Brookdale North Euclid

Allegation investigated: Facility staff did not ensure to keep facility free of pest.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliver findings for the above allegations. LPA met with Business Office Manager and explained today's visit. The licensing department received a complaint in regards to facility staff not ensuring the facility is kept free of pest. LPA conducted (8) resident interviews. 4 out of the 8 residents stated they have not had any issues with bugs. LPA observed no pest control management was associated or completed with Resident #1 (R1) pest issues. During LPAs visit on 02/18/2026, LPA observed pests located in R1’s former bedroom. Based on the evidence gathered during today’s investigation, the allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met. An exit interview was conducted and a copy of this report (LIC9099) and (LIC9099A) was discussed and provided to Business Office Manager Marcos Ramos along with copy of appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2026 · control 56-AS-20260213142951

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 31, 2026

87303 Maintenace and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation and record review, the licensee did not comply with section cited above by not ensuring Resident #1 (R1) was free from pests and maintained, which poses a potential health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Business Office Manager stated the facility would like to submit an appeal. Business Office Manager stated to understand regulation and moving forward will continue with appropriate documentation on pest control.

Type of visit: Required - 1 Year

On 07/24/2026 at 9:00 AM, Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with a staff at the reception area, and was granted entry to the facility. Business Office Manager Marcos Ramos was contacted and met with LPA Hernnadez. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred forty (140) non-ambulatory residents, approved for ten (10) hospice waivers and five (5) bedridden. The current census is (68) residents. LPA Hernandez was accompanied by Business Office Manager Marcos Ramosto conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Hernandez observed sufficient furniture and lighting throughout the facility.The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staffs have their updated ServSafe Certification and food handlers’ card. Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Hernandez reviewed ten (10) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. No issues observed. LPA Hernandez reviewed eight (8) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test Result. No issues observed. Medications/Medication Administration Record (MAR) were audited for seven (7) residents. Remaining residents self manage their medications. No issues observed. Based on the observations made during today’s visit, no deficiencies nor advisories issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), was discussed and provided to Business Office Manager Marcos Ramos.the state’s words, verbatim · CDSS document, Jul 24, 2026

Allegation investigated: Licensee financially abused resident as a form of retaliation Staff do not ensure resident receives assistance with personal and dental hygiene care needs Staff did not ensure residents call button was made accessible for use

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliver findings for the above allegations. LPA met with Business Office Manager Marcos Ramos and explained today's visit. LPA spoke with Administer Logan Harrison who stated no financial abuse due to retaliation was formed against Resident #1 (R1). Administrator stated all payments being issued were in regards to R1's care plan. Additionally, LPA observed and reviewed documentation showing invoice that was being charged to R1 that included all R1's service fees and no additional amounts. LPA conducted (8) resident interviews. 7 out of the 8 stated the facility does offer assistance with dental and hygiene needs when requested. LPA conducted (6) staff interviews. 6 out of the 6 staff stated there is transportation given to residents and assistance with dental and hygiene needs. Additionally, LPA conducted (8) resident interviews. 7 out of the 8 stated their call button is made accessible for use. LPA conducted (6) staff interviews. 6 out of the 6 staff stated call buttons are kept with residents and made accessible at all times. Unsubstantiated Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) (LIC9099C) was discussed and provided to Business Office Manager Marcos Ramos.the state’s words, verbatim · CDSS document, May 19, 2026 · control 56-AS-20260116151011

Allegation investigated: Staff did not alert the residents of power outages Staff left the residents unattended Staff allowed the residents to be soiled Staff mishandled the residents medications Staff are not properly trained Staff behavior poses as a risk to the residents Staff do not properly maintain the facility

