to residents who suffer from memory impairment, mental illness and sometimes terminal illnesses. LPA inquired about the facility's policy for when a resident misses a meal due to being out of the facility. It was reported that staff will often keep track of the resident's outings and on the day of the appt. staff will call the kitchen to ask that a meal is saved for the resident on the outing. All staff and residents deny that there isn't enough food made available to them. During the walk through of the facility, LPA observed a number of resident rooms that contained their own personal refrigerators to keep their own supply of food. Residents are also permitted to leave the facility to obtain their own food if preferred. Based on observations and interviews,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. No deficiencies were observed during this visit. An exit interview was conducted where this report was reviewed, discussed and provided the Facility Administrator.the state’s words, verbatim · CDSS document, Mar 30, 2023 · control 56-AS-20230327121826

Allegation investigated: Facility staff are providing residents with illegal drugs.

Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced visit to deliver investigative findings regarding the above allegations. The investigation was conducted by Department staff. Interviews and evidence collected revealed that Staff 1 (S1) did not provide residents with illegal drugs. Interviews will also reveal that reporting party denied seeing S1 with illegal drugs or that S1 knowingly distributed illegal drugs to residents at the facility. This agency has investigated the complaint alleging that facility staff are providing residents with illegal drugs.. We have found that the complaint was Unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Feb 1, 2023 · control 56-AS-20220831091147

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 do not prevent a resident from smoking in the facility.

Licensing Program Analysts (LPAs) Anna Bueno and Michelle Echeverria conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPAs met with administrator Tae Kim who was informed of today’s visit. The investigation consisted of physical observations of the facility, interviews with relevant parties, and review relevant records. The allegation is Staff do not prevent a resident from smoking in the facility. LPAs reviewed a copy of a written warning issued to Resident 1 (R1). Resident interviews revealed that the facility has a policy for no smoking inside the building. Furthermore, Resident 2 (R2) interview disclosed that staff quietly and individually spoke to residents who smoke tobacco about the facility house rules. LPAs observed R1 smoking in their outdoor patio with their door partially open. LPAs observed several "NO SMOKING" postings inside and outside the facility and LPAs did not smell tobacco in the building. This allegation is therefore 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 marketing director Rosalie Arreola and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 26, 2023 · control 56-AS-20230120084812

Allegation investigated: Staff do not prevent residents from smoking in the facility.

Licensing Program Analyst (LPA) Anna Bueno conducted an subsequent visit to the facility to continue the investigation of and deliver findings on the above allegation. LPA met staff Rosalie Arreola and, supervising medication technician Bernie Escueta who were informed of today’s visit. The investigation consisted of review interviews with relevant parties, observations of the physical plant, and review of relevant documents. It is alleged that the facility is not doing anything regarding residents who smoke inside their rooms. During today's visit, LPA observed one resident smoking in the designated smoking area. LPA did not smell cigarette smoke in the facility. Resident interviews confirm that the facility has a no smoking indoors policy. Staff interviews reveal that no resident has been observed smoking indoors however reports of smelling smoke were received from residents. Staff further state that they speak to the resident in person to remind them of the no smoking indoor policy and issue a 30 day eviction notice when needed. Furthermore, staff confirmed that, when there is active Covid-19 cases in the facility, residents who have patio access from utilize the access to smoke outside the facility. Records reviewed list the no smoking inside the facility listed in the resident house rules Unsubstantiated and policies and procedures. Based on the above allegations, this complaint 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 Rosalie Arreola and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 5, 2023 · control 56-AS-20221219142902

Allegation investigated: Facility staff used inappropriate language toward resident.

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPA met staff Rosalie Arreola and, medication technician supervisor Bernie Escueta who were informed of today’s visit. The investigation consisted of review interviews with relevant parties. The allegation is Facility staff used inappropriate language toward resident (R1). Interview with R1 revealed that inappropriate language was used by staff and that it was the first time staff spoke in this manner to R1. Staff interview deny any inappropriate or foul language used during a conversation with R1. Witness interviews deny that facility staff used inappropriate language with R1. Resident interviews reveal that facility staff have not spoken to them inappropriately. Based on the information discovered during this investigation, the complaint is therefore unsubstantiated. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a Unsubstantiated preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Rosalie Arreola and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 5, 2023 · control 56-AS-20221227095658

Allegation investigated: Staff did not safeguard resident's personal belonging(s).

Amy Goldenberg, Licensing Program Analyst (LPA), is conducting this unannounced 10 day visit to investigate the above-mentioned complaint allegation. It is alleged that facility staff removed the personal property, a side table, from R1's bedroom. Investigation consisted of interview of R1. R1 indicated that they informed facility staff that the item that staff was attempting to remove belonged to them and R1 indicated to LPA that staff did not remove that item from their room upon learning that it was a personal piece of furniture and not property of the facility. Based on the information received during the interview of R1, LPA has determined that no personal property was removed by staff from the bedroom of R1 as alleged. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with, and furnished to the facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Dec 28, 2022 · control 56-AS-20221219095004

Allegation investigated: Staff did not safeguard residents belonging. Staff threaten resident in care.

