Las Villas Del Norte

Type of visit: Collateral

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was greeted by, identified himself to, and discussed the purpose of the visit with Receptionist Cindy Villasenor. LPA then met and spoke with Executive Director Jolene Farish. During today’s visit, LPA conducted resident interviews to aid in an investigation occurring at another licensed care facility. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Farish, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Oct 5, 2023

Allegation investigated: Resident is severely neglected Resident is unsupervised Resident is not fed regularly

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Ana Cruz, Resident Services Director and explained the purpose of the visit. Regarding the allegation "Resident is severely neglected", it was alleged on 5/16/2023, Resident #1 (R1) had been found covered in dried feces. Review of R1's Progress Notes dated 5/16/2023 revealed during rounds, and ten minutes prior to the incident, R1 was observed to be free of feces as they sat in the hallway. Two (2) of six (6) staff interviewed reported R1 had one (1) or two (2) instances of removing feces from their incontinent garment. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed they are happy with the care R1 is provided. Regarding the allegation "Resident is unsupervised", it was alleged R1 had been found sitting alone without the presence of any staff near them. Six (6) of six (6) staff interviewed revealed residents are checked on at least four (4) times per shift. Three (3) of six (6) staff interviewed reported residents are (CONTINUED ON LIC9099-C) *THIS IS AN AMENDED REPORT Unsubstantiated (CONTINUED FROM LIC9099-A) brownish colored stain which was thick enough to be crusted in some areas. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099-D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights. (CONTINUED FROM LIC-9099) checked on every thirty (30) minutes. Review of R1's Physician's Report, Level of Care Assessments, and Progress Notes did not indicate R1 required direct supervision. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed they are happy with the care R1 is provided. Regarding the allegation "Resident is not fed regularly", it was alleged that R1 was noted to have severe weight loss. Review of R1's Physician's Report dated 8/29/2022 revealed R1 was able to feed themselves. Review of R1's Level of Care Assessment dated 5/12/2023 revealed R1 only required reminders of meal times but did not require assistance with feeding. Review of R1's Weight Record for June 2022 to May, 20, 2023 revealed R1's weight was 146 lbs. on 6/1/2022. R1's weight was noted to be 133 lbs. on 5/20/2023 indicating a weight loss of thirteen (13) pounds in nearly one (1) year's time. The weight record also indicated three (3) separate instances of weight gain following weight loss during that same period. Six (6) of six (6) staff interviewed reported R1 had a good appetite and ate well. LPA attempted to interview R1 however, R1 did not verbally respond to LPA's presence or inquires. Interview with R1's responsible party revealed the food R1 is provided at the facility is very good and that R1 was fed well. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list. *THIS IS AN AMENDED REPORTthe state’s words, verbatim · CDSS document, Sep 19, 2023 · control 18-AS-20230518160952

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 20, 2023

Personal Rights of Residents in All Facilities-(a) Residents...shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, ...and equipment. This requirement was not met as evidenced by: The licensee did not ensure personal rights were maintained for residents. Based on observations, interviews, and records reviewed, R1 was found injured sitting on top of a mattress stored in their bathroom. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 19, 2023

Plan of correction: The licensee will establish a procedure re: how and when furniture is removed from the unit when needed and conduct training of all memory care staff regarding the procedure. Proof of training to be submitted to CCL by 5PM on 9/20/2023.

Allegation investigated: Staff are not providing resident with a refund

On 1/4/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced complaint visit to deliver an amended version of this report. LPA met with Administrator, Jolene Farish. Regarding the allegation of “Staff are not providing resident with a refund” it was alleged that Resident 1 (R1) did not receive a refund for monthly care fees overcharged during R1’s absence from the facility. LPA reviewed R1’s Admission Agreement and found that on page 13, subsection 6, titled, “Absences” stated, “If you are absent from LAS VILLAS DEL NORTE for more than fourteen (14) consecutive days, you will receive a pro-rated credit toward your Monthly Care Fee starting on day fifteen (15).” *This is an amended version of the original report Unsubstantiated R1’s Admission Agreement confirms the facility is to issue a pro-rated credit towards R1’s monthly care fees if the resident was absent from the facility for more than fourteen consecutive days. R1 was absent from the facility on April 17, 2023 – July 7, 2023, which would entitle R1 to receive a pro-rated credit for monthly care fees, not a refund. Administrator Farish verbally agreed to accommodate and provide a refund for R1. LPA found that the facility issued a refund check in R1's name; however, the individual handling R1's finances requested the check be made to their name, which delayed the refund process. LPA found that the individual handling R1’s finances was not listed as the Power of Attorney agent or responsible person for R1. LPA determined that the facility did not intentionally withhold R1’s refund and instead issued the refund to R1 directly rather than the person handling R1's finances. The individual handling R1's finances was provided the overnight FedEx tracking number for the check refund. Per the admission agreement, R1 was not entitled to a refund, only a pro-rated credit for monthly care fees. However, the facility provided a refund for R1 and added a $100.00 credit to R1’s account for any inconvenience. Based on interviews conducted and record review, the allegation that "Staff are not providing resident with a refund" was found to be Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report was discussed and provided to Administrator Farish along with a Confidential Names List (LIC 811). *This is an amended version of the original report.the state’s words, verbatim · CDSS document, Aug 3, 2023 · control 18-AS-20230728094657

Allegation investigated: Staff neglect resulting in resident falling and sustaining a hip fracture Resident pushed out of wheelchair and sustaining a shoulder fracture