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliver findings for the above allegations. LPA met with Business Office Manager Marcos Ramos and explained today's visit. LPA conducted (8) resident interviews. 8 out of the 8 stated the facility will alert residents of power outages when they are scheduled. LPA conducted (6) staff interviews. 6 out of the 6 staff stated when facility is notified of power outages they will prepare and alert residents. Additionally, LPA spoke with (8) residents in regard to staff leaving residents unattended. 8 out of the 8 stated facility staff do not leave them unattended nor have witnessed facility staff leaving other residents unattended. LPA conducted (6) staff interviews. 6 out of 6 stated residents are not left unattended. In regards to allegation of staff allowing residents to be left soiled. LPA spoke with (8) residents. 8 out of the 8 stated they have either not been left soiled or have witnessed other residents being left soiled. LPA conducted (6) staff interviews. 6 out of the 6 staff stated residents are not left soiled and are changed when call button is pressed or when room checks are done periodically. Unsubstantiated In regards to allegation of staff mishandling medications. LPA spoke with (8) residents. 8 out of the 8 residents stated facility staff have not mishandled their medications or have witnessed facility staff mishandling other resident’s medications. LPA conducted (6) staff interviews. 6 out of the 6 stated they have not witnessed facility residents medications being mishandled. Additionally, a allegation was received regarding staff not being properly trained and staff behavior posing as a risk to residents. LPA conducted (8) resident interviews. 7 out of the 8 residents stated the facility staff are well trained to work at the facility and have not witnessed any behavior from staff to residents. LPA also spoke with (6) facility staff. 6 out of the 6 stated they believe the staff working are well trained and have not witnessed any behavior being posed as a risk to residents. Furthermore, LPA conducted (8) resident interviews in regards to staff not properly maintaining the facility. 8 out of the 8 stated the facility is kept clean and maintained. LPA spoke with (6) staff. 6 out of the 6 stated the facility is kept properly maintained. Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) (LIC9099C) was discussed and provided to Business Office Manager Marcos Ramos.the state’s words, verbatim · CDSS document, May 19, 2026 · control 56-AS-20260202105605

Type of visit: Case Management - Incident

On 05/08/2026 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unnanounced case mangement visit to follow up on Resident #1 (R1) death that occured on 04/20/2026. LPA met with Administrator Logan Harrison and explained the purpose of today's visit. LPA spoke with Administrator Logan Harrison to obtain additional information regarding the death. LPA requested copies of the following documents: Resident ID/emergency information, admission's agreement, physician's report, resident care plan/individual services and support plan, centrally stored medication log. The Department is requesting a copy of R1's death certificate. Further investigation may be required depending on the cause of death. No deficiencies were cited during the visit. An exit interview was conducted where this report was discussed and provided to Administrator Logan Harrison.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Incident

On 01/14/2026 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to inquire on a report that was sent to licensing on 12/16/2025. LPA met with Administrator Logan Harrison and explained purpose of visit. During today's visit, LPA spoke with Administrator to discuss Resident #1 (R1) health and any safety concerns. LPA spoke with R1 about incident and surrounding events. Additionally, LPA collected documentation pertaining to incident and spoke with additional staff. No imminent health or safety concerns were observed. No deficiency was cited during this visit. An exit interview was conducted where this report LIC809 was discussed and provided to Administrator Logan Harrison.the state’s words, verbatim · CDSS document, Jan 14, 2026

Allegation investigated: Staff do not abide to the admission agreement

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliever findings for the above allegations. LPA met with Administrator Logan Harrison and explained today's visit. For the allegation, Staff do not abide to the admission agreement. LPA observed admission agreement for Resident #1 (R1) and change in admission agreement report. Review of R1 admission agreement and change in admission agreement report revealed that R1 was received a rate change with an increase of $407. Review of R1's admission agreement report revealed that it was not signed by R1 nor R1's representative. Interveiws with staff and outside sources corroborated this attempt in increasing R1's fees due to a change in behavior. Substantiated Based on the evidence gathered during today’s investigation, the allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met. During today’s visit, a deficiency was cited/issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099), LIC9099D were discussed and provided to Administrator Logan Harrison along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 56-AS-20251207223736

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87507(c) · Plan of correction due date: Dec 17, 2025

87507 Admission Agreements: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative... Based on record review, the licensee did not comply with section cited above by charging an additional fee to R1's monthly charge due to behaviors with no signature from R1 or representative, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Licensee stated will be sending in appeal to licensing departement regarding deficiency cited.

Allegation investigated: Staff does not keep resident’s urinal clean.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliever findings for the above allegations. LPA met with Administrator Logan Harrison and explained today's visit. For the allegation, Staff does not keep resident’s urinal clean. Based off of observations, LPA observed Resident #1 (R1) urinal to not be clean and filled with residue. Based on the evidence gathered during today’s investigation, the allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met. Substantiated During today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099), LIC9099D were discussed and provided to Administrator Logan Harrison along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 56-AS-20251204105800

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 17, 2025

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation, the licensee did not comply with section cited above by not ensuring R1's urinal was kept clean, which poses a potential health, safety, or personal rights risk to to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Licensee stated to replace R1's urinal with clean urinal. POC will be cleared.