Licensing Program Analyst (LPA) Natalie Ibarra conducted an unannounced visit to the facility to conduct an investigation for the above allegations. LPA met with administrator Tae Kim and explained the purpose of today’s visit. The investigation consisted of interviews with pertinent parties and records review. The first allegation indicates staff did not safeguard residents belonging. Interviews with Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4) stated Resident #1 (R1) had informed the new administrator that their Playstation 3 (PS3) was broken by staff, but that R1 was not able to provide date nor by whom PS3 was broken by. S4 stated R1 had mentioned to the prior administrator that their PS3 was broken and was told by the prior administrator that they would look into it. Interview with R1 stated that one day they were trying to play their PS3 and noticed it wasnt working. When inspecting it, R1 noticed it was cracked and they notified the prior adminsitrator who stated they would look into it. R1 does not know how their PS3 came to have a crack nor did they state that a staff member dropped it. R3 also stated the facility did not state they would replace it but instead that he informed the prior administrator that he wanted it replaced. Unsubstantiated The second allegation indicated that staff threatened resident in care. Interviews with S2 and S3 stated they did not witness S1 swing nor threaten R1 on 9/1/2022. S1, S2, and S3 stated R1 got angry and started making threatening comments when complaining about their PS3 being broken. Police were called and a report was done. LPA reviewed Special Incident Report (SIR) sent to CCLD regarding incident and police report case number. Based on the information obtained, the allegations are UNSUBSTANTIATED. A finding of Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was discussed and provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 19, 2022 · control 56-AS-20220912140939

Allegation investigated: Resident is not being provided adequate meal service while in care

At 10:00 AM on 08/11/2022, Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegation listed above. LPA met with Kyong Suk Lee, Administrator. LPA interviewed the Administrator, Staff #1 (S1), Staff #2 (S2), Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). According to the allegation above, a resident is not being provided adequate meal service because he is being denied food service when he arrives late. When LPA interviewed the Administrator, S1, and S2, all individuals stated that food service is never denied to residents. Furthermore, all three stated that Tray Service is provided upon request if a Resident does not want to eat at the dining table. CONTINUED ON LIC 9099-C Unsubstantiated CONTINUED FROM LIC 9099 Four out of five residents, when interviewed, stated that they have never been denied food service. The same residents stated that food is provided regardless of if they were delayed in getting to the dining room. Based on the evidence gathered during the investigation, the above allegation is found to be Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. LPA conducted an exit interview where this report was discussed with the Licensee. A copy of this report was provided to the Administrator at the conclusion of this investigation.the state’s words, verbatim · CDSS document, Aug 11, 2022 · control 56-AS-20220804112846

Allegation investigated: Resident is not treated with dignity and respect. Staff interrupted a residential council meeting.

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations. LPA Gardner met with Administrator Kyongsuk Lee and explained the reason for the visit. LPA Gardner interviewed residents and staff and found that a staff member was present at a resident council meeting without an invitation. The staff member that was present at the meeting was voicing unwarranted opinions on a resident manor. The staff interrupted the resident council meeting and did not treat the residents with dignity and respect. Based on interviews conducted, the two (2) above allegations are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence standard has been met. Substantiated During today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Kyongsuk Lee along with a copy of the LIC809-D form and the appeal rights.the state’s words, verbatim · CDSS document, Aug 2, 2022 · control 56-AS-20220726113426

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.157(a) · Plan of correction due date: Aug 9, 2022

1569.157. Resident-oriented facility council. (a) Every licensed residential care facility for the elderly, at the request of two or more residents, shall assist the residents in establishing and maintaining a single resident council at the facility. The resident council shall be composed of residents of the facility. Family members, resident representatives, advocates, long-term care ombudsman program representatives, facility staff, or others may participate in resident council meetings and activities at the invitation of the resident council. This requirement was not met based on interviews conducted. The licensee did not comply with the section cited above allowing a staff member to be present in resident council meeting without an invitation to the meeting.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: The licensee has agreed to read regulation 1569.157 entirely and send LPA a self-certify letter via email, fax, or post mail that the regulation was read and understood.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 9, 2022

87468.1.Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met based on interviews conducted. The licensee did not comply with the section cited above allowing a staff to voice unwarranted opinions on a resident manor during a resident council meeting.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: The licensee has agreed to read regulation 87468.1 entirely and send LPA a self-certify letter via email, fax, or post mail that the regulation was read and understood.

Allegation investigated: Facility does not have sufficient staff to meet resident's needs. Facility is not following resident's admission agreement

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding allegations that the facility does not have sufficient staff to meet resident's needs and facility is not following resident's admission agreement. LPA Prieto met with Administrator Kyong Suk "Clara" Lee to discuss the elements of the complaint. LPA Prieto obtained client #1's (C1) admissions agreement stating that bed linen are to be changed and washed once a week. LPA interviewed Housekeeping Supervisor (S1) and obtained facility cleaning schedule. Documentation will show that cleaning of client rooms are met and sufficient staff are present to perform those duties, thus abiding cleaning of resident's linens per agreement. LPA obtained staffing schedule that shows there are sufficient staff to meet the needs of the residents. LPA interviewed client #1 (C1) in question and observed C1's living quarter to be clean and with clean linens. Based on the information obtained there is not enough evidence that the facility does not have sufficient staff to meet resident's needs and facility is not following resident's admission agreement. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed be LPA Prieto and Administrator Lee and a copy was left with the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 13, 2022 · control 56-AS-20220707142246

