Paradise Valley Manor

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit. The LPA introduced himself and disclosed the purpose of the visit to Wellness Director, Cecy Salomon. Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residents. It was alleged staff handled a resident in a rough manner. It was reported to the Department Staff # 1 (S1) had roughly assisted Resident #1 (R1) during incontinence care and while assisting a resident in repositioning in bed. Interviews with multiple internal sources corroborated staff had at times used force that was considered rough. One source stated there was no gentle way of assisting R1, and staff had to use force. A different source mentioned S1, at least on one occasion, had rushed a resident and roughly assisted the resident in dressing. (See LIC 9099-C for continuation of report.) Substantiated Although, external sources did not disclose any similar concerns, there was a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation was substantiated and a deficiency cited in an LIC 9099-D. A plan of correction was jointly formulated with Wellness Director Salomon. An exit interview was conducted with Salomon, to whom a copy of this report, LIC 9099D, LIC 811 Confidential names list and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 08-AS-20230612083454

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 31, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents, including R1, were free from neglect, which posed a potential health, safety and personal rights risk to 40 of 40 residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2023

Plan of correction: Wellness Director agreed to provide in service training to all staff, inlcuding S1, on resident rights and handling with care. Wellness Director agreed to submit documentation including training date and log of participants by 9/15/23.

Allegation investigated: Staff physically abused resident

Licensing Program Analyst (LPA), Renita Hall and Interim Assistant Program Administrator, Icela Estrada conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA and IAPA were greeted by Director, Landon Burrup, identified themselves, and were allowed into the facility. During today's visit, LPA and IAPA conducted a staff interview. The Department’s investigation consisted of interviews with staff, residents, outside source, the Ombudsman and review of records. It was alleged that staff #1 (S1) physically abused resident 1 (R1) by slamming R1's feet to the ground while dressing. A review of records revealed that R1 has Mild Cognitive Impairment (MCI). LPA spoke with outside sources and the Ombudsman, and interviews revealed R1 habitually calls 9-1-1 and other outside sources regularly and often does not remember why R1 called. Both sources stated having no concerns with the level of care provided by the facility and have not received complaints regarding above allegation from R1. See continuation form LIC9099-C Unsubstantiated Interviews with multiple staff revealed no concerns regarding the care provided by S1 or other caregivers and have never witnessed any abuse. Staff #1 denied the allegation or having issues with residents in care, but described having one resident (R1) that is verbally abusive and combative. When R1 is in a "bad mood", S1 requests to be assigned to another resident to allow R1 to de-escalate. In S1's opinion, S1 gets along with R1 and R1 often requests S1 as their caregiver. During interview, R1 described S1 as being "rough" when changing R1's socks, but stated R1 means "well". R1 did not describe any staff member as physically abusive. Interview with the lead Med-Tech revealed no issues with staff physically abusing residents or being rough with residents. Assistant Wellness Director, Cecilia Salomon confirmed that they have not reprimanded or given any written-warning to caregivers involving care. Based on LPA's observations and interviews which were conducted and record reviews, the preponderance of evidence standard has NOT been met, therefore the above allegation is found to be UNSUBSTANTIATED. An exit interview was conducted with Med Tech Frances Paragas. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Med Tech and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Jan 4, 2023 · control 08-AS-20221017115405

Allegation investigated: Facility staff failed to provide necessary medical care Facility staff illegally evicted resident from the facility

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to commence a complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Cecilia Salomon, Wellness Director. The Department’s investigation consisted of interviews and facility records review. It was alleged that the facility staff unlawfully discharged a resident and that facility staff did not ensure that a resident received medical treatment while in care. LPA requested pertinent information for the month of November 2022. A review of records and interview with the Director revealed that the resident in question has not lived at the facility licensed by the Department. The facility the resident resided in is not within the Community Care Licensing Division's jurisdiction. As such, the Department has no jurisdiction to investigate. Therefore, the allegations are determined to be unfounded, which means that the allegations are false, could not have (Continued on LIC9099C) Unfounded happened, and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (3/22) were left with the Wellness Director, whose signature on the form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Nov 21, 2022 · control 08-AS-20221118093115

Allegation investigated: Facility staff financially abused resident.

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced visit to deliver investigative findings. After introducing herself, LPA was granted entry into the facility and met with Brianna Iammarino, Director of Social Services, to whom she explained the purpose of the visit. Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of a tour of the facility, review of facility records, and interviews. It was reported to Community Care Licensing that a facility staff called Resident 1’s (R1) bank requesting a change of address and requested to set up online banking, so that R1’s bank statements could be received by the facility and the staff could have access to the resident’s information to view or make changes. During the investigation, it was discovered that R1 moved into the facility in September 2019. A few months Unfounded after R1’s admission into the facility, R1 was in arrears in monthly payments. The investigation revealed that numerous attempts were made to communicate with R1’s responsible party in an effort to obtain outstanding payments. However, the facility’s attempts to collect payments were unsuccessful. Records reviewed during the investigation reflect that in June 2020, facility staff began to contact R1’s bank. Records further reflect that in July 2020, R1 agreed, in writing, to allow the facility to deduct funds from R1’s checking account each month as payment toward R1’s monthly payment and the outstanding balance. Based upon evidence obtained during the investigation, attempts to gain access to R1’s account information and to set up online banking were done with R1’s knowledge in an effort to collect payments for R1’s living accommodations and to prevent the use of account funds for purposes outside of those authorized by R1. Accordingly, we have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, as to the above listed allegation, the facility is in compliance with Title 22 regulations at this time, and we have dismissed the complaint. An exit interview was conducted with Brianna Iammarino, and copies of this report and Licensee Rights (LIC 9058) were provided to the Director of Social Services at the conclusion of the visit. Brianna Iammarino's signature on this report acknowledges receipt of copies of the rights and report.the state’s words, verbatim · CDSS document, Oct 25, 2022 · control 08-AS-20200730164511

