Jasmin Terrace at Yucca Valley

Allegation investigated: Staff mishandled resident's medications Staff did not ensure resident was transported to resident's medical appointment.

Licensing Program Analyst (LPA) Javier Prieto and LPA Paula Guitierrez arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPAs met with Assistant Administrator Molina to discuss the elements of the complaint. Regarding the allegation staff mishandled resident's medications, staff #1 (S1) interviews and medical records obtained reveal the medications were prescribed for resident #1 (R1) on 09/22/23 and medication was not located for approximately 7 days, when R1 was dispensed the first dose. Regarding the allegation that staff did not ensure resident was transported to resident's medical appointment, S1 interview reveal that R1 missed a scheduled doctor's appointment on 09/19/23 due to staff miscommunication and later attended doctor's appointment on 09/22/23. **** continued on LIC 9099C*** Substantiated Based on evidence obtained during the investigation, the 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 where reports LIC9099 and LIC9099-D were discussed and a copy of the reports with Appeal Rights was provided to Assistant Administrator Maria Molina at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 56-AS-20230929095525

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Oct 6, 2023

Incidental Medical and Dental Care For every prescription and nonprescription PRN medication for which the licensee provided assistance there shall be a signed, dated written order from the Physician, on a blank prescription, maintained in resident's file. This requirement is not met as evidence by the following: Records reveal that medications were prescribed to resident #1 and medication were not located and dispensed according to doctor's ordersthe state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator is to train their staff on medication dispensing and storing of medication and a copy of that training to be sent to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 9, 2023

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: This requirement is not met as Records revealed resident #1 had an appointment on 09/19/23, missed appt and later attended on 09/22/23the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator to send declaration to LPA on POC date indicating that staff will better communicate with residents or resident's responsible party.

Allegation investigated: Resident sustained injuries due to lack of care and supervision by staff Staff did not ensure that resident was provided fluids to prevent dehydration per client written care plan

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPA Prieto met with Administrator Garcia and discussed the elements of the complaint. LPA Prieto interviewed resident #1 (R1), staff and gathered pertinent documentation. Regarding allegation that resident sustained injuries due to lack of care and supervision by staff.; Staff (S1) interview reveal that staff was present at the time the injury occurred to R1. S1 interview also reveal that witness did speak with S1 in person regarding R1's injury and inquiry to hydrate R1. Staffing documentation obtained to reveal additional staff was on duty at time of resident incident. Unsubstantiated Regarding the allegation that staff did not ensure that resident was provided fluids to prevent dehydration per client written care plan.; S1 interview and documentation reveal that there is no plan of care requiring fluids to prevent dehydration for R1. S1 interview does state that R1 is provided with fluids in R1's room. LPA observed a pitcher of water, with cup, in R1's room at time of investigation. Based on the information obtained there is not enough evidence that the resident sustained injuries due to lack of care and supervision by staff and staff did not ensure that resident was provided fluids to prevent dehydration per client written care plan. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Administrator Garcia and a copy was left with the facility.the state’s words, verbatim · CDSS document, Sep 25, 2023 · control 56-AS-20230920141310

Allegation investigated: Staff continues to steal medications Staff did not provide proper shower assistance to residents in care

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Michael Garcia, administrator and discussed the purpose of the visit. Regarding allegation, staff continues to steal medications, Administrator denies witnessing staff stealing resident's medications. Staff interviewed deny stealing resident’s medication nor have they witnessed other staff stealing resident’s medications. Residents interviewed deny that staff have stolen their medications. Regarding allegation, staff did not provide proper shower assistance to residents in care, Administrator and staff interviews deny not providing proper shower assistance to residents in care. Five (5) out of (6) residents interviewed stated that staff do provide them with proper shower assistance. Based on pertinent record review and interviews with relevant parties, the allegation is Unsubstantiated. 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. An exit interview was conducted where this report was discussed and provided with appeal rights to the administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 19, 2023 · control 56-AS-20230720103450

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(2) · Plan of correction due date: Sep 20, 2023

87464Basic Services(f)Basic services shall at a minimum include:(2) Safe and healthful living accommodations and services. This requirement is not met as evidenced by: medications for (2) residents were missing. Staff was unable to locate the medication; which poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2023

Plan of correction: Administator shall read and submit a self-certification of understanding to the licensing agency by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(7) · Plan of correction due date: Sep 29, 2023

87464Basic Services(f)Basic services shall at a minimum include:(7)A planned activities program which includes social and recreational activities appropriate...this requirement is not met as evidenced by: Facility staff assigned to activities are on medical leave. Four (4) out of (6) residents interviewed stated that the facility does not have activities for them.the state’s words, verbatim · CDSS document, Sep 19, 2023

Plan of correction: Administator shall read and submit a self-certification of understanding to the licensing agency by POC date.

Allegation investigated: Facility ceiling is in disrepair. Facility floor is in disrepair. Facility lights are in disrepair. Facility is malodorous.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Maria Carrillo-Molina support staff who was informed of the visit. The investigation consisted of interviews with seven (7) residents, six (6) staff members, and observations. The residents and staff were interviewed, all staff and residents stated that the facility experienced some water damage during 8/19/2023 through 8/21/2023. LPA observed repairs had been done in some of the rooms. The light fixtures had been replaced/repaired in room 128 and the celling did appear to have some dried water damage but there was no visible water leaking from the celling or light fixtures in the bedrooms or in any part of the facility. The central bathroom by memory care unit has been fully repaired there were no holes in the celling,walls,or floors. Unsubstantiated Resident R1 was relocated in another room that has been repaired. LPA observed that room 130 did not have any residents in it. Maria stated that R's personal belongings had not been moved yet but would be moved today 8/29/2023. During the tour of the memory care unit LPA observed housekeeping moping the floor and it was not malodorous and LPA didn't observe the floor to be in disrepair. Based on interviews conducted, and observations the allegations above 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 Maria Carrillo-Molina where the report was discussed and provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 29, 2023 · control 56-AS-20230824090044

Allegation investigated: Staff left residents in soiled diapers for an extended period of time. Staff are inappropriately bribing residents. Staff are not providing a comfortable environment for residents. Facility is dirty. Facility has pests. Facility floors are in disrepair.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Michael Garcia Administrator who was informed of the visit. The investigation consisted of interviews with seven (7) residents, six (6) staff members, and documents were reviewed. The residents and staff were interviewed and all stated residents are checked on every 2-3 hours or as needed. LPA was unable to determine which resident was left in soiled linen and diapers for an extended period. The residents interviewed by LPA who were incontinent stated they are assisted as needed and have not been left soiled for a long period of time and did not know of any other resident left unassisted. LPA interviewed residents regarding staff inappropriately bribing them and they all have stated staff members have not tried to bribe them for any reason nor has any other resident to their knowledge been bribed by staff members. Unsubstantiated The residents also stated that they are comfortable in their environment considering their circumstances and they have not recently experienced having or seen bugs or pests because a pest control company comes out on a regular basis. LPA also observed documents that show monthly pest control has been put in place. The residents and staff members have stated the facility is cleaned daily and during LPA's visit there were staff members cleaning rooms and common areas. During the tour of the facility LPA did not observe facility floors in disrepair and the main shower room had been repaired from prior water damage. LPA did observe unoccupied rooms being renovated or cleaned because of rain damage and there were no residents or furniture in those rooms. Michael Garcia has also stated he is in the process of hiring more staff members and he will be utilizing staffing agencies to assist with the staffing concerns and provided the name of the company that will be used. Based on interviews conducted, documents reviewed and observations, the allegations above 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 Michael Garcia where the report was discussed and provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 56-AS-20230814142101

Allegation investigated: Staff did not adequately supervise residents resulting in residents engaging in physical altercations. Staff did not ensure that facility air conditioning is working. Staff did not ensure that doors were secured in the memory care unit of the facility.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Michael Garcia Administrator who was informed of the visit. The investigation consisted of interviews with seven (7) residents, six (6) staff, and documents were reviewed. LPA obtained documents that revealed the air conditioning unit was replaced/repaired and LPA did feel cool air coming from the unit. LPA observed the thermostat at 70 degrees in the main area of the facility. LPA toured all rooms in the facility and all air conditioning units were working. LPA toured the memory care unit inside and outside; LPA observed the unit locked and secure during the visit. The sliding doors in the memory care unit were observed to open and could only be opened to 10 inches documents were received confirming measurements. The outside area where sliding doors open is in a secure perimeter where residents can not get out. The interviews conducted with staff stated the altercation started in a resident’s room and a staff member did deescalate the situation, requested assistance from another staff member. Unsubstantiated Based on the interviews, staff were available at the time of the altercation and R1 was assisted with medical attention. LPA also observed the lunch menu, toured the kitchen, and there appeared to be sufficient food supplies for the residents in care. LPA observed residents eating a balanced cooked lunch, Chili beans with vegetables and garlic bread, coffee, juice, or water. Based on interviews conducted, documents reviewed and observations, the allegations above 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 Michael Garci where the report was discussed and provided at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 56-AS-20230815162748

Allegation investigated: Staff did not refill resident's medication(s) in a timely manner.

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to continue complaint investigation and deliver findings on the above allegation. LPA met with Administrator Michael Garcia who was informed of today’s visit. The investigation consisted of LPA observations, file review, and interviews with relevant parties. Regarding the allegation, Staff did not refill resident's medication(s) in a timely manner, facility written notes reveal that Resident's #1 (R1) medication was ordered on 6/26/23, however the resident's medication was not received until 7/13/23. Administrator was not able to confirm the reason for R1's medication delay. Interviews with staff reveal that medication from R1's hospital sometimes takes longer that 10 days to receive. Facility had no documentation of follow-up contact with resident's hospital and/or Doctor to ensure resident's medication is received in a timely manner. Substantiated Based on evidence obtained during the investigation, the 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 where reports LIC9099 and LIC9099-D were discussed and a copy of the reports with Appeal Rights was provided to Administrator Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 9, 2023 · control 56-AS-20230627101007

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Aug 10, 2023

87464 Basic Services (f)Basic services shall at a minimum include:(6) Arrangements to meet health needs. This requirement is not met by: Facility did not refill resident's medication in a timely manner and did not follow-up on the delay of resident's medication.the state’s words, verbatim · CDSS document, Aug 9, 2023

Plan of correction: Administator shall read and submit a self-certification of understanding to the licensing agency by POC date.