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

Licensing Program Analysts (LPA’s) Rayshaun Nickolas and Javier Prieto made an unannounced visit to the facility. The LPA’s Nickolas and Prieto arrived at the facility to conduct a case management visit to follow up on a special incident report (SIR) that was received on July 6, 2022. LPAs met with Administrator Kyong Suk Lee and explained the purpose of the visit. The SIR documents a client observing another client inappropriately touching another client in the living room and reporting this incident to staff. The SIR documents facility staff reviewed video footage taken from the surveillance camera in the living room and the facility staff reports no inappropriate touching was captured. The SIR further documents that the police were contacted, and no arrests were made. During the visit LPAs reviewed the video captured by the surveillance camera in the living room, obtained the police report number, and interview the Administrator. LPAs advised the Administrator to ensure that the facility staff are observing and monitoring for any changes in clients condition, properly documenting changes in clients condition, adequately staffed to provide proper care and supervision of clients in care, and submitting SIR’s to Community Care Licensing Division (CCLD) with detailed documentation. No deficiencies were cited during this visit. An exit interview was conducted where this report (LIC 809) was discussed and provided to the Administratorthe state’s words, verbatim · CDSS document, Jul 13, 2022

Allegation investigated: Residents are denied access to food by the kitchen supervisor. Frozen foods are not properly stored by the kitchen supervisor. Kitchen supervisor is serving expired food. Kitchen supervisor is not treating residents with dignity.

This unannounced visit is being conducted by Amy Goldenberg, Licensing Program Analyst (LPA), to initiate the 10 day visit to investigate the above-mentioned complaint allegations. During the course of this investigation visit LPA conducted interviews with six (6) staff and interviewed six (6) residents. LPA requested a copy of the meal menus, inspected the frozen and refrigerated foods for proper storage and expiration dates. Investigation revealed the following: It is alleged that S1 had refused R1 tray service. Three (3) of six (6) employees interviewed report that S1 had made comments about refusing residents access to food, however, these three (3) staff also reported that the residents did receive food on the dates that the incidents were reported. S1 denies any intent to withhold food from R1. R1 reports that they have no complaints. Unsubstantiated It is alleged that frozen vegetables are being stored in the refrigerator and that the expired milk is being served to the residents. Review of the food supply did not produce any evidence of expired foods or improper storage. Frozen foods were found to be stored properly in a freezer at zero degrees or less. S1 denies having served expired milk. There was no supporting information obtained through interviews regarding this allegation. It is alleged that S1 is purposely posting menus high on the wall with the intent that it would upset the residents in wheel chairs. LPA observation of a white board with daily menu printed on it as well as paper monthly menu was posted above the white boards. S1 admits to posting the menu on the wall but denies that the intent is to inconvenience any residents. Information received through interviews were conflicting and were insufficient to confirm the intent of the menu posting was intentional to and in violation on the residents personal rights. 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, Jun 24, 2022 · control 56-AS-20220623094323

Allegation investigated: Facility staff member threatens resident with eviction Facility staff member innapropriately touches resident Facility staff member makes innapropriate remarks to resident

This unannounced visit conducted by Amy Goldenberg, Licensing Program Analyst (LPA), is being conducted to conclude this agency’s investigation into the complaint allegations mentioned above During the course LPA of this investigation LPA reviewed R1's record, obtained copies of documentation from the record including R1's admission agreement, physicians report, progress notes, and an eviction letter. LPA interviewed five (5) employees and ten (10) residents. Investigation revealed the following. It is alleged that R1 is being threatened with an eviction. R1 revealed that they are being told about an eviction but does not feel threatened. It is alleged that an unknown staff member keeps pushing/hitting the resident and are making inappropriate comments. R1 revealed that he is not being hit or pushed by anyone at the facility. Unsubstantiated Ten (10) out of (10) residents interviewed do not report that they are being pushed/hit by any staff and do not report being talked to inappropriately. Based on the information attainable at this time 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, Jun 24, 2022 · control 56-AS-20220324113352

Allegation investigated: Facility has insects.

This unannounced visit is being conducted by Amy Goldenberg, Licensing Program Analyst (LPA), to initiate the 10 day visit to investigate the above-mentioned complaint allegations. During the course of this investigation visit LPA toured the kitchen and dining areas, conducted interviews with three (3) staff and interviewed six (6) residents. LPA requested a copy of the pest control plan from their professional pest control company. Investigation revealed the following: Three (3) of three (3) employees interviewed state that they have seen cockroaches in the kitchen and that the kitchen staff are providing pest control measures for inside the kitchen. Three (3) of three (3) staff interviewed report that they have not seen rodents in the facility. It is reported that the professional pest control company only manages the outside of the facility. Substantiated Six (6) of six (6) residents interviewed report insects in their bedroom or bathroom. Six (6) of six (6) residents interviewed report that they have not seen any rodents in the facility. LPA tour of the kitchen and food storage areas did not reveal that the kitchen was in disrepair. Based on the information available the alleged violation that the facility has insects has been substantiated 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. Six (6) of six (6) residents interviewed report insects in their bedroom or bathroom. Six (6) of six (6) residents interviewed report that they have not seen any rodents in the facility. LPA tour of the kitchen and food storage areas did not reveal that the kitchen was in disrepair. It is alleged that the kitchen is in disrepair and that the facility has rodents. Based on the information available, we have found the complaint allegations 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, Jun 2, 2022 · control 56-AS-20220525091504

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jun 13, 2022

General Food Service: All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. The facility is not meeting this requirement as evidenced by: Information was received through interviews that the facility kitchen has cockroaches, that bedrooms have ants and earwigs.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Licensee to contact their pest control company (Dewey) for consultation and development of an addendum to the plan to eradicate pest control issues in the kitchen as well as residents rooms. Provide LPA with the addendum to the Dewey pest control contract.