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Resident Care Director Ana Cruz and Memory Care Director Klarrisa Romero and explained the purpose of the visit. Regarding the allegation “Resident pushed out of wheelchair and sustained a shoulder fracture due to lack of supervision”, it was alleged that Resident #1(R1) was pushed out of their wheelchair by two unknown women resulting in a shoulder fracture. Interview conducted with Memory Care Director Ana Cruz revealed R1 was admitted to the facility in 2019, was ambulatory at times and utilized a wheelchair other times due to personal preference. Review of R1’s Preplacement Appraisal dated 10/13/2019 revealed R1 was able to transfer to and from bed without assistance. Review of R1’s 90 day Level of Care Assessment dated 01/07/2020 and 180 day Level of Care Assessment dated 07/05/2021 revealed R1 was able to transfer independently and required no transport/escort assistance. None of R1’s records reviewed revealed R1 required direct supervision. Review of Resident Incident Report (IR) dated 10/19/2021 revealed R1 suffered an unwitnessed fall in their room on 10/19/2021. Interview conducted with Cruz and review of 10/19/2021 IR (CONTINUED ON LIC9099-C) Unsubstantiated (CONTINUED FROM LIC9099) revealed staff found R1 in a sitting position on the floor near the door of their room during rounds. There were no other persons in R1’s room when they were found. R1 was unable to explain to staff what had occurred but did complain of hip and shoulder pain and was transferred to the Palomar Hospital for evaluation where they were diagnosed with a fractured humerus as documented in R1’s Palomar Hospital medical records dated 10/20/2021. Review on 10/19/2021 IR also revealed facility staff responded appropriately, immediately requested medical attention and notified all responsible parties. Interview conducted with a member of R1’s family revealed R1 told a contradictory recollection of the 10/19/2021 incident describing how they threw a facility resident to the floor themselves rather than having been pushed out of their wheelchair. R1 was unable to be interviewed directly. Regarding the allegation “Staff neglect resulting in resident falling and sustaining a hip fracture”, it was alleged that R1 suffered an unwitnessed fall resulting in a hip fracture which contributed to their passing. Interview conducted with Memory Care Director Ana Cruz and review of Resident Incident Report (IR) dated 09/22/2022 indicated during a status check, R1 was found by staff on the floor of their room on the morning of 09/22/2022. Review of IR dated 09/22/2022 revealed R1 reported they were trying to get up on their wheelchair and fell to the floor. R1 complained of hip and back pain and was transferred to Palomar Hospital for evaluation. Palomar Hospital medical records dated 09/23/2022 indicated R1 was diagnosed with a fractured hip which was surgically repaired. Review of IR dated 09/22/2022 also revealed facility staff responded appropriately, immediately requested medical attention and notified all responsible parties. Review of R1’s Level of Care Assessment dated 07/05/2021 indicated at the time of R1’s fall on 09/22/2022, they were able to independently transfer, required no transport/escort assistance, and had been identified as a fall risk. Interview with Cruz indicated as identified as a fall risk, R1 would receive additional assistance with their Activities of Daily Living (ADLs) and more frequent status checks. None of R1’s records reviewed revealed R1 required direct supervision. Investigation did not reveal documents to corroborate nor refute staff status checks were being conducted. Following R1’s return to the facility, they were placed on hospice and passed away at the facility on 12/02/2022. Interview with R1’s hospice clinician revealed there was no evidence of “anything neglectful” related to R1’s care. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.the state’s words, verbatim · CDSS document, May 23, 2023 · control 18-AS-20221209153932

Allegation investigated: Personal Rights Violation

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Executive Director(ED) Jolene Farish and Memory Care Director(MCD) Ana Cruz and explained the purpose of the visit. During today's visit, LPA interviewed three(3) staff. Regarding the allegation "Personal Rights Violation", it was alleged that Residents #1(R1) and #2(R2) had accumulated approximately four(4) months of mail dating back to at least October 2022 at the facility and was not provided to them or their responsible party. Interviews conducted with facility staff indicated that mail is supposed to be given to the responsible party during times of visit by the front desk staff if the resident is incapable of handling the mail. Interview conducted with R1 and R2's responsible party revealed they were not aware mail was accumulating at the facility. Interview conducted with R1 and R2's family representative revealed they had visited the facility at a minimum once a week since August 2022 but was not aware R1 and R2 had mail waiting at the facility, nor were they ever informed of or provided any mail. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. (CONTINUED ON LIC9099-C) Substantiated (CONTINUED FROM LIC9099) California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC9099-D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.the state’s words, verbatim · CDSS document, Feb 16, 2023 · control 18-AS-20230213152700

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(15) · Plan of correction due date: Feb 17, 2023

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:(15) To send and receive unopened correspondence in a prompt manner. This requirement was not met as evidenced by: The licensee did not maintain the personal rights of R1 and R2. Based on interview, R1 and R2 were not provided their mail nor was it provided to their responsible party for at least 4 months. This poses in immediate threat the personal rights to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2023

Plan of correction: AD reported front desk staff will be re-trained regarding resident's rights to have their mail provided promptly to either themselves or their representative. Proof of training to be submitted to LPA by POC due date.

