A1 Del Monte Stockton

Allegation investigated: Facility staff are not cleaning residents’ room(s). Facility staff stole residents’ personal property. Facility staff are not ensuring that residents have toilet paper in their rooms. Staff are denying food to residents.

On 11-3-23 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegations noted above. LPA met with Assistant Executive Director (AED) Lucky Kaur and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPAs visit and purpose. During this investigation, LPA conducted interviews with 6 staff members and 4 residents in care. Additionally, LPA reviewed facility file documentation including housekeeping task schedule, behavior progress notes, physician reports , facility menu, inventory sheets, and admission agreements. LPA also conducted a facility observation on 9-12-23 and 10-17-23. Allegation: Facility staff are not cleaning residents’ rooms. LPA conducted interviews, record reviews, and facility observations as stated above. LPA also conducted facility observations as noted above. Based on interviews, it was revealed that housekeeping staff are observed to be regularly attending to residents’ rooms as scheduled and perform duties as required with the exception of residents who may decline services for various reasons. Unsubstantiated LPA’s review of housekeeping tasks schedule revealed rooms are scheduled to be clean on specific days which includes deep cleaning in various rooms as necessary. LPA’s observation revealed a presence of adequate housekeeping staff performing cleaning duties. LPA also observed various resident rooms to be adequately cleaned with no foul odors or stains on walls and floors within resident rooms and throughout facility. As a result, there is not a preponderance of evidence to conclude facility staff are not cleaning residents’ rooms. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Facility staff stole residents’ personal property. LPA conducted interviews and record reviews as stated above. Based on interviews, it was revealed that residents are presented with the option to inventory items upon admission and thereafter. Additionally, interviews did not reveal any corroborated statements of facility staff stealing residents’ personal property. Interviews conducted with residents further revealed all items were accounted for within resident rooms. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Facility staff are not ensuring that residents have toilet paper in their rooms. LPA conducted interviews, record reviews, and facility observations as stated above. Based on interviews, it was revealed that toilet paper and other related necessary personal supplies are provided to residents regularly and per request. LPA facility observations further revealed toilet paper on holders and additional supply of toilet paper on countertops in various resident bathrooms. LPA’s observation of housekeeping supplies closet revealed an adequate amount of toilet paper on hand. As a result, there is not a preponderance of evidence to conclude facility staff are not ensuring residents have toilet paper in their rooms, therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are denying food to residents. LPA conducted interviews, record review, and facility observations as stated above. Based on interviews conducted, there were no corroborated statements of facility staff denying food to residents. Observations by LPA revealed adequate amounts of food supply in kitchen for the resident current census. Observations also revealed residents receiving food items which matched the menu items for the given days. Interviews conducted revealed that the facility makes available and provides additional food items to residents upon request prior to and after scheduled mealtimes. Furthermore, interviews did not reveal corroborated statements of residents being denied food for any reason. As a result, there is not a preponderance of evidence to conclude staff are denying food to residents, therefore, this allegation is UNSUBSTANTIATED An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. Appeal rights provided.the state’s words, verbatim · CDSS document, Nov 3, 2023 · control 27-AS-20230908081138

Allegation investigated: Facility has bed bugs

On 9-6-23 at 10:16 am, Licensing Program Analyst (LPAs) Michael Bilger and Arvin Villanueva arrived at facility unannounced to open and continue investigating the complaint allegation noted above. A pre-investigation for this allegation was also conducted on 8-31-23. LPAs met with Assistant Executive Director Lucky Kaur and explained the purpose of the visit. During this investigation, LPAs conducted interviews with three staff and an additional witness. LPAs also conducted a facility observation and reviewed pest control service records as part of this investigation. Based on interviews, it was revealed that a presence of bed bugs existed in room 227 between the period of 8-24-23 and 8-30-23. Interviews, record reviews, and facility observation revealed residents residing in room 227 were moved to an alternative room for safety reasons, and clothing as well as other items were cleaned accordingly; incident was reported by facility to licensing department on 8-30-23. Additionally, interviews and record reviews revealed that bed bug treatment was initiated on 8-30-23 after two pest control companies were notified. Interviews also revealed room 229 was treated as a precaution. {Cont. on 9099C} Substantiated A search conducted by LPAs revealed at least 10 pest control companies are in the general vicinity of the facility’s location and not contacted based on interviews conducted and records reviewed. Based on this investigation, there is a preponderance of evidence to conclude that bed bugs existed within the facility between the period of 8-24-23 and 8-30-23. Additionally, it was determined that the licensee did not ensure a due diligence process of attempting to treat bed bugs in a timely manner. Pest control records reviewed did not indicate a preemptive measure to specifically target bed bug prevention. As a result, this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within a 12-month period. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. Appeal rights provided.the state’s words, verbatim · CDSS document, Sep 6, 2023 · control 27-AS-20230901094747