Allegation investigated: Resident's fees were increased without proper notice.

This unannounced visit is being conducted by Amy Goldenberg, Licensing Program Analyst (LPA), to initiate the 10 day visit to investigate the above-mentioned complaint allegation. During the course of this investigation visit LPA interviewed the facility administrator, interviewed resident R1, reviewed R1s facility file, and requested a copy of the facility's rate increase policy. Investigation revealed the following: R1 reports that they had a rate increase and did not receive a written notice. Staff interviewed report that a notification letter is provided for rate changed at the end of the prior year. According to the facility administrator the letter was sent out November 29th, 2021 to all of the residents which were impacted by govermental changes in Social Security rates. Unsubstantiated In addition to Social Security R1 reports that they are receiving disability benefits and according to documentation provided by the facility to R1 indicates they are responsible for an additional $20.00 monthly charge. Based on conflicting information regarding the allegation of resident's fees were increased without proper notice, we have found the allegation to be 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, Jun 2, 2022 · control 56-AS-20220524084823

Allegation investigated: Staff speaks inappropriately to resident.

On 2/16/21, Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of investigating the above allegation. The LPA met with administrator Kyong (Clara) Suk Lee, explained the nature of the visit and was granted entry. The investigation, which consisted of file reviews and interviews revealed the following: Resident 1 (R1) reported that on 2/9/22, they pressed the call button for assistance. Staff 1 (S1) and Staff 2 (S2) responded to the call. R1 denied that S1 spoke inappropriately to them while providing assistance. R1 denied that S2 spoke inappropriately to while them providing assistance. ***Continued on 9099C*** Unsubstantiated ***Continued from 9099*** S1 and S2 entered the room and R1 was on the phone with family. S1 asked R1 if they could put down the phone so that they could assist. R1's family member began asking S1 questions while on speakerphone. S1 responded to the family member and used a higher than normal tone due to being on speakerphone. Interviews with S1 and S2 revealed the only thing that S1 said to R1 while they were in the room was if R1 could put the phone down and that was said in a normal tone. S1 an denied speaking inappropriately to R1. S2 denied that S1 spoke inappropriately to R1. Staff 3 (S3) and Staff 4 (4) and reported that S1 is a very good caregiver and does not speak inappropriately to residents. Residents 2 (R), Resident 3 (R3) and Resident 4 (R4) reported that they have never experienced being spoken to inappropriately to by S1 nor have they witnessed S1 speaking inappropriately to other residents. During an interview with the administrator, it was reported that she has never received complaints about S1 speaking inappropriately to residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted where this report and LIC 811 were provided to administrator Kyong (Clara) Suk Lee.the state’s words, verbatim · CDSS document, Feb 13, 2022 · control 18-AS-20220210094410

Type of visit: Required - 1 Year

On 2/11/21 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. LPA met with Kyong Suk Lee, Administrator, explained the nature of the inspection and was granted entry into the facility. There are currently 47 residents at the facility. As of this date, there are no positive COVID-19 cases or individuals with COVID-like symptoms present in the facility. LPA toured the facility. There is one point of entry for routine COVID-19 symptoms screening is initiated for all visitors. Signs have been posted throughout the facility which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for residents. LPA observed hand sanitizer throughout the facility. LPA observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, glasses, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19. According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to the administrator.the state’s words, verbatim · CDSS document, Feb 11, 2022

Allegation investigated: Facility's supplies are stored in unsanitary manner

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to follow up on the open complaint with the allegation above. LPA Colvin met with Administrator Kyong "Clara" Suk Lee and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Facility's supplies are stored in unsanitary manner": LPA Colvin conducted a visual inspection of the area of concern in the allegation, which was specific to how paper towels in the bathroom are being stored. LPA Colvin inspected the common bathroom near the nurse station, and observed that although there is a paper towel dispenser installed on the wall, the paper towel roll is left on the counter. LPA Colvin tested the dispenser, in case the paper towels on the counter were extras, and observed that no paper towels were dispensed from the machine. By leaving the paper towel roll on the counter of the sink, persons washing their hands will need to (or have the opporunity to) grab the entire roll with their wet hands in order to dispense the amount needed. Even with LPA Colvin's best efforts, LPA Colvin failed to get paper towels from the roll without getting water from her wrist on the roll, thereby contaminating the remaining items. Substantiated A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the allegations occurred. A copy of this report was provided to Administrator Kyong "Clara" Suk Lee during the exit interview. LPA Colvin additionally observed that there is no other means to dry one's hands in the common restroom, such as an air dryer. Therefore, based on observations made, the allegation of "Facility's supplies are stored in unsanitary manner" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Kyong "Clara" Suk Lee during the exit interview.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20200324111109

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

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 by: The Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that paper towels in the common bathroom are stored on the counter, and not in the dispenser which is on the wall. This is a potential health risk to all persons.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee agrees to utilize another means for persons using the common bathroom sink to dry their hands without concern of contamination from other persons (i.e. paper towel dispenser, air dryer, etc.). Licensee to provide LPA Colvin with plan and photographic proof of utilization by Plan of Correction date.