Allegation investigated: Staff did not answer the resident's call button in a timely manner

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude a complaint investigation into the allegation list above. LPA met with Memory Care Director Ana Cruz and informed her of the purpose of the visit. Regarding the allegation "Staff did not answer the resident's call button in a timely manner", it was alleged that on May 14, 2022, Resident #1(R1) activated their call button and waited over thirty(30) minutes for staff to respond. Records reviewed indicated that on May 14, 2022, R1 activated their call button a total of six(6) times. R1's call button activation on May 14, 2022 at 11:06 AM resulted in a staff response time of thirty-five(35) minutes and eleven(11) seconds. R1's call button activation on May 14, 2022 at 2:38 PM resulted in a staff response time of thirty-nine(39) minutes and eleven(11) seconds. R1 could not be interviewed. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names list. Substantiated (CONTINUED FROM LIC9099-C) an assessment to remove the bathroom door but failed to do so. Records reviewed revealed R1 selected the assigned room prior to admission. Interviews conducted revealed R1 and their family toured their assigned room prior to admission and did not make any mention of R1's walker not fitting through the bathroom door, nor was a mention made that the bathroom door would need to be removed for R1 to use the bathroom safely. Records reviewed also indicated R1 "loved" the room assigned to them. Interviews conducted revealed R1 could ambulate with their walker through the bathroom doorway sideways but not head on. Facilty staff had suggested to R1's family that they add a floor to ceiling mobility pole to R1's bathroom to aide in their safety but this was not done. Facility staff also reminded R1 and their family that staff could be called to provide assistance should R1 want/need to use the bathroom. Interviews conducted also revealed that after assessing the issue, the bathroom door could not be removed due to current fire code requirements. Regarding the allegation "Facility staff did not assist resident with changing clothes", it was alleged that R1 was wearing the same clothes they had worn to an appointment three(3) days prior because R1 refused to change their clothes. Records reviewed revealed R1 was scheduled to be provided assistance in changing their clothes twice daily. Interviews conducted revealed R1 would often become frustrated with staff assistance in changing clothes and demand to left alone, would refuse assistance in changing clothes entirely, or would completely refuse to change clothes even after receiving encouragement to do so. R1 could not be interviewed. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list.the state’s words, verbatim · CDSS document, Jan 25, 2023 · control 18-AS-20220922143233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a) · Plan of correction due date: Jan 25, 2023

Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by: The Licensee did not ensure resident's call button was answered in a timely manner. Based on records reviewed, 2 of R1's 6 call buttons on 5/14/22 took staff more than 30 minutes to respond. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: The facility stated a training was recently conducted with all caregivers which outlined their responsibilities in responding to resident's call lights in a timely manner. Proof of training already received. Deficiency cleared during today's visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit to address a deficiency observed during the investigation of complaint control number 18-AS-20220922143233. A review of records indicated on May 24, 2022 at approximately 6:00AM, Resident #1(R1) slipped and hit their head. On May 25, 2022 at 1:45AM, R1 was found on the floor leaning against the wall and reported they slid off the bed. Later that same day at 6:00PM, R1 was found lying on their back after reportedly slipping on the way to the bathroom and again at 10:57PM R1 was found lying down on the floor and could not recall what happened. On May 26, 2022 at 1:15AM, R1 was found lying down on the bathroom floor. Later that morning at 4:22AM, R1 called staff and staff found R1 on the floor with their head leaning against the wall. R1 had a change in condition as evidenced by multiple falls in a short period of time. The facility failed to address a change in R1's condition and to conduct a reassessment for fall precautions. The following deficiency was cited per Title 22, Division 6 of the California Code of Regulations on the attached LIC809-D. An exit interview was conducted and a copy of this report was provided along with Appeal Rights as well as LIC811-Confidential Names list.the state’s words, verbatim · CDSS document, Jan 25, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Feb 8, 2023

Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: The licensee did not ensure R1 was provided assistance following a change in condition. Based on record review, beginning 5/24/22, R1 experienced 6 falls in less than 48 hours and was not reassessed or placed on fall precautions. This poses a potential threat to the health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: The facility stated an inservice will be conducted with all assisted living staff to recognize changes in resident's condition and to report those changes to facility nurses and/or management. Proof of training to be submitted to CCL by POC due date.

Allegation investigated: Staff do not properly supervise residents Staff did not assist resident with medical device Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Memory Care Director Ana Cruz and explained the purpose of today's visit. This visit was incorrectly identified as having been conducted 1/24/2023. The visit was actually conducted 1/25/2023. *This is an amended report. Regarding the allegation "Staff do not properly supervise residents", it was alleged that memory care residents were left unsupervised and then wandered into Resident #1's (R1) room and interupted R1's visit with family. Interviews conducted with staff indicated approximately ten(10) to twelve(12) residents are assigned to each caregiver during AM shift, ten(10) to fifteen(15) residents are assigned to each caregiver during PM shift, and fifteen(15) residents are assigned to each caregiver during NOC shift. There are four(4) additional staff assigned to memory care each AM shift to assist and supervise residents, three(3) additional staff assigned to memory care for at least part of the PM shift to assist and supervise residents, and one(1) additional staff assigned to memory care each NOC shift to assist staff and residents. Interviews conducted also revealed residents are free to walk about the unit at their leisure for either exercise, personal time, or to visit with other residents in the various areas of the unit. Regarding the allegation "Staff did not assist resident with medical device", it was alleged that R1 did not receive assistance with their CPAP machine at bedtime. (CONTINUED ON LIC9099-C) Unsubstantiated (CONTINUED FROM LIC9099) Interviews conducted and records reviewed revealed R1 did receive nightly assistance in donning their CPAP mask and turning it on for use however, this would not prevent R1 from removing the mask and either allowing it run dry or turn it off entirely after time. Regarding the allegation "Staff did not safeguard resident's personal belongings", it was alleged that staff did not take measures to prevent the loss of some of R1's property. Interviews conducted also revealed R1 was issued a key to their room to prevent entry to others and to safeguard their property but eventually lost it. Following the loss of the key, R1 required near constant reminder to shut their room door. Staff did not lock R1's room as this would have prevented R1 from having direct and immediate access to their room at their leisure. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List.the state’s words, verbatim · CDSS document, Jan 24, 2023 · control 18-AS-20220602121633