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 20, 2023

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and record reviews, the facility maintained a presence of bed bugs between 8-24-23 and 8-30-23 with treatment for bed bugs initiated on 8-30-23. This posed a potential health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 6, 2023

Plan of correction: Licensee designee has provided pest control service records to LPA indicating completed service. Licensee shall provide an updated plan of procedures for processes involving treatment of bed bugs and other pests in the event of reoccurrence. Update shall include evidence of a routine pest control service specifically targeting bed bugs in addition to general service. Plan to be submitted to LPA by POC due date.

Allegation investigated: Facility illegally evicted resident

On 8-21-23 at 10:25am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to open and investigate the complaint allegation noted above. LPAs met with Assistant Executive Director Lucky Kaur and explained the purpose of the visit. During this investigation LPAs interviewed Administrator and resident1 (R1). LPAs also reviewed admission agreement for R1, Physician's report for R1, functional capablities assessment for R1, and discharge paperwork for R1. Based on interviews and record reviews, it was determined that R1 was transported to local emergency department on 8-14-23 after R1 had a discussion with facility staff and signed a notice to discharge. It was further determined that facility accepted resident back to residency on 8-18-23 at approximately 5:30pm and R1 is now currently residing in R1's room. As a result, the preponderance of evidence standard is not met, and this allegation is UNFOUNDED. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. Unfoundedthe state’s words, verbatim · CDSS document, Aug 21, 2023 · control 27-AS-20230816112547

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not address change in residents condition in a timely manner Staff are not properly cleaning facility restrooms

On 8-15-23 at 11:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to deliver findings for the complaint allegations noted above. LPAs met with Director of Nursing Lucky Kaur and explained the purpose of the visit. During this investigation, LPA interviewed 8 staff members and 3 residents. LPA also conducted a facility observation on 7-12-23 and 8-4-23. LPA also reviewed facility file documentation including staffing schedule and actual hours worked for July 2023, physician’s report for resident1 (R1), needs and service plan for R1, housekeeping task schedule, and relevant incident reports. Allegation #1: Staff did not address change in resident’s condition in a timely manner. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that R1 experience a sudden change in condition while on an outing outside of facility grounds. Interviews and record reviews further revealed that R1 was brought back by a responsible person for R1, and facility staff member not on duty was notified by responsible person via phone. {Cont. on 9099C} Unsubstantiated This facility staff member then notified medication technician on duty prior to R1’s return who proceeded to address the change of condition upon R1’s return. Interviews further revealed that R1’s condition was addressed which included attempts to get R1 to respond and check vital signs. Additionally, it was revealed that 9-1-1 was notified within an adequate time frame, and R1 returned to facility without additional medical complications. Additionally, investigation did not reveal any corroborated statements of untimely medical attention for R1 or other residents during this approximate time period. As a result of this investigation, there is not a preponderance of evidence to concluded that facility did not act in a timely manner regarding resident’s change in condition. Therefore, this allegation is UNSUBSTANTIATED. Allegation #2: Staff are not properly cleaning facility restrooms. LPA conducted facility observations on 7-12-23 and 8-4-23. LPA also conducted interviews as noted above and reviewed housekeeping task schedule. Based on observations conducted, interviews, and record reviews, it was revealed that facility restrooms are cleaned regularly and monitored to mitigate unsanitary conditions. Observations did not reveal unsanitary conditions throughout facility restrooms. Interviews did not reveal any corroborated statements of unsanitary or lack of housekeeping attention to facility restrooms. As a result, there is not a preponderance of evidence to conclude that facility staff are not properly cleaning facility restrooms, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 27-AS-20230707094713