Allegation investigated: *Facility did not seek medical attention timely for a client in care

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to follow up on the open complaint with the allegation above. LPA Colvin met with Marketing Director Janet Oliver and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Facility did not seek medical attention timely for a client in care": The Department conducted interviews and reviewed documents from the facility and hospital for the resident (R1) and evaluated R1's arriving condition at the hospital on February 28, 2020 as well as services provided to R1 at the facility. R1’s rash was originally discovered by facility staff on February 23, 2020, but the staff member that discovered the rash failed to report the observation to R1’s Power of Attorney (POA) or seek medical assistance for R1. The following day on February 24, 2020, the facility called 911 due to their concerns regarding the rash, but R1 refused to be transported to the hospital. Facility staff report, they attempted to contact R1’s POA on February 24, 2020but were unable to get in contact with them. Substantiated After evaluating R1's condition and needs in the hospital, the facility determined that they would still not be able to meet R1's needs and were concerned that R1 would end up in the same condition, requiring emergency medical care, should they readmit R1 to the facility. LPA Colvin reviewed Title 22 Regulations regarding Eviction Procedures and confirmed that the facility's Admissions Agreement was in line with Title 22 regarding under what circumstances the facility may issue an eviction notice to a resident. Additionally, the facility continued to abide by the Admissions Agreement, which was signed by R1, wherein they re-evaluated R1 in the hospital to determine if R1's needs/condition had changed, and if the facility would now be able to provide adequate care for R1. The facility determined that they would still not be able to meet R1's needs, and therefore decided not to readmit R1 as of March 6, 2020. The facility's Admissions Agreement expressly states that if a resident is in the hospital and the facility determines that they will not be able to provide sufficient care for the resident at the facility, that they will not readmit the resident back to the facility at that point. This agency has investigated the complaint alleging unlawful eviction. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted where this report was discussed. A copy of all reports and forms were provided to Marketing Director Janet Oliver during the exit interview. No further steps were made to seek medical treatment for R1 until several days later, on February 28, 2020 when R1’s POA went to the facility to check on R1 and observed the large rash on R1’s chest. With the assistance of R1’s POA, 911 was called and R1 was successfully transported to the hospital where R1 was treated for the infected rash. During the investigation it was revealed that prior to R1’s hospitalization, R1 had not been seen by a doctor nor had an updated assessment since 2015. Additionally, interviews revealed that the Administrator was aware that R1’s needs were greater than what was reflected in the facility’s written record of care, yet the facility had not taken any measures to update their assessment of the resident. Interviews also revealed that R1 was observed to have a recent decline in condition in the last two months and was refusing staff assistance with showering and toileting. Facility staff documented R1’s refusals and their attempts to contact R1’s Power of Attorney, but no further action was taken. The facility failed to provide adequate observation and care of R1, which resulted in R1 being admitted to the hospital for an infected rash. Therefore, based on interviews and record reviews, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Marketing Director Janet Oliver during the exit interview.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20200306154047

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 20, 2021

Observation of the Resident:...shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This regulation was not met by: Based on interviews and record review, the Licensee did not comply with the following regulation in that Administrator observed resident to have a significant change in condition and did not re-evaluate for level of care, resulting in infected wound. This was an immediate risk to R1.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Administrator and all care staff to complete training on observations of residents, including changes in condition and warning signs of possible undiagnosed underlying medical conditions. Administrator to additionally ensure all current residents have updated Needs & Services Plans. If any residents have Needs & Services Plans that are older than 1 year, the Administrator shall evaluate the resident and update their Needs & Services Plans in accordance with Title 22 Regulation Section 87463. Administrator to provide LPA Colvin with proof of training for self & all care staff by 12/20/21.

Allegation investigated: Staff failed to provide a safe environment Lack of care and supervision