Allegation investigated: Facility staff confiscated resident's personal property.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit, to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assisted Living Wellness Director Cecy Salomon. It was alleged that licensee confiscated Resident #1 (R1)’s cell phone, because licensee required them to rely on its provided landline phone instead. CCLD’s investigation consisted of an unannounced facility tour/welfare check, review of the facility’s theft/loss records, and interviews of pertinent residents, facility staff, and outside sources. The investigation revealed that R1’s cell phone was lost, but it was never confiscated by staff. According to a written Theft and Loss report provided by licensee, R1 told staff on 06-02-2022 that their cell phone was missing. Staff unsuccessfully searched R1 and their roommates’ beds, closets, trash cans, and bathroom, as well as the facility laundry room, linen closets, and housekeeping carts. [CONTINUED ON LIC 9099-C] Unfounded [CONTINUED FROM LIC 9099] R1 themselves told LPA that their cell phone was stolen by an unknown person, but it was not confiscated by staff on the basis of some facility policy. R1’s conservator insisted R1 misplaced/lost their cell phone, as opposed it being stolen. (The conservator said they left service to the cell phone active for a full month after the date of loss and verified with the cell service provider that not a single phone call was made on it during that time.) Beyond interviewing R1, LPA also surveyed 4 resident peers and 4 direct care staff. All persons interviewed confirmed that if a resident owns a cell phone to begin with, they can keep it. All residents interviewed confirmed facility staff have never tried to confiscate their personal property. Based on records and interviews, the allegation that licensee confiscated R1’s cell phone is unfounded, meaning it was false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the allegation. An exit interview was conducted with the Salomon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jul 25, 2022 · control 08-AS-20220621082003

Allegation investigated: Licensee did not protect resident from verbal abuse.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit, to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assisted Living Wellness Director Cecy Salomon. It was alleged that Resident #1 (R1) was being called a specific racist word by their roommate [Resident #2 (R2)], and that licensee did not respond to protect R1 from said verbal abuse. CCLD’s investigation consisted of an unannounced facility tour/welfare check, review of pertinent facility records, and interview of relevant residents, staff, and outside sources. The Department’s investigation could not prove that act(s) arising to the level of verbal abuse (and which necessitated licensee intervention) occurred. According to R2, English is not their first language (something LPA observed during their interview). They confessed to once using a racist word during conversation with R1, not fully understanding its meaning. [CONTINUED ON LIC 9099-C, 1 of 2] Unsubstantiated [CONTINUED FROM LIC 9099] After seeing R1 become angry, R2 never used the word again. This contrasted with R1’s interview, where they said S2 used the racist word repeatedly, and that its use was distinctly overheard by an outside source, by their conservator, by Staff #1 (S1), and by neighboring Resident #3 (R3). However, the outside source told LPA while they heard second-hand about the allegation from R1, they never observed/overheard such act, and denied bringing it to the attention of facility staff. R1’s conservator, S1, and R3 also denied observing/overhearing any such act, or even knowing about R1’s allegation against R2. According to 2 of 2 additional direct care staff assigned to both R1 and R2’s care: they argue with each other, with R1 usually instigating the squabbles. However, none of these staff witnessed, overheard, or heard about either resident saying anything racist towards the other. The evidence did not show that licensee failed to respond to R1’s allegation. When LPA asked each resident if they wanted to change rooms to get away from each other: R1 said of R2, “[They] are not a bad [person.] They are nice to me now, after [Manager #1 (M1)] came out.” [When LPA spoke to M1: they denied witnessing, overhearing, or hearing about either resident saying anything racist towards the other and thus never needed to confront either one about that it.] R1 denied to LPA ever requesting a room change from facility staff on account of R2’s conduct (which M1 corroborated). R2 also denied to LPA ever requesting a room change from facility staff, saying of R1, “[They] talk a lot, talking and talking, shares a lot,” but also “I still want to be [their] roommate. [They] are my friend.” M1 confirmed that they approached R2 in the past to inquire if they wanted to change rooms (after seeing R1 instigate arguments with them), but R2 insisted on staying with R1. M1 said in the approximate year that R1 has lived at the facility, they had 4 other roommates before R2. R1 had a habit of shouting out unsolicited comments towards each roommate (something unanimously corroborated by staff, R1’s conservator, and the facility’s written care notes). The first roommate requested a room change to get away from R1, which M1 granted. The second roommate was largely unaware of their surroundings, to include R1. (LPA was unable to interview either one since each had passed away by the time of this complaint). M1 initiated the relocation the third roommate to a different room (this resident told LPA that R1’s behavior annoyed them). M1 initiated the separation of a fourth roommate to a different room away from R1 (this resident also told LPA that R1’s behavior annoyed them). The Department concluded that by the time of this investigation, R1 was finally situated with a roommate (R2) who wanted to cohabit with them, that the sentiment was mutual, and that licensee’s repeated flexibility with room changes supported residents’ personal rights. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Based on records and interviews, a preponderance of evidence does not exist to prove that licensee did not protect R1 from verbal abuse. The allegation is therefore unsubstantiated. An exit interview was conducted with Salomon, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Jul 25, 2022 · control 08-AS-20220621082003

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Assisted Living Wellness Director Cecy Salomon. LPA conducted a brief tour of the facility and observed the staff and residents in care. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, screening protocols, and the use of personal protective equipment. No deficiencies were cited on this date. An exit interview was conducted with Saloman. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to the licensee.the state’s words, verbatim · CDSS document, May 12, 2022