Type of visit: POC

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced Plan of Correction (POC) visit to the facility to follow up on a deficiency. LPA met with Michael Garcia and discussed the purpose of the visit. On 7/31/23, a deficiency was issued for not providing resident with follow-up medical care. Administrator stated that the resident did have a follow-up visit with resident’s doctor and would provide proof by POC date 8/01/23. During today's visit (8/09/23), POC is cleared. A civil penalty was accessed today for failure to correct the deficiency by POC date. An exit interview was conducted where this report was discussed and a copy of this report with appeal rights was provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 9, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maria Carrillo Molina, Dietary Supervisor and Michael Garcia, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (85) with a current census of (73). Hospice waiver for (10) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. Facility has no outdoor bodies of water. Facility has sufficient indoor and outdoor furniture in good repair for residents in care. Facility has a covered outdoor patio area. However, the outdoor space for Dementia residents is not completely enclosed with open access to the street. Deficiency cited. LPA inspected the kitchen. Hot water temperature is maintained at degrees 109 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. A monthly menu is posted in the kitchen. However, LPA observed roaches and insects on several areas of the kitchen. Staff stated that an exterminator is scheduled to treat the facility on August 3rd. Deficiency cited LPA inspected (10) resident bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting. LPA inspected client bathrooms and central bathroom. Bathrooms are equipped with handrails, shower chairs and operating in safe conditions. The hot water temperature tested in all bathrooms between 105 and 112 degrees F. However, upon turning on the light of the central bathroom, LPA observed bugs scattering around the floor. Staff stated that an exterminator is scheduled to treat the facility on August 3rd. Deficiency cited. LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Posters such as personal rights, ombudsman contact poster, Licensing complaint telephone number, emergency phone numbers are posted in a common area. Disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care. LPA reviewed client medications are kept in a safe and locked cabinet inaccessible to residents in care. All medication are labeled and administered as prescribed. LPA reviewed staff files for fingerprint Clearances/Exemptions, training certifications, health screening, employee rights and applications. LPA found that staff #1 did not have the required health screening. deficiency cited. LPA reviewed resident files for admissions agreements, physician's reports, needs service plans Personal Rights: Residential Care for the Elderly. LPA found resident #1 and resident #2 files were missing admissions agreements and Resident #3 file had an incomplete physician's report. Deficiency cite. Deficiencies are being cited during today's visit. An exit interview was conducted where reports (LIC809/LIC809D) were discussed and a copy of the reports with appeal rights was provided to Maria Carrillo Molina at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 1, 2023

The state marks this report as 13 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident. Staff not ensuring resident's needs are met by leaving residents in soiled diapers for extended periods.

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with Michael Garcia and explained the purpose of the visit. The investigation consisted of LPA observations, interviews, and pertinent document review. Regarding the allegation staff hit resident, the Administrator and staff interviewed deny hitting resident #1 (R1) and other residents. Residents interviewed deny staff hitting them nor have they witnessed staff hitting other residents. Facility file review reveals, R1 sustained injuries to the face when pulled by Resident #2 (R2) causing R1 to fall. Staff interviewed stated that they did not witnessed the incident and heard from Staff #1 (S1) that R1 sustained injuries to their face and buttocks when pulled by R2 causing R1 to fall. LPA made several attempts to contact S1 but they were unavailable to corroborate the allegation. R1 and R2 were unable to corroborate the allegation due to their cognitive condition. There is not enough evidence to corroborate this allegation. Unsubstantiated Regarding the allegation, staff not ensuring resident's needs are met by leaving residents in soiled diapers for extended periods, Administrator and staff interviewed deny leaving resident #1 (R1) and other residents in soiled diapers for extended periods. Staff interviewed stated that residents are checked every two hours for diaper changes. Staff interviewed deny seeing diaper rashes on residents due to being left in soiled diapers for extended period. Residents interviewed deny that staff left them in soiled diapers for an extended period. R1 was unable to corroborate the allegation due to their cognitive condition. There is not enough evidence to corroborate this allegation. Based on file review, interviews and observations, the above allegations are Unsubstantiated; meaning 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 where this report was discussed and a copy with appeal rights was provided to Administrator Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 31, 2023 · control 56-AS-20230504153119

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Magda Malcore prompted a case management visit to the facility for deficiencies identified through complaint investigation 56-AS-20230504153119. LPA met with Administrator, Michael Garcia. Criminal Record Clearance: LPA review of facility records and staff interviews reveal that Staff #1 (S1) was working at the facility without background clearance when an incident occurred at the facility on 4/28/23. LPA determined through Guardian (personnel management system) that S1 was associated to the facility on 4/07/23 and did not have a criminal record clearance. The Administrator stated that S1 resigned and is no longer employed at the facility. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D. Furthermore, LPA review of facility compliance history reveals facility was cited for the same deficiency on 1/12/23 for having an uncleared staff working at the facility. An immediate civil penalty of $1000 is hereby assessed today, 7/31/23, for repeat violation within a 12-month period. The Administrator was informed that a civil penalties will continue to accrue of $100 per day per violation until deficiency is corrected Incidental Medical and Dental Care: LPA review of facility records and staff interviews reveal on 4/28/23, resident #1 (R1) sustained injuries to their face and buttocks due to a fall. The Administrator stated that he did discuss with staff as to why medical services where not call and stated that the Medtech deemed not necessary. LPA found no documentation of staff arranging medical services for R1’s injuries. An incident report was provided to the Licensing Agency. On 6/11/23, staff found R1 on the floor with injuries in between R1’s nose and eyebrow. LPA found no documentation of staff arranging medical services for R1’s injuries. On 6/15/23, R1 was taken to the hospital for a possible fall and hip injury. R1 discharge reveal that a follow-up visit with primary care physician is needed with 1-2 days. The Administrator stated that R1's daughter was taking R1 to their doctor for a follow-up. Administrator stated that he will follow-up and provide the licensing agency documentation of follow-up with primary care physician's visit. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D. Reporting Requirements: LPA review of facility records and licensing agency records reveal that the licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23. Administrator provided LPA with written incident reports and stated the he will provide proof that the incident was provided to the licensing agency within the required 7 days. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D. Furthermore, LPA review of facility compliance history reveals, facility was cited for the deficiency on 4/03/23 for not reporting an incident regarding a resident in care to the licensing agency. An immediate civil penalty of $1000 is hereby assessed today, 7/31/23, for repeat violation within a 12-month period. The Administrator was informed that civil penalties will continue to accrue of $100 per day per violation until deficiency is corrected. An exit interview was conducted where reports (LIC809/LIC809-D) were discussed and copies with appeal rights were provided to the administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 31, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Aug 1, 2023

Criminal Record Clearance (e)All individuals subject to a criminal record review...prior to working...in a licensed facility shall...(1)Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by: Facility records and staff interviews reveal, Licensee did not ensure a criminal record clearance was obtained for Staff #1 (S1) prior to employment, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2023

Plan of correction: Administrator stated S1 is no longer employed at the facility. Administrator to submit a statement of understanding that the facility will ensure that all staff and/or volunteers are criminally cleared prior to start date and submit statement to the Licensing agency by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(1) · Plan of correction due date: Aug 1, 2023

Incidental Medical & dental care (a) A plan..shall be by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions & needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, R1 had multiple physical injuries between 4/28/23 and 6/11/23 that required follow-up medical care. However, it was not until 6/15/23, when R1 sustained subsequent injuries that R1 was sent to the hospital, which poses and immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2023

Plan of correction: Administrator to provide proof of R1 follow-up visit with primary physician's to the licensing agency by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 7, 2023

REPORTING REQUIREMENTS (a)Each licensee shall furnish to the licensing agency…(1)A written report…within seven days...(D)Any incident which threatens the welfare, safety or health of any resident…This requirement is not met by: The licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23 with 7 days; which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 31, 2023

Plan of correction: The Administrator provided LPA with one (1) incident report. Administrator provide the additional incident report by shall provide by POC date.

Allegation investigated: Facility does not ensure that staff are capable of communicating with residents Staff do not ensure an adequate quantity of food is served to residents in care Staff does not ensure transportation assistance is provided for residents Residents were left in soiled diapers for extended periods of time Resident left on the floor for an extended period of time Staff speaks inappropriately to residents

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to deliver findings on the above allegations. LPA met with Administrator, Michael Garcia and discussed the purpose of the visit. The investigation consisted of observations, reviewing pertinent documents, and interviews with relevant parties. Allegation #1 – facility does not ensure that staff are capable of communicating with residents. Administrator and staff interviewed deny not being capable of communicating with residents. Residents interviewed deny that there is a communication barrier with staff. Allegation #2 - staff do not ensure an adequate quantity of food is served to residents in care. LPA toured the facility kitchen and observed a sufficient supply of nonperishable foods and perishable foods for residents in care. LPA observed that menus consisted of a variety of meals for breakfast, lunch, and dinner. The Administrator and staff interviewed deny not ensuring residents are served an adequate quantity of food. Unsubstantiated The Administrator stated that residents are provided three meals a day, snacks are provided to residents between meals. Residents interviewed stated that they are provided adequate quantity of food. Allegation #3 - staff does not ensure transportation assistance is provided for residents. Administrator and staff interviewed deny not ensuring transportation assistance for residents. The Administrator stated that the facility arranges transportation for the residents using a dedicated driver, other staff, and third-party transportation services. Residents interviewed deny that the facility does not ensure transportation assistance when needed. Allegation #4 – residents were left in soiled diapers for extended periods of time. Administrator and staff interviewed deny that residents are left in soiled diapers for extended periods. Staff interviewed stated that residents are check every (2) hours to assist with their needs. Residents interviewed deny that staff leave them in soiled diapers for long periods of time. Allegation #5 – resident left on floor for an extended period of time. Administrator and staff interviewed deny that resident #1 (R1) was left on the floor for an extended period. R1 stated that they did fall at night and called for help. R1 stated that staff quickly arrived to assist them and was taken to the hospital. Allegation #6 - staff speaks inappropriately to residents. Administrator and staff interviewed deny speaking inappropriately to residents. Residents interviewed deny that staff have spoken inappropriately to them. Based on evidence obtained during this investigation, the allegations above are Unsubstantiated; meaning 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 where this report was discussed, and a copy of this report was provided to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 56-AS-20230329091754

Allegation investigated: Staff are withholding resident’s personal funds

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Maria Carrillo Molina, Dietary Supervisor and explained the purpose of the visit. LPA toured the facility, obtained pertient documents and conducted interviews. Regarding the allegation that staff are withholding residents' personal funds, On 6/26/23, Resident #1 (R1) went to see the Administrator regarding a $100 dollar check that R1 received. R1 stated that the Administrator was not as facility and did not cash the check. On 6/27/23, Staff #1 (S1) stated that (R1) had approached (S1) about a $100 dollar check. S1 stated that the Administrator is out of state and S1 did not have access to the residents' cash funds. On 6/27/23, S1 provided R1 with $20 dollars out of their own money and provided an additional $80 dollars today, 6/28/23, again out of their money. Interviews with staff confirm that the Administrator is currently out of state and returing on 7/02/23. Substantiated Based on the evidence gathered during the 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. A deficiency is being cited according to California Code of Regulations, Title 22, Division 6 and listed on the attached LIC 9099D. An exit interview was conducted, and a copy of this report (LIC9099 and LIC9099D) with appeal rights was provided to Maria Carrillo Molina at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 28, 2023 · control 56-AS-20230627101007

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jul 7, 2023

87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have the following..(3)To be free from...actions of a punitive nature, such as withholding residents’ money. This requirement is not met as evidence by the following: Staff did not provide resident with the entire money requested which poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jun 28, 2023

Plan of correction: Resident was provided with the entire funds requested. Administrator to submit to Licensing an updated resident ledger showing funds received and disbursed to resident by POC date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained injuries while in care. Resident was left on the floor for an extended period of time. Staff sleep on residents' beds while on shift.