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to follow up on the open complaint with the allegation above. LPA Colvin met with Administrator Kyong "Clara" Suk Lee and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Staff failed to provide a safe environment": LPA Colvin interviewed staff and residents as well as reviewed resident records in regards to this allegation. Through interviews conducted, LPA Colvin confirmed that a facility resident (R1) has hit both staff and residents on multiple occasions through the use of R1's electric scooter in the facility. Records from R1's file show that R1 had been given at least three written warnings for their behavior, none of which included running into other persons with their electric scooter, despite several witnesses confirming that this has occurred. Despite R1's behavior and endangering those in the facility with their continued reckless use of the elctric scooter, there is no evidence that R1 was ever provided with an eviction notice or was instructed that they would not be permitted to use the device indoors, due to their repeated incidents with running into others and causing harm. Substantiated Therefore, since the facility did not intervene in R1's actions (which had proven to be hazardous to others in the facility) other than providing written warnings, the allegation of "Staff failed to provide a safe environment" is SUBSTANTIATED. Regarding allegation "Lack of care and supervision": LPA Colvin reviewed the facility file for one resident (R2) as well as conducted interviews with staff and residents. LPA Colvin observed that R2 had a significant change in condition from 2019 - 2021, as evidenced by R2's Physician's Reports. In 2019, R2 was ambulatory and able to care for all of their daily needs, but by 2021, R2 was non-ambulatory and needed significant assistance with toileting and bathing. During review of R2's file, LPA Colvin did not observe any updates to the facility's assessment for R2's Care Plan since the quarterly review dated 3/28/20. LPA Colvin did observe an assessment from the Assisted Living Waiver (ALW) Program, though this assessment did not include an evaluation of daily grooming needs. Interviews confirm that R2 originally was very independent, but since R2's return from the hospital in February 2021, R2 needed an increasing amount of assistance. Additionally, LPA Colvin reviewed the Death Report for R2 from 6/3/21 and observed that the caregivers on duty observed that R2 was non-responsive, but failed to provide aid or contact 911 until after the facility's nurse arrived for their scheduled shift at 6:59am, at which point the staff notified the Nurse, who then instructed them to call 911 while the Nurse provided CPR. It was reported that R2 appeared to have a liquid (possibly soda) in their mouth, which was drained out by the Nurse turning R2 onto their side. R2 was pronounced deceased by the paramedics at 7:38am. It should be noted that R1's Advance Directive stated that R1 wanted full treatment of life saving measures. Due to staff's failure to document changes in R2's condition and needs, as well as staff's failure to immediately provide life saving measures upon finding R2 unresponsive, the allegation of "Lack of care and supervision" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Kyong "Clara" Suk Lee during the exit interview. 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, and a copy of this report was provided to Administrator Kyong "Clara" Suk Lee.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20200310171720

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 20, 2021

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin learned that R1 has hit residents & staff with their electric scooter on multiple occasions. There is no record of facility intervention. This is an immediate safety risk.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee agrees to address the reported concern with staff and residents in order to determine if this concern is still an issue. If the issue is still present, the facility shall address it accordingly with R1 and R1's POA. If the issue is no longer present, the Licensee agrees to hold a meeting with the residents to remind them of safety practices when operating an electric device (wheelchair or scooter) and that misuse of such devices may result in additional action from the facility, such as eviction. Licensee to provide LPA Colvin with an update on status of issue, and may self-certify once facility meeting has been completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 20, 2021

Additional Personal Rights of Residents in...Facilities : (a) In addition to the rights listed...residents... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the above regulation with one resident (R2). LPA Colvin learned that R2 had a change in condition, and their facility Care Plan was not updated. Staff additionally failed to immediately provide R2 with life saving measures. This was an immediate health risk for R2.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee agrees to have all staff re-trained on what to do in a medical emergency. Licensee additionally to review all current resident files and ensure that their Care Plans are up to date and accurately reflect the services needed by the residents and who they are provided by (Home Health, Hospice, Facility Staff). Licensee to provide LPA Colvin with proof of staff training and may self-certify once review of resident records is complete. Plan of Correction due 12/20/21.

Allegation investigated: Facility is in disrepair

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to deliver findings on the open complaint with the allegation above. LPA Colvin met with Marketing Director Janet Oliver and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Facility is in disrepair": For this investigation, LPA Colvin conducted interviews and reviewed facility records in regards to a reported ceiling collapse in Room #32. Through investigation, LPA Colvin learned that the reported ceiling collapse occurred on 11/23/20, at which time the occupant of the room was temporarily relocated. Upon further follow up on the status of the repairs of the room on 12/15/20, LPA Colvin was informed by facility staff that Room #32 was still under repair, and that the ceiling had not been finished. This fact was supported by facility maintenance logs, which showed Room #32 being periodically worked on from 11/25/20 to 12/15/20 (date records were requested). Though the facility had ongoing work scheduled to complete the repairs for the ceiling, the extended time that it took for the project to be completed left the occupant of Room #32 displaced from their room for over three weeks. Substantiated Therefore, based on interviews and record review, the allegation "Facility is in disrepair" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Marketing Director Janet Oliver during the exit interview.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20201123163753

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Dec 31, 2021

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin confirmed that Room #32 was in a state of disrepair for over 3 weeks, leaving the occupant displaced. This was a potential personal rights violation of the occupant.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee agrees that in the future, all repairs will be completed within a timely manner, especially when the repair directly affects a resident. Licensee to provide LPA Colvin with a Statement of Understanding of this expectation by the Plan of Correction date of 12/31/21.

Allegation investigated: Facility is not providing residents with access to their money in a timely manner Facility is not maintained in a healthful manner