Allegation investigated: Staff are not meeting resident's hygiene needs. Staff are not meeting resident's toileting needs. Resident is left in soiled diapers for extended periods of time. Staff do not ensure that resident's room is clean.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit for the purpose of deliever findings for the above allegations. LPA met with Administrator Logan Harrison and explained today's visit. For the allegation, Staff are not meeting resident's hygiene needs. LPA conducted (8) resident interviews. 7 out of the 8 stated facility staff do help with residents with hygeine needs. Resident #1 (R1), Resident #2 (R2) and Resident #6 (R6) stated facility staff do assist with showering and brushing teeth as needed. LPA conducted (6) staff interviews. 6 out of the 6 staff stated residents are assisted with hygeine needs such as bathing, showering, and teeth brushing when needed. 6 Additionally, 5 out of the 6 staff stated some residents may refuse hygeine services, such as bathing or teeth brushing. LPA observed facility shower schedule. Unsubstantiated For the allegation, Staff are not meeting resident's toileting needs. LPA conducted (8) resident interviews. 7 out of the 8 stated facility staff does meet residents toileting needs. LPA conducted (6) staff interviews. 6 out of the 6 stated facility staff do assist with toileting needs and room checks are conducted throughout the day to check on residents in care and assist with any toileting needs. For the allegation, Resident is left in soiled diapers for extended periods of time. LPA conducted (8) resident interviews. 3 out of the 8 residents required use of diapers. 2 out of the 3 stated facility staff do not leave residents in soiled diapers for extended periods of time. LPA conducted (6) staff interviews. 6 out of the 6 staff stated facility staff will change residents diapers in a timely manner and have not witnessed residents being left in soiled diapers for extended amount of time. For the allegation, Staff do not ensure that resident's room is clean. LPA conducted (8) resident interviews. 8 out of the 8 residents stated facility staff do ensure residents rooms are kept clean and are on a cleaning schedule weekly. LPA conducted (6) staff interviews. 6 out of the 6 stated residents rooms are kept clean and have a weekly schedule for each resident's room. Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) (LIC9099C) was discussed and provided to Administrator Logan Harrison.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 56-AS-20251009094016

Type of visit: Required - 1 Year

On 08/20/2025 at 9:30 AM, Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with a staff at the reception area, and was granted entry to the facility. Executive Director Logan Harrison was contacted and met with LPA Hernnadez. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred forty (140) non-ambulatory residents, approved for ten (10) hospice waivers and five (5) bedridden. The current census is sixty-seven (67) residents. LPA Hernandez was accompanied by Executive Director Logan Harrison to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Hernandez observed sufficient furniture and lighting throughout the facility. LPA Hernandez measured and observed the water temperature in a resident bathroom to be at 106 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staffs have their updated ServSafe Certification and food handlers’ card. Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Hernandez reviewed ten (10) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. No issues observed. LPA Hernandez reviewed eight (8) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test Result. No issues observed. Medications/Medication Administration Record (MAR) were audited for ten (10) residents. No issues observed. Based on the observations made during today’s visit, no deficiencies nor advisories issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), was discussed and provided to Executive Director Logan Harrison.the state’s words, verbatim · CDSS document, Aug 20, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Bernadette Allen made unannounced case management visit regarding a self-reported incident on the relocation of (19) nineteen residents from Brookdale Ocean House facility number 198-204758 due to mandatory evacuation orders from Fire Advisory. LPA Allen met with Marcos Ramos Business Office Manager who was informed of the purpose of the visit. At 7:00PM Lisa To Executive Director arrived and she was informed of the purpose of the visit. During the visit, LPA Allen conducted a health and safety check and there were no concerns observed. LPA reviewed and obtained resident and staff rosters for both facilities. Per interview with Marcos Ramos and Helen Lee, (19) nineteen residents have been relocated from Brookdale Ocean House which (2) two residents were in route to the facility. During the visit there were (17) seventeen residents accounted for. The facility has sufficient beds, hygiene supplies, beddings, linens, and everyone has a designated room. The dining room is large enough to accommodate all residents. The kitchen has sufficient two-day perishable and seven-day non-perishable food supplies. LPA observed Medications and MARs for the residents transferred and residents’ files can be accessed electronically. The residents transferred are ambulatory per Lisa To- Executive director. There is sufficient staffing available to provide care for residents of both facilities. It has been verified that a routine Fire inspection and testing was completed on August 1, 2024, and a fire & disaster drill was conducted on December 12, 2024. Lisa To confirmed that all families and/or responsible parties have been notified about the relocation. Lisa To has confirmed residents from Brookdale Ocean House residents will not share rooms with Brookdale North Euclid residents. LPA Allen also observed Brookdale Ocean House residents are one (1) to (2) two persons to a room. An exit interview was conducted, and a copy of this report was provided Lisa To- Executive director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jan 10, 2025