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with MedTech Andres Castaneda and explained the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with relevant parties. Allegation #1 “Resident sustained injuries while in care”. The allegation alleged that on December 21, 2022, resident #1 (R1) was discovered by the reporting party (RP) with a bump on the right forehead and two (2) cuts and wounds on the left leg. LPA Nickolas' interview with the RP revealed that upon discovering R1, the RP notified the administrator, and the administrator agreed to call the paramedics. LPA Nickolas' interview with the administrator confirmed that RP discovered R1 in R1's room with injuries. The administrator confirmed that the RP notified them of this discovery, and emergency services were called. LPA Nickolas' file review revealed that on December 23, 2022, our agency received an Unusual Incident/Injury Repor (LIC 624) from the facility reporting the incident. The LIC 624 also confirmed that emergency services were contacted, and R1 was taken to the hospital for sustained injuries. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Unsubstantiated Allegation #2 “Resident was left on the floor for an extended period of time”. The allegation alleged that on December 21, 2022, the RP discovered R1 on the floor with injuries. The allegation alleged that the R1 told the RP that they fell and were sitting on the floor for about two (2) hours. LPA Nickolas’ interview with the RP revealed that the RP was arriving on the second floor and heard someone say help. The RP stated they discovered R1 on the floor. The RP stated that after assessing the situation, they notified the administrator. LPA Nickolas’ interview with the administrator revealed that the administrator did confirm arriving in R1’s room and observing R1 on the floor. Although R1 was discovered on the floor, no witnesses can verify how long R1 was left on the floor. Therefore, the finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. Allegation #3 “Staff sleep on residents' beds while on shift”. The allegation alleged that on December 21, 2022, the RP received several complaints from residents that staff #1 (S1) and staff # 2 (S2) took naps on the resident's bed during their shift. LPA Nickolas’ interview with client #1 (C1) revealed that they denied this allegation. LPA Nickolas’ interview with client #2 (C2) confirmed the allegations. C2 stated that they permit staff to sleep on their bed. However, C2 would not provide names of the staff. LPA Nickolas’ interview with S1, revealed that S1 denied the allegation. LPA Nickolas interview with the administrator revealed that the administrator denied the allegation. The administrator also stated that C2 is no longer employed at the facility for an unrelated reason. Therefore, the finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. 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 copy of this report was providedthe state’s words, verbatim · CDSS document, Jun 27, 2023 · control 56-AS-20221222161036

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have staff signed amended complaint investigation report #56-AS-20220707091011. LPA met with Maria Molina, Facility Nutritionist, and explained the complaint and purpose for signature. Both LPA Prieto and MS Molina signed a copy of the amended complaint investigation report and this Facility Evaluation Report to document visit and a copy of both reports were left at the facility.the state’s words, verbatim · CDSS document, May 22, 2023

Allegation investigated: Staff do not ensure safe personal hygiene while in the kitchen

Licensing Program Analyst (LPA) Magda Malcore conducted a 10-Day complaint investigation at the facility. LPA Malcore met with Dietary Supervisor Maria Carrillo Molina an discussed the purpose of the visit. The investigation consisted of facility tour, interviews, obtaining and reviewing pertinent files and documents. Regarding the allegation that staff do not ensure safe personal hygiene while in the kitchen, LPA toured the kitchen and observed all staff in the kitchen wearing mask, gloves, and hair nets. LPA did not observed any food left out and open. The kitchen was free of odors, kitchen counters and floors were clean. LPA reviewed staff files which reveal that staff is trained in safety protocals. Staff interviews deny that staff do not ensure safe personal hygiene while in the kitchen. Three (3) out of four (4) residents interviewed stated they have not witnessed staff not using safe personal hygiene while in the kitchen. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited at this time. An exit interview was conducted where the report was discussed and a copy of this report with appeal rights was provided to the Maria Carrillo Molina at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 56-AS-20230424105500

Allegation investigated: Staff hit resident

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to deliver findings on the above complaint allegation. LPA met with Licensee/Administrator, Michael Garcia and discussed the purpose of the visit. The investigation consisted of interviews with residents, staff, and document review. Regarding the allegation that staff hit resident, the Administrator and all staff interviewed deny hitting residents or witnessing staff hitting residents in care. Three (3) out of five (5) residents deny being hit by staff nor have they witnessed staff hit any residents in care. Two (2) residents we unable to corroborate or refute the allegation. Interviews with staff reveal that resident #1 (R1) had an unwitnessed fall that resulted in R1 sustaining a cut above left eye. An unusual incident/injury report was submitted to Community Care Licensing. R1 was given first aid, medically assessed by two (2) caregivers and R1’s family were notified of the incident. Unsubstantiated Based on interviews and documents obtained during the investigation, the above allegation is Unsubstantiated. Unsubstantiated meaning 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 provided to the Licensee/Administrator Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 3, 2023 · control 56-AS-20230309152937

Allegation investigated: Staff mismanage residents' medication Staff failed to provide a safe and comfortable environment for residents Untrained staff

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to continue the complaint investigation and deliver findings on the above allegations. LPA met with Licensee/Administrator, Michael Garcia and discussed the purpose of the visit. The investigation consisted of interviews with residents, staff, and document review. Regarding the allegation that staff mismanage residents' medication, interviews with staff deny spilling residents’ medication, giving discontinued medication, and giving double dosages to residents in care. Three (3) residents interviewed deny that staff has mismanaged their medications. One (1) resident interviewed stated that they do not take medication. Interviews with staff reveal that two (2) medical technicians (MedTechs) count the medication prior to administering the medication to the resident to ensure that the proper dosage is given. Interviews with staff reveal that discontinued medication is logged, packaged, and returned to the pharmacy. Unsubstantiated LPA reviewed the Medication Administration Record log (MAR) which does not corroborated the allegation of mismanagement. LPA observed that the medication room and centrally stored medication cabinets are locked. LPA observed that the MedTechs carry the key on their lanyard. Regarding the allegation that staff failed to provide a safe and comfortable environment for residents, all staff interviews deny not providing a safe and comfortable environment for the residents. All residents interviewed stated that staff provides a safe and comfortable environment to residents in care. Regarding the allegation of untrained staff, All resident interviews deny that staff is untrained. Interviews with staff reveal that staff have received training or are being trained in medication. Interview with staff #3 (S3) reveals that S3 is receiving hands-on medication training while being shadowed by a MedTech. LPA reviewed documentation of staff training. Based on interviews and documents reviewed during the investigation, the above allegations are Unsubstantiated. Unsubstantiated meaning 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 provided to the Licensee/Administrator, Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 3, 2023 · control 56-AS-20230221161840

Type of visit: Case Management - Deficiencies

On 4/3/23, Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to the facility. LPA met with Administrator/Licensee, Michael Garcia and explained the purpose of the today’s visit. Based on document review obtained during complaint# 56-AS-20230309152937 and complaint #56-AS-20230221161840 the following deficiencies are being cited in accordance with the California Code of Regulations, Title 22: The facility did not submit a Special Incident Report (SIR) to the Community Care Licensing Division (CCLD) to report resident 1’s (R1) fall on 1/23/23; which poses a potential health and safety risk to resident in care, see (LIC809D). The facility did not ensure that staff 1 (S1) and staff 2 (S2) had a verifiable health screening that indicates whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. LPA found a Health Screening Report (LIC 503) which was completed by (S1) and (S2) with the physician evaluation summary left blank, no physician stamp and signature, no date of evaluation, see (LIC809D) Plans of Corrections were reviewed and developed with Administrator/Licensee, Michael Garcia. An exit interview was conducted, a copy of this report and appeal rights was discussed and provided to Administrator/Licensee.the state’s words, verbatim · CDSS document, Apr 3, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f) · Plan of correction due date: Apr 7, 2023

87412 Personnel Records(f)All personnel...shall be in good health...Good physical health shall be verified by a health screening...performed by a physician not more than six (6) months prior to or seven (7) days after employment. This condition is not met by: The facility did not ensure that staff 1 (S1) and staff 2 (S2) had a verifiable health screening that indicates whether the person is physically qualified to perform the duties to be assigned. Which poses health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2023

Plan of correction: Licensee shall provide community care licensing documentation of S1 & S2 completed health screening by POC date. .

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Apr 7, 2023

87211 Reporting Requirements(a)Each licensee shall furnish...reports...including ...(1)A written report shall be submitted to the licensing agency within 7 days.. of the occurrence of...(D)Any incident which threatens the welfare, safety or health...of resident. This requirement was not met bythe state’s words, verbatim · CDSS document, Apr 3, 2023

Plan of correction: Licensee provided LPA with incident report on 4/3/23. Licensee will provide training to all staff regarding reporting requirements, overview of regulation and submit proof of training to Community Care Licensing by POC date

Allegation investigated: facility has bed bugs facility's not clean and sanitary

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to continue the complaint investigation and deliver findings on above complaint allegations. LPA Malcore met with Administrator, Michael Garcia and discussed the purpose of the visit. Regarding facility has bedbugs, LPA reviewed and obtained copies of service reports for pest control treatment at the facility. During the investigation, LPA observed staff moving furniture in resident's (R1) bedroom in preparation for bed bug heat treatment. R1 was relocated to another bedroom temporarily. LPA observed that R1’s temporary bedroom was clean and did not observe any insects. LPA observed that R1’s bathroom was clean and toilet functional. All five (5) residents interviewed did not observe bed bugs in the facility. Although the facility is experiencing a bed bug incident, they are taking appropriate steps to help mitigate the issue. Unsubstantiated Regarding facility is not clean and sanitary, LPA observed that the facility is clean and sanitary. LPA observed facility hallways are free of clutter. Licensee, four (4) staff, and five (5) residents were interviewed. All interviews deny that the facility is not clean and sanitary. Based upon the investigation, the allegations are unsubstantiated. While the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. no deficiencies were cited at this time. An exit interview was conducted, and a copy of this report was provided to Administrator, Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 13, 2023 · control 56-AS-20230222085840

Allegation investigated: Resident had multiple falls due to lack of supervision Staff member physically abused resident causing injury

Licensing Program Analysts (LPAs), Magda Malcore and Anna Bueno conducted an unannounced visit to initiate and deliver a complaint investigation regarding the above-mentioned allegations. LPAs met with Administrator, Michael Garcia and informed Garcia the purpose of the visit. During today’s visit, LPAs toured the facility, obtained copies of relevant documents, interviewed staff and residents. Records reveal that resident does not require walking assisted devices. LPAs observed resident (R1) walking on their own. Interview with staff reveal that R1 does not require assistance getting out of bed. LPAs reviewed video of incident that occurred on 2/12/23 involving R1. The video showed R1 walking and tripping on a long blanket that R1 was holding and fell face down on the floor. LPAs attempted to interview R1 but they were not responsive. Resident interviews deny that staff is physically abusive. Resident interviews confirm that they have not heard of staff abusing residents. Unsubstantiated Based on documents reviewed and interviews there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Administrator, Michael Garcia and a copy of this report (LIC 9099) was provided to Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 17, 2023 · control 56-AS-20230216082711

Allegation investigated: Staff did not prevent roaches in the facility

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to conduct a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Michael Garcia. During LPA Allen visit a tour of the facity was done and there were roaches seen through out the facility. Documents were also reviewed and the exterminators have provided recommendations for the inside and outside of the facility to assist with the control and or ellimination of the rodents. The records reviewed does show that there were visits on 12/30/2022, 1/9/2023 and 1/25/2023 and the recommendations have not been put in place control and /or eliminate the rodent problem. Based on observation,record review and interviews conducted the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D. An exit interview where this report was discussed with Michael Garcia and a copy of this report was provided with appeal rights at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 56-AS-20230120164232

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(c) · Plan of correction due date: Jan 27, 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... This requirement was not met as evidenced by: Based on observation, interview and record review, the Licensee did not comply with the section cited above by not applying the recommendation of the exterminator for the rodents/roaches at the facility which poses immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2023

Plan of correction: Licensee will repair holes/gaps in walls throughout the facility as recommended by the exterminator company this includes kitchen,dining area. The outside west wing of the facility need to be cleaned and the screen needs to be placed on door/pannels on outside/inside of air conditioners. Proof of correction will be submittedd to LPA Allen by the plan of correction date of 1/27/2023 by pictures. The licensee with also provide a signed written statement confirming that they have read the regulation cited to its entirety and confiming understanding. The written statement must signed and emailed by 1/27/2023.