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to follow up on the open complaint with the allegation above. LPA Colvin met with Administrator Kyong "Clara" Suk Lee and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Facility is not providing residents with access to their money in a timely manner": LPA Colvin interviewed staff and residents, as well as reviewed P&I records for residents for the year of 2020, when this complaint was filed. Interviews revealed that each month the Licensee takes the checks for residents (who have their Social Security sent directly to the facility) to the bank and cashes them before returning the cash to the facility where it is kept on hand for residents for when they request it. Interviews additionally revealed that in April 2020, the Licensee did not cash the residents' checks at the bank until 4/9/20, due to bad weather and scheduling conflicts. According to witnesses, the resident checks normally arrive at the facility on the 3rd of each month. Due to the delay in cashing the checks, some residents were unable to access their P&I funds for the month for almost one week. Substantiated This was further evidenced through review of the P&I logs, in which show multiple residents having their P&I funds deposited 4/9/20, and then subsequently cashed out to the residents on 4/9/20. These residents who were most affected do not maintain a carryover balance from the previous month, meaning that they have no available funds until the Licensee cashes their Social Security check and makes these funds accessible to them. Therefore, due to the residents' funds being delayed 6 days due to the Licensee electing to not deposit the checks, the allegation "Facility is not providing residents with access to their money in a timely manner" is SUBSTANTIATED. Regarding allegation "Facility is not maintained in a healthful manner": LPA Colvin investigated this allegation, which is specific to the facility smelling like cigarette smoke, by conducting a tour of the facility and interviewing residents. LPA Colvin concentrated her investigation on the wing of the facility closest to the entry/exit which is closest to the designated "smoking area". Interviews conducted by LPA Colvin resulted in multiple statements of cigarette smoke bothering the residents, even while the residents are present indoors and in their own bedrooms. LPA Colvin additionally observed the strong smell of cigarette smoke when passing Room #37, which LPA Colvin did not enter, but who's door was open. LPA Colvin additionally observed warning notices in at least one resident's (R1) file, for smoking indoors. Also of note, LPA Colvin observed that at least two residents in the wing near the entrance exit to the smoking section are on oxygen, and therefore are more susceptible to any second hand smoke which enters the facility. LPA Colvin additionally observed that R1 has been given three warnings for the same behavior, but there was no eviction notice on file, despite the warning form stating that after three warnings a resident will be given a 30-day eviction notice. Therefore, due to observations, interviews, and record review, the allegation "Facility is not maintained in a healthful manner" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Kyong "Clara" Suk Lee during the exit interview.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20200407112426

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(27) · Plan of correction due date: Dec 31, 2021

Additional Personal Rights of Residents in... Facilities : (a) In addition to the rights listed...residents...shall have all of the following personal rights: (27) To keep, have access to, and use their own personal possessions...and to keep and be allowed to spend their own money... This requirement was not met by: Based on interviews and record review, the Licensee did not comply with the above regulation with at least 4 residents. LPA Colvin observed 4 residents did not have access to their April 2020 P&I until 4/9/20, six days after the Licensee received the checks. This was a potential personal rights violation.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee to submit plan to LPA Colvin to ensure that residents have access to their funds upon request. Possible solutions include: Giving other staff access/ability to cash checks; loaning residents funds from facility petty cash until their checks can be cashed; ensuring that checks are cashed in a timely manner. Licensee to provide LPA Colvin with plan by the Plan of Correction date of 12/31/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 31, 2021

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and observation, the Licensee did not comply with the above regulation with at least one aspect of the facility. LPA Colvin confirmed that the wing of the facility near the exit which leads to the smoking section smells like cigarettes. This is a potential person right violation of residents.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee to evaluate options on how they can address the concerns with the facility smelling like cigarettes. LPA Colvin reccomends for the Licensee to include residents (including those who smoke) in the discussion, for opportunity to hear all resident opinions or concerns. Licensee to provide LPA Colvin with plan on how this issue will be address. Plan due to LPA Colvin by Plan of Correction date of 12/31/21.

Allegation investigated: Facility is in disrepair

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to deliver findings on the open complaint with the allegation above. LPA Colvin met with Administrator Kyong "Clara" Suk Lee and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Facility is in disrepair": LPA Colvin investigated the complaint through conducting interviews of residents and staff and reviewing the facility's maintenance log. LPA Colvin was unable to confirm the allegation as there was no entry on the maintenance log for the allegation of the toilet in a resident's room not flushing, and there were no supporting statements in the interviews conducted. Additionally, the resident who's toilet was reportedly to be affected informed LPA Colvin that they fixed the fixture themselves, therefore, there was no remaining evidence of the issue for LPA Colvin to observe and record. Therefore, based on lack of evidence, the allegation "Facility is in disrepair" 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. Unsubstantiated An exit interview was conducted, and a copy of this report was provided to Administrator Kyong "Clara" Suk Lee.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20201210082804

Allegation investigated: Facility staff did not ensure that residents have towels

Licensing Program Analyst (LPA) Anna Bueno conducted a subsequent visit to the facility to deliver findings on the above allegation. LPA met with administrator Tae Kim who was informed of the purpose of today’s visit. The investigation consisted of resident interviews. The allegation is Facility staff did not ensure that residents have towels. On 12/17/2021, LPA Crystal Colvin stated that on 12/10/20, the facility only had one clean towel in the laundry room (where spare towels and linen are kept). While it is likely that additional towels were on hand with the housekeepers who clean the resident bedrooms throughout the day and replace the linens, this would not be sufficient if most residents needs their towels changed out. During today's visit, LPA Bueno conducted resident interviews and discovered that the facility provides laundry services once a week and on an as needed basis, even during times of Covid-19 outbreak. Interviews with residents also reveal that, while the facility provides linens and towels, residents may purchase, store, use, and clean their own items. This allegation is therefore 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 Administrator Tae Kim. Unsubstantiated Due to observations made by LPA Colvin, the facility was cited and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Kyong "Clara" Suk Lee during the exit interview.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 18-AS-20201203110823