Allegation investigated: Insufficient staffing to meet residents’ needs Facility doesn’t have enough supplies Facility did not provide adequate food service

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigaton into the allegations listed above. LPA met with Executive Director Jolene Farish and explained the purpose of the visit. During today's visit, LPA interviewed one(1) staff. Regarding the allegation "Insufficient staffing to meet resident's needs", it was alleged that the needs of residents in the memory care unit were not being met due to a lack of staffing due to a high turnover rate. Interviews conducted with six(6) memory care residents revealed three(3) of six(6) memory care residents reported their needs were met or exceeded by the staff in the memory care unit. Three(3) of six(6) memory care residents were unable to be qualified to be reliable witnesses. Interviews conducted with five(5) memory care staff revealed four(4) to five(5) staff are scheduled for each AM shift, three(3) to four(4) staff are scheduled for each PM shift, and two(2) to three(3) staff are scheduled for each NOC shift. Additionally, a med tech and a licensed vocational nurse is available for further supervision and assistance to residents during the AM and PM shifts. An activites person and the memory care director is also available for the AM shift and part of the PM shift. A med tech is available to memory care residents and assisted living residents during the NOC shift as well. Regarding the allegation "Facility doesn't have enough supplies", it was (CONTINUED ON LIC9099-C) Unsubstantiated (CONTINUED FROM LIC9099) alleged that the memory care unit has run out of food, soap, shampoo, and blankets several times. Interviews conducted with six(6) memory care residents revealed three(3) of six(6) memory care residents reported they have never been denied the use of food, soap, shampoo, or blankets at the facility due to lack of supply. Three(3) of six(6) memory care residents were unable to be qualified to be reliable witnesses. Interviews conducted with five(5) memory care staff revealed the memory care unit has not run out of supplies such as soap, shampoo, food, or blankets. During a tour of the memory care unit, LPA observed numerous staff interacting with residents, a stock of supplies of blankets, towels, washcloths, snacks, drinks, soap, shampoo, toothpaste, toothbrushes and personal grooming items. Regarding the allegation "Facility did not provide adequate food service", it was alleged that the memory care residents are usually served food that is expired. Interviews conducted with six(6) memory care residents revealed three(3) of six(6) memory care residents have never observed the food their were provided to be expired or spoiled. Three(3) of six(6) memory care residents were unable to be qualified to be reliable witnesses. Interviews conducted with five(5) memory care staff revealed the memory care unit has not served residents expired food however one(1) staff interviewed reported milk had twice arrived from the main kitchen spoiled during the summer and residents were not served the milk. During a tour of the memory care unit, LPA did not observe any expired or spoiled food or drinks. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 6, 2023 · control 18-AS-20220712101108

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner

Licensing Program Analyst(LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Executive Director Jolene Farish and explained the purpose of the visit. Regarding the allegation "Staff did not respond to resident's call for assistance in a timely manner", it was alleged that when Resident #1(R1) activated their call pendant, it took staff forty(40) minutes to one(1) hour to respond. It was further alleged that R1 had fallen from their scooter on one occasion and waited for hours on the floor for assistance. Interviews were conducted with ten(10) residents. Nine(9) of ten(10) residents reported facility staff do respond to call lights in a timely manner. One(1) of ten(10) residents interviewed has not utilized the call light system. However, records reviewed indicated R1 activated their call light thirty-seven(37) times in the period in question. Only forteen(14) of R1's thirty-seven(37) call lights were responded to within fifteen(15) minutes. Eight(8) of R1's thirty-seven(37) call lights were responded to in sixteen(16) to twenty(20) minutes, five(5) of R1's thirty-seven(37) call lights were responded to in twenty-one(21) to thirty(30) minutes, six(6) of R1's thirty-seven(37) call lights were responded to in thirty-one(31) (CONTINUED ON LIC9099-C) Substantiated (CONTINUED FROM LIC9099) to forty-five(45) minutes, one(1) of R1's thirty-seven(37) call lights was responded to fifty-one(51) minutes, and three(3) of R1's thirty-seven(37) call lights were responded to beyond one hour(1) and nineteen(19) minutes. Records reviewed revealed the longest response time for any of R1's call lights was one(1) hour and thirty-three (33)minutes. Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List and Appeal Rights.the state’s words, verbatim · CDSS document, Jan 6, 2023 · control 18-AS-20220720173917

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a) · Plan of correction due date: Jan 20, 2023

Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by: The Licensee did not ensure resident's call light alarms were answered in a timely manner. Based on records reviewed, R1'sl light alarms were not answered in a timely manner. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2023

Plan of correction: The facility stated a training will be conducted with all caregivers to outline their responsibilites in responding to resident's call lights in a timely manner. Proof of training will be provided to LPA by January 20, 2023.