Allegation investigated: Staff pushed resident Staff verbally abuse resident Staff did not administer residents medication Staff did not prevent resident from burinng face Staff are not treating resident with respect

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to conduct a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Michael Garcia. LPA interviewed resident one (1) who said that staff members have not physically, verbally abused or disrespect them. (R1) said that they were mad and missed their family down the hill. (R1) said that their medications were given to them daily but through them away in the trash because they wanted to leave the facility. Records reviewed also showed that (R1) was given their medications daily. (R1) was asked if the staff tried to stop them from burning their face and (R1) said yes but they wouldn't allow them to get close (R1) also stated that staff does threat them with respect. Interviews were conducted with four (4) staff members who said staff did try to provide assistance to (R1) but (R1) would not allow anyone to get close enough to stop them from burning themself. Unsubstantiated Based on observations, documentation and interviews the (5) five allegations 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 and discussed with Michael Garcia who was provided with a copy of the report with appeal rights.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 56-AS-20230120164232

Allegation investigated: Staff neglect resulted in R1 being injured by R2.

Licensing Program Analyst (LPA) Melody Brown met with Licensee Virginia Garcia and Administrator Michael Garcia at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/12/2023 at 01:00 PM to deliver findings for the allegations listed above. LPA Brown explained the purpose of the requested Office Visit. The Department investigation included staff interviews, interviews with other pertinent individuals, and review of relevant records. Based on the evidence collected during the investigation, the Department determined that there was corroborating evidence to support that staff neglect resulted in R1 being injured by R2. Department investigation revealed that on 01/09/2022, two (2) staff were working at the facility during the night shift (11:00 PM - 7:00 AM). At around 01:00 AM, Staff # 1 (S1) was on a break when Staff #2 (S2) who was responsible for care and supervision of around 59 facility residents, exited the facility Memory Care Unit to assist another resident. **** Continuation in LIC9099C **** Substantiated Approximately 20 minutes later, S2 returned to the Memory Care Unit and heard R1 yelling from bedroom. S2 went to the room and observed R2 hitting R1 with a medical walking boot. S2 took the boot away from R2 and told R2 to leave the room. During S2 time away from the Memory Care Unit, there was no staff to provide care and supervision to residents in the unit. Law enforcement and medical assistance was called for R1. According to medical records, R1 sustained a fractured nasal bone and one (1) cm laceration on the right side of forehead. According to facility records and staff interviews, R2 was known to exhibit aggressive behaviors at times. This was known to occur when R2 is being administered medication or during incontinent care. According to staff, R2 would push, hit and punch staff. On same day of incident on January 9, 2022, staff reported that R2 was in another resident room grabbing a resident and pushing resident against the wall. On or around 06/03/2020, R2 was reported to have choked another resident. Staff did not report if injuries resulted in either of these cases. In addition, R2 was reported to have been confused and aggressive on 12/14/2019 and 12/15/2019, and staff reported on 11/10/2019 that R2 made threatening statement to harm those at the facility. Following staff knowledge of R2 behaviors, there was no evidence to support that there was a reappraisal conducted for R2 nor that adequate supervision or assistance was provided to R2. The Department has determined that this neglect resulted in R1 being injured by R2. Complaint 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. This posed an immediate Health, Safety and Personal Rights risk to residents in care. An immediate Civil Penalty of $500.00 is being assessed. Licensee Garcia and Administrator Garcia were informed that a civil penalty may be assessed based on Health and Safety Code 1569.49 (c)(1). Please see LIC 9099D for deficiencies cited. An exit interview was conducted where this report (LIC 9099), LIC9099D, LIC421IM and Appeal Rights were discussed, and a copy was provided to Licensee Virginia Garcia and Administrator Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 18-AS-20220120084124

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 13, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the...(3) To be free from punishment, humiliation, intimidation, abuse...This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above due to facility staff neglect to ensure R1 is free from abuse from R2 and resulted to R1’s injury which pose immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee stated to train all staff on CCR 87468.1(a)(3) and submit proof of Training Log to LPA Brown by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 87468.1(a)(3) and submit to LPA Brown by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melody Brown met with Licensee Virginia Garcia and Administrator Michael Garcia at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/12/2023 at 01:00 PM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation. On 12/29/2022, LPA Brown received Personnel Report Summary (LIC500) from Administrator Garcia and Staff December 2022 Work Schedule. LPA Brown observed per records review that Staff # 5 (S5) was listed “pending” in LIC500 with date 12/05/2022 but per 12/2022 Staff Schedule received, it indicated S5 working at the facility 12/01/2022. On 01/09/2023, LPA Brown received 12/2022 and 01/2023 Staff Work Schedule from Administrator Garcia and both 12/2022 and 01/2023 staff work schedule indicated S5 working at the facility. On 01/12/2023, LPA Brown contacted S5 and S5 reported working at the facility since 06/07/2021 on a night (NOC) shift schedule. During the office visit on 01/12/2023, Administrator Garcia confirmed that S5 started working at the facility 06/07/2021. LPA Brown observed per records review that S5 criminal background clearance is “in process” per Guardian website and the facility allowed S5 to work at the facility without criminal background clearance. LPA Brown will issue a deficiency as this pose immediate health, safety and personal rights risk to residents in care. LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for a staff working at facility without criminal background clearance last 08/09/2022. Civil Penalty was assessed for repeat violation on Criminal Background Clearance within a 12-month period with the amount of $3,000.00 and will continue to be assessed of $100.00 per day per citation until corrected during the Office Visit due to the facility allowed S5 to work without Criminal Background Clearance since 06/07/2021. An exit interview was conducted with Licensee Virginia Garcia and Administrator Michael Garcia where a copy of this report (LIC 809) along with LIC 809D, LIC421BG and Appeal Rights were discussed and provided.the state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 13, 2023

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...(1) Obtain a California 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 allowing Staff #5 to work at the facility without criminal background clearance since 06/07/2021 which pose immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date. The licensee stated to remove S5 from the facility and not allow S5 to work at the facility until S5 has a criminal background clearance.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melody Brown met with Licensee Virginia Garcia and Administrator MIchael Garcia at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/12/2023 at 01:00 PM AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation. On 02/08/2022 document review, the Department observed Staff # 4 (S4) was not listed in Personnel Report Summary with date 02/28/2022. The Department Interviewed staffs and reviewed documents and it indicated S4 started working at the facility 06/2021. LPA Brown observed per records review that S4 have criminal background clearance but the facility failed to associate S4 to the facility. LPA Brown observed that the facility recently associated S4 to the facility last 08/09/2022. LPA Brown will issue a deficiency as this pose immediate risk to residents in care. In addition, LPA Brown informed Staff # 3 (S3) that per records review, S2 had criminal background clearance and associated to the facility but the facility encoded incorrect information in Guardian website. LPA Brown requested S3 to make sure correct information are used when processing criminal background clearance and S3 expressed understanding. Civil penalty was assessed with the amount of $500.00 during the Office Visit for failure to associate/transfer S4 Criminal Background Clearance to the facility. Moreover, the Department reviewed R2 documents and it indicated that R2's last reappraisal date was 09/2019 and the facility failed to conduct R2's reappraisal annually. Documents review indicated R2's behaviors last 11/2019 and 12/2019 and R2's aggressive act last 06/2020 but the facility failed to conduct reappraisal on R2. ***Continuation in LIC809C *** LPA Brown will be issuing a deficiency as the facility failed to ensure that R1 have annual medical assessment and reappraisal done annually that includes reassessment of R2's dementia needs which pose immediate health, safety and personal rights risk to resident in care. An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee Virginia Garcia and Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jan 13, 2023

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...(2) Request a transfer of a criminal record clearance as specified... 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 failure to associate Staff # 4 to the facility which pose immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) and submit to LPA Brown by POC due date. Licensee associated/transferred S4 Criminal Background clearance to the facility last 08/09/2022, POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(5) · Plan of correction due date: Jan 13, 2023

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall... (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...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 failure to ensure that R2 have annual medical assessment and reappraisal done annually which pose immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Licensee stated to train all staff on CCR 87705(c)(5) and submit Training Log to LPA Brown by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(5) to LPA Brown by POC due date

Type of visit: Case Management - Other

On 01/09/2023, at 9:28 a.m., Licensing Program Analysts (LPA’s) Rayshaun Nickolas and Magda Malcore made an unannounced visit to the facility to conduct a Health and Safety case management visit. LPAs met with Administrator Michael Garcia and explained the purpose of the visit. During today's case management visits LPAs conducted a tour of the facility inside and out to assess for any Health and Safety concerns of the clients in care. At 9:36 a.m., LPAs met with Dietary Supervisor Maria Molina and toured the kitchen. LPAs observed that the kitchen was clean. LPAs also inspected facility food supplies and observed more than two (2) days supply of perishable foods and more than seven (7) days supply of non-perishable foods. LPAs also observed expiration dates on the food supply. LPAs also obtained copies of the food delivery invoices. LPAs also obtained copies of service invoices from Western Exterminator Company for the months of September, October, November, and December of 2022, which documents interior and exterior treatment services. Per the Administrator the facility does not use an outside exterminator to treat bedbugs; however, the facility treats bed bugs by the use of a heat treatment machine that was purchased by the corporate office. LPAs randomly selected nine (9) clients from the facility's client roster and conducted a medication audit. LPAs observed that although medication were listed on the Central Stored Medication and Destruction Record (LIC 622), any subsequent refill for that medication was not referenced on the LIC 622, the refill of said medication changed the RX number referenced on the medication. LPAs also discovered during their medication audit that the Medication Administration Records (MARs) for January 2023 was not thoroughly filled out on all nine (9) clients. LPAs discussed this issue with the med techs, who stated that they were working on updating the LIC 622 and the MARs. No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.the state’s words, verbatim · CDSS document, Jan 9, 2023

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility on 12/23/2022 at 12:57 PM for the purpose of a Health & Safety check. LPA Guerrero identified herself to Alma Cano and discussed the purpose of the visit. Residents in care were present during visit. LPA Guerrero observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection. An exit interview was conducted where this report (LIC809) was discussed and provided to Alma Cano.the state’s words, verbatim · CDSS document, Dec 23, 2022

Allegation investigated: Staff gave marijuana products to residents in care without proper authorization Staff yells at residents in care Staff did not store food in a safe and healthful manner Staff do not provide proper incontinence care to residents in care.

Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to conduct a complaint investigation and deliver the findings for the complaint allegations listed above. LPA met with Administrator Michael Garcia. During today’s visit, LPA Allen toured the facility, interviewed nine (9) staff members and nine (9) residents, and reviewed resident file. Allegation #1-Staff gave marijuana products to residents in care without proper authorization. LPA Allen interviewed nine (9) staff members and nine (9) residents and found that staff member has not given marijuana products to the residents in care. Allegation #2-Staff yells at residents in care. LPA Allen interviewed nine (9) staff members and nine (9) residents and LPA Allen found that staff members does not yell at residents in care. Unsubstantiated Allegation #3- Staff did not store food in a safe and healthful manner. LPA Allen toured the kitchen and observed that the food was stored properly and there were no health and safety concerns. Allegation #4- Staff do not provide proper incontinence care to residents in care. LPA Allen interviewed nine (9) staff members and nine (9) residents and based on the interviews with the staff and resident LPA found that staff does provide proper incontinence care to residents in care. Based on observation, and interviews conducted, and record review the four (4) allegations listed above are deemed Unsubstantiated. A finding that a complaint is 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 this report and appeal rights was discussed and provided to Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 16, 2022 · control 56-AS-20221110130446

Allegation investigated: The licensee did not maintain a comfortable temperature in the facility.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate a complaint investigation for the above-mentioned allegation. LPA met with Administrator Michael Garcia and discussed the purpose of the visit. Allegation: The licensee did not maintain a comfortable temperature in the facility. LPA Allen toured the inside of the facility and observed two thermostats in the main dining area, one read 85 degrees, and the other read 90 degrees. The administrator informed LPA that he is currently working with an air conditioning company to get the air conditioning unit fully operational. LPA observed one cooling fan at the reception area, two cooling fans in the dining area, two cooling fans in the kitchen area, and three cooling fans in the TV room. LPA toured eleven (11) residents’ rooms in assisted living and nine (9) resident rooms in memory care unit. All resident rooms that were toured did have working air conditioning units. Interviews conducted with six (6) residents and three (3) staff members all reported that the air conditioning unit is not working in the common areas nor in the main kitchen. The investigation revealed that the facility’s air conditioning unit is inoperable in common areas resulting in uncomfortable temperatures in the facility. This poses a potential Health and Safety risk to the clients in care. Based on the interviews conducted with residents and facility staff LPA determined the mentioned allegation is Substantiated. An exit interview was conducted where this report was discussed, and a copy of this report 9099, 9099D and appeal right was provided to Michael Garcia Administrator at the conclusion of the visit. Substantiatedthe state’s words, verbatim · CDSS document, Sep 7, 2022 · control 56-AS-20220907102215

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 8, 2022

Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews conducted with residents and facility staff. The facilities air conditioning unit is not working in the main common areas and the kitchen. This poses a potential Health and Safety risk to the clients in care.the state’s words, verbatim · CDSS document, Sep 7, 2022

Plan of correction: The administrator agreed to provide CCL with a work contract to replace or repair the air conditioning unit and provide CCL with a plan of options to have resident meals in their rooms and/or areas where the AC unit is working until the unit is working.This POC is due by 9/8/2022.

Allegation investigated: Facility does not provide activities

On 08/26/2022 at 10:30 AM, Licensing Program Analysts (LPA) Melody Brown and Paola Guerrero met with Administrator Michael Garcia at California Community Care Licensing Division (CCLD) Regional Office to deliver the findings for the above allegation. The investigation was conducted by LPA Brown. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that facility does not provide activities. Interviews with staffs and residents indicated that the facility has no activities for residents. LPA Brown interviewed six (6) residents and seven (7) staffs. Interview with residents indicated that facility do not have activities for the residents and LPA Brown was not able to interview three (3) residents due to them being not oriented and unable to answer LPA Browns' questions. LPA Brown interviewed seven (7) staff. and five (5) out of seven (7) staff stated that the facility do not have activities for residents. *** continuation on LIC 9099C*** Substantiated Based on residents and staffs interviews and record reviews, LPAs Brown and Guerrero determined that the allegation Facility does not provide activities 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. LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for not providing activities to residents last 02/25/2022. Civil Penalty was assessed for repeat violation within a 12-month period in the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected. An exit interview was conducted with Administrator Garcia where a copy of this report (LIC 9099) along with LIC 9099-D, LIC421FC and Appeal Rights were discussed and provided. Moreover, staff interviews also indicated that no bruise was observed at R1 when they conducted physical assessment/check on R1. Interviews with residents revealed no resident sustained bruises while in care. The second allegation indicates Facility does not meet resident's nutritional needs. During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that Facility meets resident's nutritional needs and breakfast, lunch, dinner and snacks were provided to all residents. Also, residents, staffs and witness interviews indicated sufficient amount of food were served to all residents and all residents can request for additional servings if they prefer. In addition, interviews with staffs revealed that they all check on their residents after meal to make sure that all residents eat their meals. Based on the information obtained and observation, there is not enough evidence to state Resident sustained bruises while in care (allegation #1) and Facility does not meet resident's nutritional needs (allegation #2). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report (LIC 9099) was discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Aug 26, 2022 · control 18-AS-20220128162918

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(7) · Plan of correction due date: Sep 1, 2022

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia ... (7) An activity program shall address the needs and limitations of residents with ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not provide activities for residents at the facility, which poses a potential Health, Safety, or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: Licensee will submit List of Activities and Activities Schedule for residents in care self-certified by the Activities Director and Administrator by POC due date to Community Care Licensing Department (CCLD) or LPA Brown. Licensee will submit Statement of Understanding for CCR 87705(c)(7) to LPA Brown by POC due date.

Allegation investigated: Staff do not treat resident with dignity.

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 allegation. LPA Gardner met with Administrator Michael Garcia and explained the reason for the visit. At the time of the visit, there were seventy-five (75) residents, and twelve (12) staff present. During today’s visit, LPA Gardner toured the facility, interviewed staff members, and interviewed residents. For allegation: Staff do not treat resident with dignity: LPA Gardner found through interviews conducted that the above allegation could not be collaborated by witnesses. There was not enough evidence found during the investigation to prove the allegation occurred. Based on the information found and provided, the allegation listed above is deemed UNSUBSTANTIATED. Unsubstantiated A finding that the complaint is 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, therefore the allegation is deemed unsubstantiated. 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 was discussed and provided Administrator Michael Garcia, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Aug 9, 2022 · control 56-AS-20220804081200

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Gardner met with Administrator Michael Garcia and was granted entry to the facility. At the time of visit there were twelve (12) staff, and seventy-five (75) residents present. LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Michael Garcia. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a vaccination verification/negative COVID test check, a temperature check, and a symptom check. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the storage closet. The facility has a thirty (30) day supply of PPE Items such as gloves, face shields, gowns, surgical masks, disinfectant, and hand sanitizer. The facility was notified they need to obtain a full thirty (30) day supply of N95 masks. The facility will be issued a Technical Advisory note for not having a full thirty (30) day supply of N95 masks All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19. During today’s visit, LPA Gardner found that a Staff (S1) has been working at the facility for four (4) months without a criminal record clearance. The facility will be issued a citation and issued a $500-dollar civil penalty for allowing S1 to work at the facility without a criminal record clearance. LPA Gardner also found expired peanut butter, expired soup base chicken, and expired sauerkraut in the kitchen pantry. The facility will be issued a citation for having expired food in the pantry. Based on the observations made 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 Michael Garcia, along with a copies of the two (2) LIC-809D forms, LIC-421BG form, LIC-811 form, LIC-9102 form, and a copy of the appeal rights.the state’s words, verbatim · CDSS document, Aug 9, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 08/01/2022 at 09:15 AM announced in order to amend the LIC809D Case Magement - Deficiency issued last 07/28/2022 . LPA Brown met with Administrator Michael Garcia and LPA Brown explained the purpose of today's visit. An exit interview was conducted where this report (LIC809) was discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Aug 1, 2022

Allegation investigated: Staff do not properly report incidents involving residents.

Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit 07/28/2022 at 09:00 AM to deliver the findings for the above allegations. LPA Brown was greeted and granted entrance to the facility by staff Andrew Castaneda. Administrator Michael Garcia was contacted and arrived during the visit. LPA Brown explained the purpose of today's visit. The investigation consisted of file review, observation and interviews with relevant parties. LPA Brown toured the facility, conducted interviews and reviewed facility files. The allegation indicates staff do not properly report incidents involving residents. LPA Brown conducted interviews with residents, staffs, resident responsible party. Staffs and responsible party interviews indicated that staff do not properly report incidents involving residents and LPA Brown was able to corroborate the allegation. LPA Brown will be issuing a deficiency as Licensee did not report the incident to R1's responsible party and this poses potential Health, Safety and Personal Rights risk to residents in care. *** Continuation on LIC9099C *** Substantiated The second allegation indicates that Staff unlawfully evicted residents while in care. During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that staff did not unlawfully evicted residents while in care. Interviews with staff and R3's responsible party indicated that R3 was transported by Staff 5 to Loma Linda Hospital for a Specialist Consultation but not to evict R3. During the visit, LPA Brown observed R3 still residing at the facility. Based on the information obtained and observation, there is not enough evidence to state Staff interfering with on going investigations (allegation #1) and Staff unlawfully evicted residents while in care (allegation #2). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report (LIC 9099) was discussed and provided to Administrator Michael Garcia. Based on the information and interviews gathered the allegation Staff do not properly report incidents involving residents 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. Please see LIC 9099D for deficiencies cited. An exit interview was conducted where this report (LIC 9099), LIC9099D and Appeal Rights were discussed, and a copy was provided to Administrator Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 28, 2022 · control 18-AS-20220112113915