Allegation investigated: Unlawful eviction. Staff not providing an accurate dosage of medication to resident. Staff not allowing resident to have visitors. Staff stealing money from resident.

On 11/5/2024 Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unannounced visit to deliver findings on the allegations listed above. LPAs met with Business Office Manager Marcos Ramos and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour. For the allegation, Unlawful eviction. During record review, LPA's verified documentation for resident #R1 eviction notice. LPAs obtained a copy of 30 day notice issued to R1 on 12/19/2023 due to room and board payments. The 30 day notice was signed by R1 and dated 12/29/2023. S1 stated Adult Protective Services assisted with relocation of R1. Unsubstantiated For the allegation, Staff not providing an accurate dosage of medication to resident. LPAs Hernandez and Rico conducted (5) resident interviews and (4) staff interviews. During resident interviews, 5 out of the 5 residents stated the accurate dosage of medication is given to them. During staff interviews 4 out of the 4 staff stated an accurate dosage of medication is given to each resident. For the allegation, Staff not allowing resident to have visitors. LPAs conducted (5) resident interviews and (4) staff interviews. During resident interviews 5 out of the 5 stated the facility allows them to have visitors when they would like. During staff interviews 4 out of the 4 staff stated all residents are allowed to have visitors at the facility. Additionally, LPAs conducted a facility tour and observed visitor logs for the residents in the facility. For the allegation, Staff stealing money from resident. LPAs conducted (5) resident interviews and (4) staff interviews. During resident interview 5 out of the 5 residents stated no staff has stolen money or personal belongings from them. During staff interview 4 out of the 4 staff stated they have not stolen any money or personal belongings from the residents at the facility. Additionally, staff reported they have not witnessed or suspected any other staff at the facility has stolen any money or personal belongings from residents. Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) (LIC9099C) was discussed and provided to Business Office Manager Marcos Ramos.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 56-AS-20241029154509

Allegation investigated: Staff are not assisting resident with transfers from wheelchair into transportation vehicles. Staff are not properly destroying discontinued medications

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the investigation on the above allegations. LPA met with Business Office Manager, Marcos Ramos, who was informed of today’s visit. The investigation consisted of LPA observations, document review, interviews with staff and residents. Regarding the allegation, staff are not assisting resident with transfers from wheelchair into transportation vehicles, interviews with (6) staff deny not assisting residents with transfers from wheelchair into transportation vehicles. Four (4) out of six (6) residents interviewed deny that staff are not assisting residents with transfers from wheelchair into transportation vehicles. Regarding the allegation, staff are not properly destroying discontinued medications, LPA review of Medtech room reveals there a box where medications are kept and shipped back to the pharmacy for destruction. Interviews with (6) staff and six (6) residents reveals not enough evidence to corroborate the allegation. Unsubstantiated Based on observations, interviews and record review, 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 of this report was provided with appeal rights to Business Officer Manager Ramos at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 56-AS-20240612081444

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magda Malcore conducted a case management based on LPA observations during complaint#56-AS-20240612081444. LPA met with Business Office Manager (BOM), Marcos Ramos, and discussed the purpose of the visit. LPA review of Staff #1 (S1) file reveals S1 is currently being shadowed and training started on October 2, 2024. BOM Ramos was advised to cover training regarding the facilities policy on discontinued medications and destruction. A technical advisory on incidental and medical care was issued today. An exit interview was conducted where this report was discussed and a copy provided to BOM Ramos at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 25, 2024

Allegation investigated: Facility restroom lights on timer turned off resulting in a fall to resident