Allegation investigated: Physical Abuse of a Resident

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegation listed above. LPA met with Executive Director Jolene Farish and explained the purpose of the visit. Regarding the allegation "Physical Abuse of a Resident", it was alleged that Resident #1(R1) was physically abused by Staff #1(S1) while in care. During the investigation, eleven(11) residents were interviewed however, only four(4) residents were able to be qualified. Two(2) of four(4) residents interviewed reported being hit by a staff member, one(1) of four(4) residents interviewed reported being hit by S1, and one(1) of four(4) residents interviewed reported observing a staff member hit another resident. Six(6) staff were also interviewed. One(1) of six(6) staff members interviewed reported they had been told to keep wandering residents away from S1's work area. Two(2) of six(6) staff interviewed reported being told of S1's abuse of residents. Finally, one(1) of six(6) staff interviewed reported observing S1 handle residents in a rough manner, push residents, and exhibit rude limited patience with residents. (CONTINUED ON LIC9099-C) Substantiated (CONTINUED ON FROM LIC9099) Based on LPA’s observations and interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with LIC811 Confidential Names List.the state’s words, verbatim · CDSS document, Nov 16, 2022 · control 18-AS-20220517142036

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 30, 2022

Personal Rights of Residents in all Facilities-(a) Residents in all...care facilities for the elderly shall have... the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions... such as...interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on observation and interviews conducted with staff and residents, the Licensee did not ensure R1 was free from physical abuse while in care which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2022

Plan of correction: Licensee/Executive Director stated all staff will attend training regarding the personal rights of residents to ensure compliance regarding this requirement. Proof of completion of training to be submitted to CCL by POC due date of 12/9/2022.

Allegation investigated: Staff are not maintaining a clean bathroom for the resident

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to collect additional records and deliver findings regarding the above-mentioned allegation. The LPA was greeted by Generations Program Director, Ana Cruz identified himself, and disclosed the purpose of the visit. The Department’s investigation consisted of tours of the facility, review of records, and interviews with internal and external sources. It was alleged staff did not maintain a clean bathroom for Resident # 1 (R1). An outside source reported multiple visitors had witnessed R1’s bathroom floor to be dirty. An interview with an outside source revealed that on one occasion, R1’s bathroom floor was witnessed to have urine. This outside source reported the dirty floor to staff, spent the next two hours at the facility, and the dirty floor was not addressed by staff. Review of records obtained at the facility revealed staff had witnessed R1 urinating in different places, including hallways, and R1’s bedroom floor. Substantiated Interviews with internal sources corroborated incidents of unexpected bowel movement resulting in dirty bathroom floors to be common. These internal sources also revealed the facility has had a plan in place to address such incidents when the housekeeping unit was not on site, but these procedures were not always followed, resulting in dirty bathroom floors. Based on the evidence gathered, the preponderance of evidence standard was met to Substantiate the above allegation. This deficiency was cited in the attached LIC 9099D. A Plan of Correction was jointly discussed and formulated with Generations Program Director, Ana Cruz. An exit interview was conducted with Generations Program Director, Ana Cruz, to whom a copy of this report, LIC 9099D, and the Licensee Rights (LIC9058 9/16) were provided to via electronic mail. An electronic mail read receipt confirms the documents were received. These sources also revealed staff provided manicures, and additional showers to residents with incontinence, regardless of the level of care and number of weekly showers scheduled. Review of records obtained at the facility did not reveal any concerns with R1 missing, nor refusing showers while at the facility. Additional records corroborated facility management responded to these concerns, and on multiple occasions attempted to schedule a care conference to discuss the appropriate level of care with R1’s responsible party. Review of records, interviews with internal and external sources, corroborated the responsible party did not visit the facility, and did not schedule a care conference. It was alleged the facility staff were not assisting Resident # 1 (R1) with wearing hearing aids. Interviews with internal sources revealed R1 would often remove the hearing aids and misplace them. Review of records corroborated management had notified R1’s responsible party R1 often attempted to remove the hearing aids and often misplaced them. These records also revealed management notified staff to assist R1 with wearing the hearing aids. An interview with an outside source, who visited R1 on several occasions, confirmed staff had mentioned R1 would consistently remove the hearing aids, and they often went missing. It was alleged staff did not safeguard Resident # 1 (R1) personal property. An outside source reported R1’s shoes, clothing and hearing aids would often go missing. Interviews with internal sources revealed it was common for residents in the memory care unit, including R1, to wonder and misplace R1’s items. The memory care unit had a protocol in place that required all items to be labeled, prior to the residents moving in. If unlabeled items were found during by the washing and drying process, the laundry department would hold them until the owner was identified. Review of records corroborated R1 had displayed wondering behaviors. An interview with an outside source, who visited R1 on multiple occassions, confirmed facility staff had notified this outside source, R1 would often misplace R1’s hearing aids, or staff would place them in the staff office when R1 was witnessed removing the hearing aids. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did, or did not occur, therefore, the allegations are unsubstantiated. An exit interview was conducted with Generations Program Director, Ana Cruz, to whom a copy of this report and the Licensee Rights (LIC9058 9/16) were provided to via electronic mail. An electronic mail read receipt confirms the documents were received.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 08-AS-20220128112125

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Oct 27, 2022

87303 Maintenance and Operations (a) (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. this requirement was not me as evidenced by: Based on interviews, the licensee did not ensure florr surfaces were clean and sanitary, which posed a pontential health, safety and personal rights risk to 1 of 171 residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Generations Program Director agreed to conduct in service training for all staff regarding cleaning and sanitation procedures, by 11/23/2022. Generations Program Director agreed to submit proof of completed trainings and attendance sheet by 11/23/2022.