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: Aug 4, 2022

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident's physician, family members ... Based on observation, interview and record review, the Licensee did not comply with the section cited above by not notifying Resident 1 (R1) responsible party of the incident last 01/09/2022 which poses a potential Health, Safety or Personal Rights risk to resident in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Licensee stated to train staff on CCR 87705(b)(1) and submit Training Log to LPA Brown by POC due date. Licensee stated to submit Statement of Understanding on CCR 87705(b)(1) to LPA Brown by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/28/2022 at 09:00 AM unannounced in order to initiate a Case Management visit. LPA Brown met with Administrator Michael Garcia and LPA Brown explained the purpose of today's visit. During the visit last 04/25/2022 at 12:30 PM, LPA Brown pressed the pull button/cord at room number #116 located near the resident bed and LPA Brown observed the call button/pull cord is not working. LPA Brown pressed the pull button/cord at resident bathroom and LPA Brown observed that it works and creates a sound at the reception area to inform staff that resident on that room number needs help. LPA Brown informed Administrator Garcia that the call button near the residents’ bed needs to be fix and Administrator Garcia said "I'll fix that today." Administrator Garcia also added that they assigned two (2) staff and one (1) staff reliever at the Memory Care available to assist the residents. LPA Brown pressed the call button at resident bathroom (room #116) and it took 5 minutes for a staff to arrive to help. LPA Brown will be issuing a citation for the observed pull button/cord not working near the resident bed as this deficiency poses immediate risk to residents in care. In addition, LPA Brown reviewed facility's incident reports and LPA Brown did not find any Incident Reports that the facility submitted to Community Care Licensing Division (CCLD) to report R1's unwitnessed falls and LPA Brown will issue a citation for not reporting R1's unwitnessed falls at the facility as this pose potential risk to residents in care. An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Jul 28, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 26, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe and sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by: Based on observations and interviews, the Licensee did not comply with the section cited above by having a pull button/cord in room 116 near the resident bed in disrepair which poses an immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Licensee stated to replace and/or repair pull button/cord near resident bed at room 116 and submit proof to LPA Brown by POC due date. Also, LIcensee stated to check all residents room that the pull button/cord near resident beds and bathrooms are working and submit proof 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: Aug 3, 2022

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven ... Based on observations, interviews and record review, the Licensee did not comply with section cited above by not reporting incidents of unwitnessed fall of Resident 1 (R1) at the facility to Community Care Licensing Division (CCLD) which poses potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Jul 28, 2022

Plan of correction: Licensee stated to report all incidents at the facility to CCLD and train staff on CCR 87211(a)(1) Reporting Requirements and submit Training Log to LPA Brown by POC due date. Also, Licensee stated to submit Statement of Understanding on CCR 87211(a)(1) to LPA Brown by POC due date.

Allegation investigated: Staff engaged in inappropriate interactions with other staff members in the presence of residents Staff did not treat residents with dignity and respect Staff member smokes marijuana on the premises in the presence of residents Staff did not administer medication as prescribed Staff did not provide a comfortable environment for residents in care Uncleared staff on the premises

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above named allegations. LPA Prieto met with Director Garcia to discuss the element of the allegations. Garcia states the staff #1 (S1), in question, has not been employed that this facility for some time, and not available for questioning relating to the allegations. Garcia does state, though, that he is not aware of S1 engaging in inappropriate interactions with other staff in the presence of residents or that S1 treated residents without dignity or respect. Garcia states that there is no knowledge of S1 returning to the facility to smoke marijuana in the presence of residents. There was no specific information pertaining S1 not administering medications as prescribed, during S1s employment at the facility, or being rude to any residents in care and making their environment uncomfortable. Garcia states that, alleged uncleared, staff #2 (S2) is not employed at this facility. Garcia clarified that S1 and S2 are not currently employed at this facility nor are they volunteers returning or visiting this facility. Unsubstantiated Staff #3 (S3) interviewed is not aware of any staff or resident's smoking marijuana at the facility, staff not treating residents dignity, or any other inappropriate behaviors by staff in the presence of residents nor providing an uncomfortable environment. Staff #4 (S4) interviewed is not aware of any staff or resident's smoking marijuana at the facility, staff not treating residents dignity, or any other inappropriate behaviors by staff in the presence of residents nor providing an uncomfortable environment. S4 explained medication dispensing procedures and cannot conclude that medications are not being dispensed appropriately. Staff #5 (S5) interviewed is not aware of any staff or resident's smoking marijuana at the facility, staff not treating residents dignity, or any other inappropriate behaviors by staff in the presence of residents nor providing an uncomfortable environment. S5 explained medication dispensing procedures and cannot conclude that medications are not being dispensed appropriately. Residents #1 (R1), (R2), (R3), (R4), (R5), were interviewed and the consensus of those interviews could not conclude that they observed any staff engaging in inappropriate activity, smoking marijuana at the facility by staff, treating residents without dignity, or making the environment uncomfortable. Based on the information obtained there is not enough evidence that staff engaged in inappropriate interactions with other staff members in the presence of residents, staff did not treat residents with dignity and respect, staff member smokes marijuana on the premises in the presence of residents, staff did not administer medication as prescribed, staff did not provide a comfortable environment for residents in care, and uncleared staff on the premises. Therefore, the allegations are deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jul 12, 2022 · control 56-AS-20220707091011

Allegation investigated: Staff does not treat residents with respect. Staff uses derogatory terms. Staff is creating a hostile environment. Staff failed to assist resident after sustaining a fall. There is an unclear staff working at the facility.

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 04/25/2022 at 11:00 AM for the purpose of delivering the findings to the above allegations. LPA Brown met with staff Priscilla Soto. LPA Brown explained the purpose of the visit and was granted entry. Administrator Michael Garcia met with LPA Brown during the visit. The investigation was conducted by LPA Brown. LPA toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates that staff does not treat residents with respect. During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. LPA Brown interviewed twelve (12) residents and four (4) staff and interviews with staff and residents indicated that staff treat residents with respect.10 out of 12 residents stated that all staff treated them with respect.and *** continuation on LIC 9099C*** Unsubstantiated and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they treat all residents with respect. The second allegation indicates that staff uses derogatory terms During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that staffs do not use derogatory terms when they speak to the residents. 10 out of 12 residents reported that all staff speak to them nicely and with respect and no staff uses derogatory terms when they speak to them and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they never use derogatory terms when they speak to the residents. The third allegation indicates staff is creating a hostile environment. LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that staff are not creating a hostile environment to the residents. 10 out of 12 residents indicated that staff at the facility do not create a hostile environment to the residents. They reported that staff are nice to them, and they assist them if they need help or need something. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they never create hostile environment to the residents. The fourth allegation indicates staff failed to assist residents after sustaining a fall. LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that all staff helps resident after sustaining a fall. 10 out of 12 residents reported that all staffs help residents after sustaining a fall. LPA Brown interviewed four (4) staff. 4 out 4 staff stated that they always help residents after sustaining a fall. The fifth allegation indicates there is unclear staff working at the facility. LPA Brown was not able to obtain evidence to corroborate the allegation. During the visit, LPA Brown checked all staff working at the facility and observed that all staff working have fingerprint clearance. LPA Brown interviewed four (4) staff and 4 out of 4 staff reported they need to have fingerprint clearance before they can start working at the facility. ***Continuation in LIC9099C*** Based on the information obtained and observation, there is not enough evidence to state Staff does not treat residents with respect (allegation #1), Staff uses derogatory terms (allegation #2), Staff is creating a hostile environment.(allegation #3), Staff failed to assist resident after sustaining a fall (allegation #4), and There is an unclear staff working at the facility (allegation # 5). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report (LIC 9099) was discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Apr 25, 2022 · control 18-AS-20211108163107

Allegation investigated: Insufficient staffing to meet resident's needs. Staff did not respond to resident's call button in a timely manner. Resident has sustained several unwitnessed falls due to lack of supervision.

Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 07/28/2022 at 9:00 AM to deliver findings for the above allegations with Administrator Michael Garcia. LPA Brown introduced herself and explained the purpose of today’s visit. The investigation consisted of interviews with pertinent parties and records review. The first allegation indicates Insufficient staffing to meet residents needs. LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs, residents, witness and documents review did not indicate insufficient staff working at the facility to meet resident's needs. Also, interviews revealed that facility needed more staff but all work shifts were covered by staff working extra hours if needed. The second allegation indicates Staff did not respond to residents' call button in a timely manner. Based on residents, staffs and witness interviews and observation, LPA Brown did not find evidence to corroboare the allegation. ***Continuation in LIC9099C*** Unsubstantiated The second allegation indicates Resident's toileting needs are not being met. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and documents review indicated residents toileting needs are being met. Interviews with staffs indicated all residents incontinence needs are checked by staff every two (2) hours. Interviews with residents revealed that all staff checks on them and their incontinence needs are met. The third allegation indicates Resident's bathing needs are not being met. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and documents review indicated residents toileting needs are being met. Interviews with staffs indicated that they have a Bathing Schedule that they follow to make sure all residents bathing needs are met. Interviews with residents indicated that their bathing needs are met at the facility. Administrator Garcia showed proof of Bathing Log and Bowel Movement Log of a resident during the visit. Based on interviews and records review, the above allegations Questionable Death (Allegation #1),Resident's toileting needs are not being met.(Allegation #2), and Resident's bathing needs are not being met (Allegation #3) 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 violations did or did not occur. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report (LIC9099) was discussed and provided to Administrator Michael Garcia. Interviews with staff and residents revealed that it takes about 10 minutes to 15 minutes for a staff to respond to residents when they need assistance by pressing the call/pull cord button. The third allegation indicates Resident has sustained several unwitnessed falls due to lack of supervision. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and witness indicated that few unwitnessed falls occured at the facility and staff always helps residents. Also, interviews with staffs, residents and witness indicated that there's no incident that a resident sustained unwitnessed falls due to lack of supervision. Based on LPA Brown’s observations, interviews, and record review, the above allegations Insufficient staffing to meet resident's needs (Allegation #1), Staff did not respond to resident's call button in a timely manner (Allegation #2), and Resident has sustained several unwitnessed falls due to lack of supervision (Allegation #3) 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 violations did or did not occur. An exit interview was conducted where this report (LIC9099) was discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Apr 25, 2022 · control 18-AS-20211001092216

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Apr 26, 2022

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee do not have adequate number of direct care staff working at the facility to meet residents needs which poses an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Licensee stated to have additional staff working on the floor available to assist residents that need help. Licensee will submit Staff Work Schedule that shows adequate number of direct care staff scheduled to work on each shift. Licensee will submit Statement of Understanding for CCR 87705(c)(4) to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Apr 26, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the facility do not have working call button (rroom #116) near the residents bed to alert staff if residents need care which poses an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Facility agreed to replace and/or repair call button near residents' bed (Room #116) by POC due date and submit proof to LPA Brown by POC due date. Also, Licensee stated to check all residents rooms that the call button near resident beds and bathroom are working and submit proof of correction to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Apr 26, 2022

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee do not have adequate number of direct care staff working at the facility to respond to resident’s call button in a timely manner in which poses an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Licensee stated to train all staff to make sure that they all respond to resident’s call button in a timely manner and will submit Training Log to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Apr 26, 2022

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply by not having adequate number of staff working at the facility to monitor residents and prevent unwitnessed falls which poses an immediate risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Licensee stated to have additional staff to supervise residents and prevent unwitnessed falls. Licensee will submit Staff Work Schedule that shows adequate number of direct care staff scheduled to work on each shift by POC due date to LPA Brown. Licensee will have all staff complete a Resident Status Check Log every hour to appropriately supervise all residents and prevent unwitness fall. Licensee will also train all staff on the proper procedure and implementation of the Resident Status Check Log and will submit a copy of Resident Status Check Log and Training Log to LPA Brown by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: May 2, 2022

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of ...(1) Procedures for notifying the resident’s ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the Licensee did not comply by not reporting incidents of unwitnessed fall of Resident 1 (R1) at the facility to Community Care Licensing Department (CCLD) which poses a potential risk to resident in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Licensee stated to report all incidents at the facility to CCLD and train staff on reporting requirements. Also, Licensee will submit Statement of Understanding for 87705(b)(1)and Staff Training Log to LPA Brown by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 03/25/2022 at 10:00 AM to follow up on a Death Report regarding Resident 1 (R1) death at the facility. LPA Brown identified herself to Administrator Michael Garcia, who was also advised of the purpose of the visit. On 03/22/2022 Community Care Licensing Department (CCLD) was notified of the death of Resident 1 (R1) last 03/21/2022. LPA Brownrequested the following documents: -ID/Emergency information -Admission Agreement -Physician's report -Psychiatric and Medical notes/orders -Resident Appraisal -Medication records -Weight record LPA Brown also requested additional documentation be sent to CCLD; such as, the Coroner's Report, Police Report, and a Death Certificate upon availability. An exit interview was conducted where this report (LIC809) was discussed, and a copy was provided to the Administrator Michael Garcia at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 25, 2022

Allegation investigated: Facility has no activities for residents.