On 10/09/2024 Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPAs met with Administrator Lisa To and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour. For the allegation, Facility restroom lights on timer turned off resulting in a fall to resident. LPA Hernandez conducted (5) resident interviews and (5) staff interviews. During resident interviews (5) out of the (5) residents stated staff comes when help pendant is pressed or pull cord is pulled. Additionally, (5) out of the (5) residents stated to not having any issues or falls within the public bathroom. Moreover, (5) out of the (5) staff interviewed stated no residents at facility have had any issues with public bathrooms and with their help pendant and pull cord. Unsubstantiated During facility tour, LPAs Hernandez and Rico observed upstairs men and women public bathroom. Both bathrooms are motion censored and have a light switch to turn off and on the light. Additionally, both bathrooms pull cords are working. LPAs tested residents help pendants and pull cord and verified equipment is working. During record review, LPAs received a copy of LIC624. LPAs verified facility followed the right protocols to ensure the residents safety. Based on the evidence gathered during today’s investigation, the allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Lisa To.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 56-AS-20241004171919

Type of visit: Required - 1 Year

On 02/26/2024 at 9:30 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff at the reception area, and was granted entry to the facility. Executive Director Lisa To was contacted and met with LPA Brown. At the time of the visit there were five (5) direct care staffs present, and sixty-six (66) residents present. The facility is a ninety-seven (97) rooms, one hundred and three (103) bathrooms with a kitchen/dining area, and living room/activity room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred forty (140) non-ambulatory residents, approved for ten (10) hospice waivers and five (5) bedridden. The current census is sixty-six (66) residents. LPA Brown was accompanied by Business Office Manager Marcos Ramos to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in a resident bathroom to be at 106 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book/manual at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staffs have their updated ServSafe Certification and food handlers’ card. Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA Brown observed resident files reviewed were complete. LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test Result. LPA Brown observed that staff files reviewed were complete. Medications/Medication Administration Record (MAR) were audited for four (4) residents, and LPA Brown observed no issue. Based on the observations made during today’s visit, no deficiencies nor advisories issued per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), was discussed and provided to Executive Director Lisa To.the state’s words, verbatim · CDSS document, Feb 26, 2024

Allegation investigated: Staff are mismanaging residents medication. Staff are charging residents for services not rendered.