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Dec 31, 2021

Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3)...the licensee shall assure provision of: (C)...bath towels, hand towels and wash cloths. The quantity shall be sufficient... This requirement was not met by: Based on interviews and internal audit, the Licensee did not comply with the above regulation with at least one category of item. LPA Colvin confirmed that the facility did not have a sufficient supply of towels, as there was only one spare clean towel. This was a potential health risk to all residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2021

Plan of correction: Licensee agrees to institute a regular audit of the facility's linens and towels to ensure that the facility has plenty of supplies at all times. Licensee to submit an updated Program Plan (Adendum) which includes which staff role is responsible for the audit, how frequently it will occur, and what number of items need to be available at all times. Porgram Plan Adendum to be submitted to LPA Colvin by the Plan of Correction date of 12/31/21. Along with the Adendum, the Licensee shall submit their first audit of the towels/linens.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA ) Crystal Colvin arrived at the facility unannounced for the purpose of following up on multiple complaints. During LPA Colvin's inspection, LPA Colvin reviewed the Resident Council meeting notes and observed in the notes from the meeting on 8/20/21, that in the Council's "New Business" the following item was listed as item "C." in "Kitchen issues": "If you are too late to meals you may not be served". LPA Colvin advised the Administrator that residents are not to be denied meals or food service regardless of whether or not they arrive on time to the dining room. LPA Colvin is issuing a Technical Violation Advisory Note today instead of a deficiency, as LPA Colvin does not know at this time if any resident has been denied food service due to being late. An exit interview was conducted with Administrator Kyong "Clara" Suk Lee and a copy of this report, Technical Violation Advisory Note (LIC9102-AN) were provided.the state’s words, verbatim · CDSS document, Dec 17, 2021

Allegation investigated: Facility denied resident a refund

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced to follow up on the open complaint with the allegation above. LPA Colvin met with Assistant Administrator Tae Kim and advised of the purpose of today's visit. Below is a summary of the findings of the investigation: Regarding allegation "Facility denied resident a refund": For the investigation of this allegation, LPA Colvin conducted interviews and reviewed relevant records regarding the resident (R1). In LPA Colvin's review of these records, LPA Colvin confirmed that R1 signed an Admissions Agreement with the facility on 2/22/19 which outlined the monthly rates, causes for eviction, and refund policy. R1 left the facility via ambulance on 5/8/20 due to continued medical complecations, for which the facility could no longer care for and were unable to meet R1's needs. On the date that R1 left via ambulance, it was communicated to R1's Power of Attorney (POA) that R1 would not be admitted back to the facility when she is ready for discharge, due to these continued issues which have lead to recent hospitalizations. The Administrator provided LPA Colvin with a picture of a refund check that was sent out to R1's POA, dated 5/11/20 for $801.30. Unfounded The Administrator additionally provided LPA Colvin with a picture of the Return Receipt showing that the check was sent via Certified Mail, as well as the retail receipt showing the purchase for sending the mail. LPA Colvin was informed that the check was a refund for the remaining days of the month of May 2020 that R1 would not be residing in the facility, as R1 had previously been issued an eviction notice and the facility would not be accepting R1 back from the hospital. According to R1's Admissions Agreement with the facility, R1 was being charged $1,080 each month, or approximately $36 per day. Since R1 paid $1,080 for the month of May 2020, but only stayed at the facility for eight days (until 5/8/20), then if R1 was charged the $36 daily rent fee for eight days, R1 would owe the facility $288 for R1's time at the facility. Record review shows that R1 was effectively only charged $278.70 for the eight days in May 2020, as the facility issued a refund in the amount of $801.30 to R1's POA. Additionally, R1 is not entitled to any additional funds for time spent at the hospital during a previous hospitalization in February 2020, as page eight (item "J") of R1's signed Admissions Agreement clearly states "If a resident leaves the facility temporarily, the holding for his/her room is $36 per day. At the end of the item, there is a space for the resident to initial, which R1 did. This agency has investigated the complaint alleging "Facility denied resident a refund". We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Assistant Administrator Tae Kim and a copy of this report was provided. LPA Colvin was informed that the refusals were documented separately on staff notes, which LPA Colvin reviewed and observed, but these notes were not all-inclusive of the dates missing notation on the MARs log. LPA Colvin was additionally told through interviews that due to the number of times R1 would refuse the medications (more often than not), the dates were simply left blank and were known by staff to be refusals. Since it is not in Title 22 Regulations that a facility must utilize and maintain a MARs Log, LPA Colvin cannot impose upon the facility how they are to document the refusals (marking it on the log versus making a separate note in the file). Additionally, though the facility staff notes did not include all dates missing notation in the MARs log, R1 has a substantial documented history of refusing medication, which LPA Colvin confirmed through Home Health records as well. Therefore, it is plausible that facility staff made attempts to administer the topical medication to R1 as frequently as prescribed. Additionally, facility staff are unable to forcibly administer medication to any residents in accordance with Title 22 Regulations, therefore, dates where the resident refused and medication was not administered staff were unable to administer medication due to needing to uphold residents' rights to refuse treatment. Due to interviews, record review, and observations made by LPA Colvin, the complaint 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 Assistant Administrator Tae Kim and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2021 · control 18-AS-20200709144134