Allegation investigated: Facility refrigerator is not maintained in working condition

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Executive Director (ED) Jolene Farish and explained the purpose of the visit. During today's visit, LPA toured the kitchen, resident Bistro area, and interviewed ED Farish. Regarding the allegation "Facility refrigerator is not maintained in working condition", it was alleged that the facility's refrigerator had been non-operable for approximately three (3) weeks and that the food in the refrigerator was rotten. It was additionally alleged that it was unknown how staff were feeding the residents and that the menu was subsequently not been followed as posted. Interview conducted with ED Farish revealed the main walk-in refrigerator in the facility kitchen did stop working on July 3, 2022 and a technician was summoned to the facility who made some repairs to get the refrigerator working again. On July 4th, the refrigerator stopped working once again and a technician came back to the facility and made a temporary fix but also discovered the compressor needed full replacement due to age. While waiting for replacement (CONTINUED ON LIC9099C) Unfounded (CONTINUED FROM LIC9099) quotes, the facility moved all perishable foods into another smaller refrigerator in the kitchen, two (2) additional refrigerators in the resident Bistro, and meats were placed in the walk-in freezer which was verified by LPA during today's visit. There have been no changes in the menu as a result of the issue. This agency has investigated the complaint alleging "Facility refrigerator is not maintained in working condition". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2022 · control 18-AS-20220708092838

Allegation investigated: Neglect/Lack of Supervision

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. The LPA was greeted by Executive Director, Jolene Faris, identified himself, and disclosed the purpose of the visit. The Department’s investigation consisted of a health and safety check, review of records, and interviews with internal and external sources. It was alleged Lack of supervision resulted in Resident # 1 (R1), Resident # 2 (R2), and Resident # 3 (R3) being sexually abused by a stranger. A review of Police reports obtained by the Department, confirmed the identity of the suspected abuser (SA) - See Confidential Names list LIC 811 to identify SA. An interviewed with R1 revealed that on 12/03/2021, at approximately 4:00 am, SA entered R1’s room and stood by the door. (See LIC 809C) Substantiated When asked what SA was doing at the facility by R1, SA proceeded to grab his genitals and state SA was there to please the women. R1 proceeded to ask SA to leave, only to have SA come back within 15 minutes and again R1 telling SA to leave again. An interview with an outside source, a review of a police report, and an interview with Police Officer (P1), who responded to the facility, and obtained R1’s initial statement, corroborated the information provided by R1 to be consistent. An Interview with R2 revealed that on 12/3/2021, R2 woke up to find SA lying next to R2, masturbating and groping R2’s breast. R2 proceeded to tell SA to leave. SA initial refused, but soon after complied and left. R2 then walked to the facility’s Wellness Center on the second floor of the facility and notified Staff # 1 (S1). An interview with an outside source, a review of a police report, and an interview with P1, corroborated the information provided by R2 to be consistent. An interview with R3 revealed SA entered R3’s room at approximately 4:30 am, on 12/3/2021. SA stood by the doorway with SA’s hands on SA’s private parts, until R3 screamed at SA to leave. An interview with an outside source, a review of a police report corroborated the information provided by R3 to consistent. Interviews of S1 and Staff # 2 (S2) revealed SA was seen inside the facility withing the hours of 4am to 5am. S2 saw SA walking through the memory care unit doors, noticed SA was not an employee and proceeded to ask S1 for assistance in locating SA. While conducting a search and checking doors, Staff # 3 and Staff # 4, staff assigned to the memory care unit, notified S1 and S2 one of the resident (S4) in the memory care unit had reported an unknown individual knocked on a patio door and attempted to grab the resident. S1 and S2 continued to search the facility and witnessed SA exiting R3’s room. Both S1 and S2 escorted SA out of the facility and notified law enforcement. A police report obtained during the investigation revealed SA encountered several locked doors around the facility but was able to gain entry through the unlocked lobby doors. Interviewed staff declined ever witnessing the lobby doors being propped open or being unlocked during the timeframe in question. Interviews with outside sources revealed the front doors to the lobby have been found unlocked and propped open early in the morning, on multiple occasions. Facility observations during the investigation revealed multiple patio doors, meant to be locked, were unlocked. An interview with staff revealed this was not the first time an unknown individual has entered the facility campus. Based on the evidence gathered from police reports, records reviewed, and interviews with internal and external sources, the preponderance of evidence standard was met to Substantiate the above allegation. This deficiency was cited in the attached LIC 9099D. A Plan of Correction was jointly discussed and formulated with Executive Director, Jolene Farish. At this time, per Health and Safety Code Section 1569.49, a civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. An exit interview was conducted with Executive Director, Jolene Farish, to whom a copy of this report and the Licensee Rights (LIC9058 9/16) were provided to.the state’s words, verbatim · CDSS document, Jun 29, 2022 · control 08-AS-20211206131259

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jun 22, 2022

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 is not met as evidenced by: Based on observation, interviews, record review, the licensee did not ensure residents were free from sexual abuse in 3 of 166 persons in care [R1, R2, and R3] which posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 29, 2022