On 02/07/2024 at 09:05 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to deliver findings for the allegations listed above. LPA Brown was greeted and granted entry by a staff at the reception area and Executive Director (ED) Lisa To was contacted and informed of the visit. LPA Brown explained the purpose of the visit to ED To. The investigation consisted of observation, interviews, and a review of pertinent documentation. Through the information gathered during the investigation, it was confirmed by observation, documents review and interviews that Staff are mismanaging residents medication. It was alleged that Resident #1 (R1) was not given a prescribed medication for three (3) days and Resident #5 (R5) was not given a prescribed medication for five (5) days. Per review of R1 Medication Administration Record (MAR), LPA Brown confirmed that R1 was not given the prescribed medication on 02/14/2023 to 02/16/2023. LPA Brown observed no entry on R1's MAR on 02/14/2023 to 02/16/2023. *** Continuation in LIC9099C *** Substantiated During the visit on 02/07/2024, Staff #8 (S8) unable to explain to LPA Brown why R1's MAR on 02/14/2023 to 02/16/2023 was blank, and provided LPA Brown R1's doctor order for the medication not dispensed to R1. In addition, LPA Brown reviewed R5 MAR and observed that R5 was not given a prescribed medication on 02/24/2023 to 03/01/2023 and another prescribed medication was not given to R5 on 02/19/2023 to 02/23/2023. During the visit on 02/07/2024, S8 confirmed to LPA Brown that R5 medications on 02/24/2023 to 03/01/2023 and 02/19/2023 to 02/23/2023 was not dispensed due to required pharmacy action. LPA Brown reviewed R1 and R5's Personal Services Plan (PSP) and LPA Brown observed that ordering and coordinating medications are included on R1 and R5's PSP in addition to assistance with taking medications and medication storage. Interview with Resident #6 (R6) indicated that staffs at the facility did not give R6 medication twice and reported that staffs at the facility occasionally mismanaged their medications. The second allegation indicates Staff are charging residents for services not rendered. LPA Brown determined that there was corroborating evidence that staff charged R1 for services not rendered. LPA Brown reviewed R1 Invoice from 02/2023 to 07/2023, and LPA Brown observed that the facility charged R1 for Escort/Mobility services not rendered or provided to R1 on 04/2023, 05/2023, and 06/2023. Staff #3 (S3) reported to LPA Brown that on incidents that a resident was charged of services not provided or rendered to the resident which happens, they immediately addressed the issue and they deduct the charged services that was not rendered or provided to the residents' account. During the visit on 02/07/2024, Staff #1 (S1) informed LPA Brown that residents are re-assess as needed and if there are any refunds needed, they give that to the residents as reflected in the residents' invoice the following month. S1 added that their facility nurses have full control of the assessment and if there are adjustments made to the residents' PSP but it's still their billing department that will adjust the amount in the residents monthly bill which takes time. Based on observation, interview and records review, the allegation of Staff are mismanaging residents medication (Allegation #1) and Staff are charging residents for services not rendered (Allegation #2) are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and Appeal Rights were discussed and provided to Executive Director Lisa To. Staff interviews revealed that they are recommending halo to the residents, but no incident happened that staffs are forcing residents to remove their bed rail. During the visit on 07/13/2023, R1 reported to LPA Brown that staffs at the facility are recommending halo as replacement for R1 and R5 bed rail but R1 did not state a staff forcing them to remove their bed rail. The second allegation indicates Residents room floor is not level. Resident interviews indicated that their room floors are level, and they are not aware of a resident stating that their room floor is not level. Staff interviews indicated that no resident at the facility reported that their room floor is not level. Staff interviews revealed that none of them observed any residents' room floor not level. The third allegation indicates Staff refused to take resident's blood pressure. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated staffs at the facility are taking their blood pressure regularly and no staffs at the facility refused to take their blood pressure when they request them to check or take their blood pressure. Staff interviews indicated that they never refused to take or check a residents' blood pressure. Staffs interviews revealed that Medical Technician staffs are taking or checking residents blood pressure every month and no incident happened at the facility that a staff refused to take or check a residents' blood pressure. Based on the evidence, the allegation that Staff are forcing residents to remove their bed rails (Allegation #1), Residents room floor is not level (Allegation #2), Staff refused to take resident's blood pressure (Allegation #3) are 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 allegations are unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Lisa To.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 56-AS-20230706140934

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Feb 8, 2024

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...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not giving R1 and R5 their medications as prescribed by their physician which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Feb 16, 2024

87507 Admission Agreements (f) The Licensee shall comply with all applicable terms and conditions set forth in the Admission Agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by charging R1 for Escort and mobility services not rendered or provided to R1 on 04/2023, 05/2023 and 06/2023 which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee stated to train all staff on CCR 87507(f) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

Type of visit: Case Management - Deficiencies

On 02/07/2024 at 09:05 AM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility to initiate a Case Management visit. LPA Brown was greeted and granted entry by a staff at the reception area and Executive Director (ED) Lisa To was contacted and informed of the visit. LPA Brown explained the purpose of the visit to ED To. The investigation consisted of observation, interviews, and a review of pertinent documentation. During the tour of the facility on 07/13/2023, LPA Brown observed the half bed rails on Resident #1 (R1) and Resident #5 (R5) and staff interview and records review revealed no written order from R1 and R5 physician indicating the need for the postural support maintained in R1 and R5 facility record when they moved in at the facility on 01/31/2023. Staff #1 (S1) confirmed to LPA Brown that R1 and R5 moved in at the facility with their bed rails and their doctor's written order indicating the need for postural support were obtained around 07/2023, months after they already moved in at the facility. LPA Brown informed ED To that deficiency will be issued as this poses potential health, and safety risk to residents in care. An exit interview was conducted where this report LIC809, LIC809D and Appeal Rights were discussed and provided to Executive Director Lisa To.the state’s words, verbatim · CDSS document, Feb 7, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Feb 16, 2024

87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency... This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #1 (R1) and Resident #5 (R5) half bed rail with no written order from R1 and R5 physician indicating the need for the postural support maintained in R1 and R5 facility record upon moving in at the facility on 01/31/2023 which poses a potential health, safety or personal rights risk to residents in care. The Licensee stated to submit written order from R3's physician indicating the need for the posturalthe state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee stated to train all staff on CCR 87608(a)(3) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.