Allegation investigated: Facility failed to prevent the spread of head lice

On 8-15-23 at 10:28am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to deliver findings for the complaint allegation noted above. LPAs met with Director of Nursing Lucky Kaur and explained the purpose of the visit. During this investigation, LPA interviewed 8 staff members and 3 residents. LPA also conducted a facility observation on 7-12-23 and 8-4-23. Additionally, LPA reviewed facility file documentation including individualized service plan (ISP) and physician’s report for resident1 (R1). Based on interviews and record reviews, it was determined that R1 resided at facility until approximately end of May 2023 and discharged to another licensed facility and received services noted in the ISP. Interviews, record reviews and observations conducted further revealed during this investigation that there were no corroborated statements or evidence to prove head lice existed in facility during or after R1’s residency. As a result, the preponderance of evidenced standard is not met, and this allegation is UNSUBSTANTIATED. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky. Appeal rights provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 15, 2023 · control 27-AS-20230703083122

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 8-15-23 at 2:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding facility's current volume of 9-1-1 calls. LPAs met with Assistant Executive Director (AED) Lucky Kaur and explained the purpose of the visit. During today's case management, LPAs discussed the volume of 9-1-1 calls which revealed a consistent increase from June to August of 2023. LPAs offered resources for alternative methods of meeting resident emergency needs as warranted. AED stated some emergency calls are initiated by residents in care for various purposes. Additional technical advise was offered to AED to involved facility's nurse practitioner and Physician to evaluate reasons for 9-1-1 calls in attempts to determine if non-emergency methods may be used to meet resident needs. At this time AED has agreed to the following: (1) Accepting of resources for non-emergency needs, (2) Communicate with nurse practitioner and physician for evaluating resident emergency needs, (3) Continue to call 9-1-1 for emergencies warranting such intervention and per regulatory requirements. No citations issued today as a result of this case management. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky.the state’s words, verbatim · CDSS document, Aug 15, 2023

Type of visit: Case Management - Health Checks

On 8-15-23 at 12:15pm, Licensing Program Analysts ( LPA) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA met with Assistant Executive Director Lucky Kaur and explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 147. Facility has 77 bedrooms and 77 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. There were 10 caregivers and 3 med techs on duty for resident care. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. The facility has an approved infection control plan in place. The facility has a designated infection control lead. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Signal system in place and functional. Memory care door was tested and determined to be functioning properly. Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 75*F.upstairs and downstairs. LPA toured kitchen and observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 5/31/23. {Cont. on 809C} Five resident charts reviewed and contained all required documentation including updated needs and service plans and physician's reports. Staffing schedule reflects Administrator on duty at least 40 hours per week. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Assistant Executive Director Lucky Kaur.the state’s words, verbatim · CDSS document, Aug 15, 2023

Type of visit: Case Management - Incident

On 8-4-23 at 10:05am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding various incidents reported between May and July of 2023. Incidents reported were of resident to resident altercations. Incidents were reported to licensing department, ombudsman and local law enforcement per regulatory requirements. Based on record review it was determined that incidents occurred between afternoon and night shifts. Resident1 (R1) appeared in 3 of 9 incident reports reviewed today as the aggressor in the resident to resident altercations. R1 as since discharged after these incidents. LPAs discussed with facility's director of nursing (S1) and Administrator various resources available and the need for further staff training on mental health interventions including the de-escalation of behaviors which may contribute to resident to resident altercations. At this time, Licensee and director of nursing have agreed to the following: (1) A designated facility staff member will conduct resident rounds across shifts and report any potential changes in physical or mental health well being. Licensee will ensure documentation of rounds to be conducted. (2) Licensee or designee will identify residents with history of behavioral challenges and provide additional resources in such areas including but not limited to: Crisis intervention, drug and alcohol abuse, and general mental wealth well-being. (3) Licensee or designee will conducted bi-weekly meetings with staff to ensure proper identifying and interventions for residents with mental health needs; documentation of meetings to be maintained. (4) Licensee or designee will ensure additional staff training on various mental health topics including but not limited to: De-escalation of behaviors and peer conflicts, identifying triggers for various behaviors, safe intervention techniques regarding aggression and anger. (5) Licensee or designee will ensure additional activities for residents in care. Licensee made aware of intention for follow up on future visits. As a result of today's case management, no citations are issued today. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky.the state’s words, verbatim · CDSS document, Aug 4, 2023