Plan of correction: Administrator has implemented a quality assurance protocol where personnel verify lobby doors are locked. Moving forward, the administrator will develop a log to track who is verifying the lobby doors are locked. Administrator has trained all facility personnell on the new protocol, and will submit a log to the LPA documenting the attendees. Administrator will submit all documention by 6/30/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met with Assistant Executive Director Lorena Vivar and explained the purpose of today's visit. LPA was informed that Executive Director Jolene Farish was on a call but would join LPA upon conclusion of the call and did so as reported. During the inspection, LPA interviewed Vivar regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPA observed appropriate postings at the facility front entrance, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents with COVID-19 positive results and/or exposures. 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 emergency personnel in the event the resident presents any COVID-19 symptoms. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 24, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit regarding a recently reported incident. LPA met with Executive Director (ED) Jolene Farish and explained the purpose of the visit. On May 10, 2022, Community Care Licensing (CCL) received information regarding an incident self-reported by the facility which took place on May 6, 2022 and involved Resident #1 (R1). Per incident report, R1 was noted to have a skin tear to the left forearm and was observed to be weak and unable to sit up unassisted. Staff obtained the vital signs of R1 and activated emergency services due to low oxygen saturation. During today's visit, LPA interviewed two (2) staff, reviewed documents pertaining to R1, and obtained copies of documents. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this reported was provided along with LIC 811- Confidential Names List.the state’s words, verbatim · CDSS document, May 24, 2022

Allegation investigated: Staff did not assist resident from fall in a timely manner.

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Assistant Executive Director Lorena Vivar. Below is a summary of the complaint investigation findings: Regarding allegation "Staff did not assist resident from fall in a timely manner.": LPA Colvin reviewed resident's (R1) file, relevant facility records, and conducted interviews with parties knowledgable of the circustances surrounding the allegation and the operation of the facility. Through interviews and record review, LPA Colvin confirmed that on 4/24/22, R1 had fallen in their private room. LPA Colvin additionally confirmed that 911 was contacted by non-staff members to assist R1, as R1's pendant calls and other phone calls to the facility (to assist R1) were not being answered. Interviews additionally revealed that others called the facility on behalf of R1 at 6:16pm, but was unable to get a hold of anyone at the facility. Substantiated A copy of a fax cover sheet from the facility to R1's doctor confirms that family members of R1 called 911 to assist R1 from an unwitnessed fall. Interviews and facility records confirm that one of the staff members (S1) who generally has possession of one of the two "after-hours" phone lines was on a FaceTime call with another resident's doctor (and therefore unable to answer the telephone) during the time that 911 responded to the facility to assist R1. Staff are unclear on why the other after-hours phone was not answered. The facility's pendant alert call records show that on 4/24/22 at 5:41pm, R1 pressed their pendant for assistance. The same records show that a staff member (S2) acknowledge the call over one hour later, but the call was not cleared for over 11 hours. Facility staff charting notes that 911 responded to the facility at approximately 6:35pm, which is almost one hour after R1 initially pressed their call button, and approximately one half hour before the pendant alert logs show that staff even acknowledged the alert on their devices. When LPA Colvin interviewed the Assistant Executive Director (AED) requesting their opinion on how long is an appropriate amount of time for a resident to wait for assistance, the AED declined to provide a specific time frame. LPA Colvin asked the same question of another staff in a leadership position, and was answered with "5 to 8 minutes" or to have staff at least "pop in to see what is needed if they know they are going to take longer". In either case, it is clear that this was not followed as R1 pressed their pendant for assistance at 5:41pm, and was not provided with assistance until 911 responded nearly an hour after R1 initially requested staff help through pressing their call button. Therefore, based on interviews and record review, the allegation "Staff did not assist resident from fall in a timely manner." is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Assistant Executive Director Lorena Vivar during the exit interview.the state’s words, verbatim · CDSS document, Apr 29, 2022 · control 18-AS-20220426111939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 2, 2022

Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...to meet their needs. This requirement was not met by: Based on record review and interviews, the Licensee did not comply with the above allegation with one resident. On 4/24/22, R1 pressed their call button for help at 5:41pm, but was not provided assistance by staff. 911 respond at 6:35pm. This was an immediate safety risk to R1.the state’s words, verbatim · CDSS document, Apr 29, 2022

Plan of correction: Licensee agrees to review staffing needs for facility based on call response times for residents. Licensee to consider contracting with additional staffing agencies to ensure reliable coverage for facility. Licensee may self-certify to LPA Colvin what the results of their review is and what their plan for staffing moving forward is to essure resident's calls are being responded to in a timely manner. Self- Certtification to be submitted to LPA Colvin by Plan of Correction date of 5/2/22.

Allegation investigated: Facility staff did not provide timely medical treatment for resident