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 02/25/2022 at 09:15 AM for the purpose of delivering the findings to the above allegation. LPA Brown met with staff Priscilla Soto. LPA Brown explained the purpose of the visit and was granted entry. Administrator Michael Garcia arrived during the visit. The investigation was conducted by LPA Brown. LPA toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that facility has no activities for residents. Interviews with staffs and residents indicated that the facility has no activities for residents. LPA Brown interviewed five (5) residents and four (4) staff. 3 out of 5 residents reported that facility do not have activities for the residents and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 2 out of 2 staff stated that the facility do not have activities for residents. *** continuation on LIC 9099C*** Substantiated Based on resident and staff interviews and record reviews, LPA determined that the allegation Facility has no activities for residents 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 Administrator Garcia where a copy of this report (LIC 9099) along with LIC 9099-D and Appeal Rights were discussed and provided. 3 out of 5 residents stated that they are not locked in their room and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they do not lock residents in their room. The second allegation indicates that staff do not assist residents or are sleeping. Interviews with staff and residents also indicated that the facility staff assist residents and facility staff are not sleeping. 3 out of 5 residents stated that facility staff assist them if they need help, and no staff were found sleeping and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they assist residents if they need help and they do not sleep while at work. Based on the information obtained and observation, there is not enough evidence to state residents are locked in their room (allegation #1) and staff do not assist residents or are sleeping (allegation # 2). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report (LIC 9099) was discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Feb 25, 2022 · control 18-AS-20211012172650

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(7) · Plan of correction due date: Mar 4, 2022

87705 Care of Persons with Dimentia (c) Licensees who accept and retain residents with dementia ... (7) An activity program shall address the needs and limitations of residents with dementia and include ... This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not provide activities for residents at the facility, which poses a potential Health, Safety, or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2022

Plan of correction: Licensee will submit List of Activities and Activities Schedule for residents in care by POC due date to Community Care Licensing Department (CCLD) or LPA. Licensee will submit Statement of Understanding for CCR 87705(c)(7) to LPA Brown by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 02/02/2022 at 10:40 AM to conduct a health and safety check. LPA Brown identified herself and discussed the purpose of the visit with receptionist Priscilla Soto. Assistant Administrator and Dietary Supervisor Maria Molina was contacted and arrived at the facility and LPA Brown explained the purpose of the visit due to complaint # 18-AS-20220128162918. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Brown observed sufficient staff present at the facility to provide care. LPA Brown inspected facility food supplies and observed more than two (2) days supply of perishable foods and more than seven (7) days supply of non-perishable foods. The needs of the residents in care appears to be met during this inspection. An exit interview was conducted where this report (LIC809) was discussed and provided to Assistant Administrator and Dietary Supervisor Maria Molina.the state’s words, verbatim · CDSS document, Feb 2, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a health and safety check. LPA Brown identified herself and discussed the purpose of the visit with receptionist Priscilla Soto. Administrator Michael Garcia was contacted and arrived at the facility and LPA Brown explained the purpose of the visit due to complaint # 18-AS-20220120084124. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Brown observed no health and/or safety hazards inside the facility. LPA Brown inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Brown observed sufficient staff present at the facility to provide care. LPA Brown inspected facility food supplies and observed an adequate supply of perishable and non-perishable food. The needs of the residents in care appear to be met during this inspection. An exit interview was conducted where this report (LIC809) was discussed and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Jan 21, 2022

Allegation investigated: Lack of supervision resulting in resident wandering away from facility

Licensing Program Analysts (LPAs) Melody Brown and Rohit Lama made an unannounced joint visit to the facility for the purpose of investigating the allegation(s) of this complaint. LPAs identified themselves and the purpose of the visit to Administrator Michael Garcia, who arrived to the facility during the inspection. Below is a summary of what LPAs Brown and Lama observed: The investigation was conducted by LPAs Brown and Lama. LPAs toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that due to a lack of supervision on 1/8/2022 Resident 1 (R1) wandered away from the facility. LPAs were informed that on the night of 1/8/2022, R1 managed to leave the facility via the delayed egress door in the hallway and supposedly made it to the curb where she fell and obtained minor injuries to R1’s face. Substantiated Interviews with S1, S2, S3 indicate that R1’s absence was not known until a call was received from the two individuals (names not obtained) that had found her. This poses an immediate health & safety risk to the resident in care. LPAs also checked the delayed egress door’s alarm and observed that it goes off the moment the door handle bar is depressed and remains activated until a code is entered. LPAs also observed that the delayed egress door only opens after the handle bar is depressed for a duration of one minute. LPAs attempted to interview Resident 1 (R1) however were unable to due to the fact that R1 is not alert nor oriented. Based on resident and staff interviews and record reviews, LPAs determined that the allegation: Lack of supervision resulting in resident wandering away from facility, 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 Micahel Garcia where a copy of this report (LIC 9099) along with LIC 9099-D and Appeal Rights were reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jan 18, 2022 · control 18-AS-20220111153446

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(8) · Plan of correction due date: Jan 25, 2022

87705 - Care of Persons with Dementia - Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as... evidenced by: Interviews, record reviews, and observation, the licensee did not ensuire that staff were able to provide adequate care and supervision for R1. R1 was found wandering outside the facility on 1/9/2022 without care and supervision. Interviews revealed that only two staff members were working that shift. This poses an immediate health & safety risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 18, 2022

Plan of correction: Licensee needs to hire additional care giviers and schedule additional staff per shift to adequately meet the needs of the residents in care. Licensee shall provide proof of hiring attempts by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Melody Brown and Rohit Lama conducted an unannounced visit to the facility to conduct a case management visit to address an incident involving the death of Resident One (R1). The Department received an incident report from the facility 01/14/2022 regarding the R1's death on 01/14/2022. A Special Incident Report (SIR) details the resident, on 01/14/2022, was found in shower, down on his buttocks and back. The report details facility staff seeing water leak in front of R1’s room and when staff entered the room, staff found R1 unresponsive, down on his buttocks and back and contacted emergency medical services (911). A review of records revealed R1 had hypernatremia, peripheral edema and foot pain-swelling and was under Home Health Care for which medication was prescribed and the prescription completed. In addition, R1 have diagnosis of Aggressive behavior, Heart Failure with reduced ejection fraction (HCC), automatic cardioverter/defibrillator present (AICD), paroxymal atrial fibrillation (HCC) and traumatic brain injuty (TBI). LPAs reviewed medications and MARS, and observed the medication and initials on MARS matched. No follow up medical appointment was scheduled due to R1 under Home Health Care. Staff interviews corroborated the summary of events reported in the SIR and Death reports. Administrator Garcia will send LPA Brown a copy of the death certificate once available. No information was received by the LPAs to indicate there was any lack of care and/or supervision. No citations have been issued at this time. This report was reviewed with Administrator Michael Garcia and a copy provided.the state’s words, verbatim · CDSS document, Jan 18, 2022

Allegation investigated: Facility Staff do not wear a mask Facility is malodorous

Licensing Program Analysts (LPAs) Melody Brown and Rohit Lama made an unannounced visit for the purpose of delivering the findings to the above allegations. The LPAs met with Dietary Supervisor and Assistant Administrator Maria Molina. LPAs explained the purpose of the visit and were granted entry. Administrator Michael Garcia arrived during the the visit. LPAs Brown and Lama observed temperature checks at the entrance area of the facility, visitors were asked the screening questions, and all staff are wearing masks. In addition, LPAs Brown and Lama observed Covid-19 signages throughout the facility, sufficient hand sanitizers located in the common areas of the facility and social distancing are being implemented. The first allegation indicates that facility staff do not wear a mask. During the investigation, LPAs Brown and Lama did not obtain evidence to corroborate the allegation. LPA Brown interviewed 8 residents and 6 staffs. *** continuation on LIC 9099C*** Unsubstantiated 6 out of 8 residents stated that staff always wore masks while at the facility and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 6 staff. 6 out of 6 staff stated that they always wear mask and they were provided the necessary personal protective equipment (PPE). The second allegation indicates that facility is malodorous. Interviews with staff and residents also indicated that the facility does not have malodorous smell. 6 out of 8 residents stated that facility does not have malodorous smell and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 6 staff. 6 out of 6 staff stated that facility does not have malodorous smell. During today’s visit, LPAs Brown and Lama toured numerous parts of the facility, including common areas and several resident bedrooms, and did not observe any malodorous scent. Based on the information obtained and observation, there is not enough evidence to state facility staff do not wear a mask (allegation #1) and facility is malodorous (allegation #2). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report (LIC 9099) was provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Dec 14, 2021 · control 18-AS-20210927092059

Allegation investigated: Staff do not wear Personal Protective Equipment Facility has pests Facility not maintained clean and sanitary

Licensing Program Analysts (LPAs) Melody Brown and Rohit Lama made an unannounced visit to the facility to deliver findings for the allegation(s) listed above. LPAs met with Dietary Supervisor and Assistant Administrator Maria Molina and Administrator Michael Garcia. The investigation consisted of file review, interviews with staff and residents as well as observation. The first allegation indicates that staff do not wear personal protective equipment (PPE). During the investigation, LPA Brown did not obtain evidence to corroborate the allegation. LPA Brown interviewed 8 residents, 6 staffs and observed the facilities supply of PPE's for resident and staff use. 6 of 8 residents reported that staff wears PPE and 6 of 6 staff reported that they wore PPE all the time. In addition, LPAs Brown and Lama observed staffs wearing PPE. LPA Brown checked and determined that the facility had an ample supply of face masks, hand sanitizer, gloves and gowns for use. The quantity of the supplies met with the recommended 30-day supply to have available. *** continuation on LIC 9099C*** Unsubstantiated The second allegation indicates that facility has pests. The investigation consisted of the following: LPA Brown interviewed Administrator Michael Garcia, Dietary Supervisor and Assistant Administrator Maria Molina. 8 residents, 6 staffs and reviewed pest control reports/invoice. The investigation revealed the following: Administrator Michael Garcia said they have a pest control company who comes to the facility monthly to treat for pests. LPA Brown reviewed the pest control invoice and observed the pest control technician does treat the facility monthly. Administrator Michael Garcia and Dietary Supervisor and Assistant Administrator Maria Molina both state the pest control technician has not found any rodent droppings or any evidence of rodent activity in the facility. Moreover, 8 residents and 6 staffs were interviewed and 6 of 8 residents and 6 of 6 staffs have not seen any rodents in their rooms or at the facility, nor have they seen any rodent droppings. LPA Brown reviewed the pest control report, and it says they have not found any signs of a rodent infestation. Based on interviews conducted by LPA Brown and review of the pest control report, LPAs Brown and Lama did not obtain evidence to corroborate the allegation. The third allegation indicates facility not maintained clean and sanitary. LPAs Brown and Lama did not obtain evidence to corroborate the allegation. Interviews with residents and staff denied that the facility’s not maintained clean and sanitary as the facility staff clean the premises on a regular basis. 6 of 8 residents and 6 of 6 staffs reported that the facility is always clean. LPAs Brown and Lama toured the physical plant, including the yard, and observed that the premises are clean and sanitary. Based on the information obtained, there is not enough evidence to state staff do not wear personal protective equipment (PPE) (allegation #1), facility has pests (allegation #2) and facility not maintained clean and sanitary (allegation #3). 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. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report (LIC9099) was reviewed with and provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Dec 14, 2021 · control 18-AS-20210930082659

Allegation investigated: Staff are not following the proper protocols for COVID 19.

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to commence a complaint investigation as well as to deliver findings for the allegation listed above. LPA met with Administrator Michael Garcia and Dietary Supervisor and Assistant Administrator Maria Molina. The investigation consisted of file review, interviews with staff and residents as well as LPA Brown's observation. The investigation, which consisted of interviews and document reviews revealed the following: LPA Brown observed temperature checks at the entrance area of the facility, visitors were asked the screening questions, and all staff are wearing masks. In addition, LPA Brown observed Covid-19 signages throughout the facility, sufficient hand sanitizers located in the common areas of the facility and social distancing are being implemented. During the investigation, LPA Brown did not obtain evidence to corroborate the allegation. Unsubstantiated LPA Brown interviewed 8 residents and 6 staffs. 6 out of 8 residents stated that all staff wore masks, gowns, gloves, practice social distancing while at the facility and 2 residents are not oriented and unable to answer questions. LPA Brown interviewed 6 staff. 6 out of 6 staff stated that they were provided the necessary personal protective equipment (PPE) and were provided training on donning and doffing PPE and covid prevention. Interviews with staff and residents also indicated that residents with Covid were quarantined and isolated and no staff goes in and out of the memory care unit and to the assisted living side of the facility after being exposed to residents who have covid. Based on the information obtained and observation, there is not enough evidence to state staff are not following the proper protocols for Covid-19. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted, and a copy of this report was reviewed with and provided to Dietary Supervisor and Assistant Administrator Maria Molina. Administrator MIchael Gracia is unavailable due to scheduled Technical Assistance (TA) Visit.the state’s words, verbatim · CDSS document, Oct 14, 2021 · control 18-AS-20210924093532

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to conduct an annual inspection, with emphasis on infection control. LPA Brown was greeted and granted entrance by Dietary Supervisor and Assistant Administrator Maria Molina and Administrator Michael Garcia and LPA Brown explained the purpose of today's visit. Dietary Supervisor and Assistant Administrator Maria Molina accompanied LPA Brown on a tour of the inside and outside of the facility. Administrator Michael Garcia is unavailable due to scheduled Technical Assistance (TA) Visit. During today’s visit, LPA Brown made observation pertaining to the facility’s current infection control measures. LPA Brown observed a screening area, proper Covid-19 signages throughout the facility, sufficient hand hygiene supplies, cleaning supplies, and a sufficient supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas/surfaces. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident’s physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Dietary Supervisor and Assistant Administrator Maria Molina.the state’s words, verbatim · CDSS document, Oct 14, 2021

Allegation investigated: Administrator is not present on the premises as required. Staff did not administer a resident's medication as prescribed.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA met with Maria Molina-Director of Nutrition Services and explained the purpose of the visit. Administrator was unavailable due to being out and picking up a new resident for the facility. The investigation consisted of a review of Medical Authorization Records (MAR), medications, file review, interviews with staff and residents as well as observation. Allegation: Administrator is not present on the premises as required. LPA George had a discussion with Administrator prior to the complaint, regarding his availability. The most recent conversation occurred on 6/14/21. LPA and Administrator discussed, Administrator putting himself on the facility schedule and indicating the hours that he will be working on the floor, so that there would not be a question as to when he would be working. Administrator stated that he could do that, as it is hard to separate the times, with him residing on grounds. During 6/14/21,L PA also observed a resident pacing back and forth in front of Administrator’s office whom made the statement multiple times “I never know when you are going to be here”. Substantiated LPA has been contacted by an individual from a different agency, on 7/28/21 stating that they were having a difficult time getting a hold of the administrator and wanted to confirm contact information. During an interview with Administrator he stated that he was on vacation for two weeks and the facility designee is Maria Molina-Director of Nutrition Services, whom is also indicated on the LIC308. LPA conducted interviews and the consensus was that it is unknown when the administrator would be on the premises. Per Administrator he is always available due to being on-call 24/7. LPA has called the facility and staff has informed LPA that administrator was not available and did not know when he would be. LPA reviewed the facility schedule and there were no hours indicating as to when the Administrator would be available, as he was not listed. Therefore, the allegation of Administrator is not present on the premises is SUBSTANTIATED. Allegation: Staff did not administer a resident’s medication as prescribed. LPA George reviewed MARs, as well as the prescribed medications, which revealed that Resident # 1(R1) was in fact not given their medications prescribed. R1 was admitted to the facility on 06/02/21 and was prescribed the following: Clonazepam, Ziprasidone, Halperidol, Benztropine, Trazadone). LPA interviewed R1 whom was not able to confirm that they had been without their medications. However, it was confirmed during staff interviews that at the time of admission R1 only had 2 weeks worth of their prescribed medications, and that at minimum of 1 month, that R1 was without their prescribed medication. Per staff interviews staff made attempts but the Doctor stated that they had not seen R1 since 2019, but the prescription label revealed that R1 was prescribed medication in March 2020. Per facility staff a second request was made and did not hear back from the Doctor. There was not any recent follow up until 7/28/21, which is when R1 was able to get their prescription filled. LPA observed at the time of the visit that R1 does have a 30 day supply of medication. Therefore, the allegation of Staff did not administer a resident’s medication as prescribed 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 appeal rights was provided to Maria Molina-Director of Nutrition Services.the state’s words, verbatim · CDSS document, Aug 2, 2021 · control 18-AS-20210721135526

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87564(a) · Plan of correction due date: Aug 3, 2021

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: based on observation, interview and record review the licensee did not administrator medication as prescribed on 1 out of 1 times. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 2, 2021

Plan of correction: The administrator agrees to have a medication administration training, focusing on the importance of taking prescribed medication. Proof is to be submitted to the department by 5pm on the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618(a) · Plan of correction due date: Aug 16, 2021

1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. This requirement is not met as evidenced by: based on observation, interview and record review the administrator was not available during normal working hours on 1 out of 1 times. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 2, 2021

Plan of correction: The administrator agrees to add himself to the schedule indicating the hours and days that he will be working at the facility and follow it. Administrator will send a revised copy of the schedule for the month of August. Proof is to be submitted to the department by 5pm on the due date indicated.

Allegation investigated: Facility has a cockroach infestation.

Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to commence an investigation and deliver findings for the allegation listed above. LPA was greeted and granted entry by Director of Nutrition Services Maria Molina and explained the purpose of the visit and also assisted with the tour of the facility. Administrator Michael Garcia arrived shortly after. The investigation consisted of observation, interviews and a review of pertinent documentation. Allegation: Facility has a cockroach infestation. LPA conducted a tour of the physical plant. LPA observed the juice dispenser which was found to be clean and free of pests. The machine was last serviced on 5/27/21. At 10:38am LPA observed in the kitchen a roach motel, and two bait traps, as well as a live roach crawling around the bait trap located underneath the shelf by the kitchen sink. LPA also observed a dead cockroach against the wall in bedroom number 108. *Continued on 9099C Substantiated Based on observation and interview's conducted the allegation of the allegation of staff do not properly maintain the facility is UNSUBSTANTIATED. Allegation: Staff are mishandling residents personal funds. LPA reviewed resident #2 (R2) and resident #3 (R3) files. R2 is placed at the facility on an assisted living waiver. R2 has access to their funds, as they have their own bank account. R2 refused to answer questions when LPA attempted to interview them. R2 would not confirm that they had their bank card in their possession. LPA reviewed resident's statement for the facility showing the outstanding amount of rent due. The facility has only received rent for the month of May 2021. Administrator did attempt to take R2 to the bank with LPA present, and had stated that they had previously done so in the past to assist with getting their account straightened out, but R2 continuously refuses. LPA reviewed the facility's resident rent roll form, and observed that R2 did pay their rent for May 2021, with cash, LPA reviewed supporting documents such as a receipt confirming that cash deposit was made into the facility's business bank account. R3 is conserved and a check is sent and the money is deposited, where R3 can make withdrawals with staff. R3's file was also reviewed and receipts revealed that when R3 was taken to 7 eleven on 7/6/21, per their request that, they only purchased what they had initially requested which was a hot dog, a drink and spicy hot dog. The purchase was paid for with $10.00 cash, and not an ATM card this transaction was also noted on resident's record of resident's safeguarded cash resources log. Based on observation, interview and record review the allegation of Staff are mishandling residents personal funds is UNSUBSTANTIATED. A finding that the complaint is 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, therefore the allegation is unsubstantiated at this time. An exit interview was conducted and a copy of this report was provided to Administrator Michael Garcia. Per Administrator Michael the facility just had the extermination company came out to the facility to treat for cockroaches on Monday 7/12/21. However, per the invoice reviewed the kitchen was not noted as one of the areas serviced. Based on observation and interviews the allegation of Facility has a cockroach infestation 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 and appeal rights was provided to Administrator Michael Garcia.the state’s words, verbatim · CDSS document, Jul 16, 2021 · control 18-AS-20210715124753

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.256(a)(5) · Plan of correction due date: Jul 17, 2021

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5)To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not ensure safe and healthful accommodations on 2 out of 2 times.the state’s words, verbatim · CDSS document, Jul 16, 2021

Plan of correction: The licensee will have the exterminator treat the kitchen, and any other areas as they see fit. Proof is to be submitted to the department by 5pm on the due date indicated.