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA identified herself and discussed the complaint findings with Assistant Executive Director, Lorena Vivar and Executive Director, Jolene Farish. During the investigation, LPA briefly toured the facility, requested records and interviewed staff, residents, and outside sources. It was alleged facility staff did not provide timely medical treatment for Resident #1 (R1). R1’s Physician’s Report reflected R1 is ambulatory, able to walk without assistance, and able to follow instructions. Facility’s Level of Care Assistance documentation dated 05/19/21 reflected R1 requires assistance with bathing; dressing; medication; and ordering supplies for toileting; requires reminders with grooming; and eating. However, R1 is independent with transfer ability; and transport/escort. It was reported there were two separate incidents involving R1, and the facility did not seek timely medical treatment for either incident. The first incident occurred on 03/27/21. R1 was found on the ground of the patio with injuries at approximately 1:30pm. Facility’s documentation reflected R1 was assessed and 911 was activated. R1 was sent to the hospital at approximately 1:42pm, which was timely medical treatment. Continued on an LIC 9099C. Substantiated The second incident occurred on 07/14/21. Facility’s documentation indicated on 07/14/21 at approximately 5:00pm, R1 was observed by staff to be very restless, agitated, and unable to redirect. R1 was also observed by staff leaning towards their right side and unstable while walking; R1 required staff assistance while walking to prevent R1 from falling. On 07/15/21 at 12:44pm the facility contacted R1’s Psychiatrist for direction. The Psychiatrist’s nurse responded at 1:03pm, and recommended contacting R1’s Primary Care Physician (PCP). The facility did not contact the PCP until instructed by the Psychiatrist’s nurse. On 07/15/21, the facility contacted the PCP at approximately 1:03pm but did not receive a return call until 1:48pm. The PCP advised staff to send R1 to the hospital for evaluation. Staff interviews revealed R1’s vitals were taken and there was no urgency to send R1 out for evaluation. Facility’s documentation indicated R1 required medical attention on 07/14/21 when R1 was observed leaning towards the right side and unable to walk unassisted. Facility’s documentation indicated on 07/15/21 at approximately 1:51pm, facility staff activated 911. R1 did not receive medical attention until 07/15/21 at 2:20pm, which was arrival to the hospital. On 07/15/21, R1 was transported to the hospital via 911, not non-emergency ambulance services, which demonstrated immediate medical attention was needed. At the hospital, R1 was diagnosed with a medical condition and prescribed a new medication. Emergency Department Physician Notes reflected the chief complaint was for right sided weakness and stated, "facility thinks it was around 5:00pm on 07/14/21, does have a facial droop". It also stated R1 had “been leaning to the right when sitting, staff were concerned for mild right facial droop. The symptoms are close to 24 hours since onset.” Facility staff were aware R1 had right sided weakness and unable to walk without assistance but did not send R1 out for evaluation. R1 didn’t receive timely medical treatment until approximately 21 hours after observation of weakness and leaning to their right side, along with facial droop. Based on documentation and interviews, which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The facility did not seek timely medical treatment for R1. R1 was not evaluated until approximately 21 hours after observation of weakness and leaning to their right side. California code of Regulations, Title 22, Division 6 & Chapter 8, is being cited on the attached LIC 9099D. [See LIC 811 Confidential Names List to identify Resident #1]. An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents. Staff indicated they are busy providing care to the residents and are unable to answer the phone each time it rings. However, staff are required to check the voicemail's by the end of their shift and return all voicemail's. Further outside source interviews revealed in 2021, there were some issues with not receiving returned calls, but it was unknown if it was due to lack of staffing. Additional interviews revealed once the facility was aware of the issue, it was rectified, and the facility provided the facility’s nurse’s contact information to families/friends as a resource. A review of the facility’s staffing schedule for July 2021 revealed the facility had sufficient staffing to answer the phones. The facility’s staffing schedule reflected caregivers and medication technicians on all shifts. Staff interviews revealed in addition to the schedule, the facility also had an LVN for the AM/PM shift, lunch, and throughout the NOC shift; and the memory care unit Director who is also an LVN worked 5 days a week and was on call 24/7. Based on interviews, which were conducted and record review, we have found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred and is therefore determined to be unsubstantiated. An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Administrator via electronic mail. An electronic read receipt confirmation was requested to be sent by the Administrator upon receipt of the documents.the state’s words, verbatim · CDSS document, Mar 22, 2022 · control 08-AS-20210715152600

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 23, 2022

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by: Based on interviews, the licensee did not contact 911 or obtain emergency medical services for 1 out of 160 residents. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: The Executive Director agreed to ensure that all staff receive training, provided by an outside vendor, pertaining to contacting emergency medical services. The Executive Director agreed to provide the date of scheduled training to Community Care Licensing (CCL) by POC due date and provide proof of training to CCL upon completion, which will be scheduled to occur within two weeks.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Liliana Silveira and Licensing Program Manager (LPM) Denise Powell conducted a case management visit at the facility to obtain additional information on a self-reported death report of Resident 1 (R1). LPA and LPM met with Executive Director Jolene Farish and explained the reason for the visit. LPA and LPM conducted a health and safety check of the residents, reviewed R1's file and obtained copies of resident records. Further review is needed at this time. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director Jolene Farish, to whom a copy of this report and the LIC9058 Licensee/Appeal Rights were provided via E-mail. An electronic read receipt verifies receipt of these documents.the state’s words, verbatim · CDSS document, Sep 29, 2021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Liliana Silveira and Licensing Program Manager (LPM) Denise Powell conducted an unannounced case management visit. LPA and LPM identified themselves and stated the purpose of the visit to Executive Director Jolene Farish. The facility self-reported an incident regarding Resident 1 (R1) to Community Care Licensing on 09/21/21. The facility reported that on 09/17/21, R1 left the facility (AWOL) unattended and was returned to the facility by staff. Staff were able to redirect the resident back to the community. On today’s date, LPA and LPM toured the facility and conducted a health and safety check. LPA and LPM briefly spoke to staff, interviewed the Executive Director and requested copies of facility records. No health or safety risks were observed and no deficiencies were cited at this time. An exit interview was conducted with Jolene Farish, to whom a copy of this report and the LIC9058 Licensee/Appeal Rights were provided via E-mail. An electronic read receipt verifies receipt of these documents.the state’s words, verbatim · CDSS document, Sep 29, 2021