Type of visit: Case Management - Other

On 7-12-23 at 12:05pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding a relocation of memory care door. LPAs met with business office manager Eddie Itliong and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPAs visit. On 6-20-23 LPA received LIC 200 and updated facility sketch from licensee indicating plans for memory care door relocation. At that time, Licensee was to not complete construction prior to clarification for the need to update fire clearance. Upon entry, LPAs observed memory care door was moved forward from previous spot allowing for extra rooms accessible to assisted living residents. LPAs interviewed Staff1 (S1) and Administrator. Based on interview and observation, it was determined that door construction was completed prior to a fire department consultation as well as an updated fire clearance. Moreover, it was determined that a building permit was not obtained prior to construction. Additionally, based on observation, the memory care door alarm was not functioning due to a malfunctioning bar door when tested by LPAs. During LPA's visit today, maintenance immediately repaired door to appropriate functional status as observed and tested by LPAs. Furthermore, it was determined based on interview and record review, that licensee did not ensure a plan of provision of safety during time of this construction to ensure adherence of memory care resident rights and overall safety. Based on today's case management, deficiencies are cited under Title 22, Division 6. Immediate civil penalties in the amounts of $500 were issued in addition to citations due to fire safety hazards and fire clearance. An exit interview was held with Eddie Itliong and a copy of this report was left with Eddie. Appeal Rights provided.the state’s words, verbatim · CDSS document, Jul 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jul 13, 2023

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observation and interview, Memory care door alarm was not functioning in that bar door was unable to move forward, which poses an immediate health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: Door was repaired during LPAs visit and LPAs observed alarm to be functioning properly. Licensee will read regulation 87203 and submit a signed declaration of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a) · Plan of correction due date: Jul 13, 2023

Fire Clearance. (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement was not met as evidenced by: Based on interview and record review, Licensee initiated a relocation of memory care door without securing an updated fire clearance. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: Licensee will update LIC 200 and submit to LPA by POC due date as process for updating fire clearance. Licensee will read regulation 87202 (a) and submit a signed declaration of understanding to LPA by POC due date. *Civil Penalty assessed for Fire Safety*

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(a) · Plan of correction due date: Jul 13, 2023

Alterations to existing buildings and new facilities. (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by: Based on interview and record review, licensee did not secure a buidling permit for an alteration regarding memory door relocation. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: Licensee will submit proof of application for building permit to LPA by POC due date. Licensee will read regulation 87305(a) and submit a signed declaration of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(h)(5) · Plan of correction due date: Jul 13, 2023

Administrator Qualifications-Duties. (h) The administrator shall have the responsibility to:(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure a provision of safety for residents in that a plan to ensure resident rights and safety was not submitted in regards to a building alteration. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: Licensee will read regulation 87405(h)(5) and submit a signed declaration of understanding to LPA by POC due date.

Type of visit: Required - 1 Year

On 6-20-23 at 10:04am, Licensing Program Analyst (LPAs) Michael Bilger and Arvin Villanueva arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Anuradha Saini and explained the purpose of the visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential care facility for the elderly with a current census of 144. Facility has 89 bedrooms and 89 bathrooms for resident use. Facility has a formal dining room LPA also conducted the inspection using the CARE tool. Facility currently provides care for 41 ambulatory residents, 103 non-ambulatory residents, 7 of these residents are receiving hospice care, and 0 bedridden. Water temperature reads 105*F to 120*F in the bathroom and room temperature reads 71*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 5-31-23. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were secured during today's visit. Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. During this inspection 8 resident files and 11 staffing files were reviewed for regulatory compliance. All staff noted on LIC 500 contained criminal background clearances. LPA completed 5 resident interviews and 5 staff interviews. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. {Cont. on 809C} Facility’s liability insurance is current and update to date per regulatory requirements. Facility does not contain any bodies of water. LPA observed personal rights, resident council and complaint information posted. Facility has appropriate internet access available for resident use. LPA observed facility’s activity calendar and sufficient equipment and supplies to meet activity program needs of residents in care. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills. LPA requested an updated copy of LIC 308 and LIC 500. Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini. Appeal rights provided.the state’s words, verbatim · CDSS document, Jun 20, 2023

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

Allegation investigated: Staff abandoned resident at hospital

On 6-8-23 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Director of Nursing Lucky Kaur and explained the purpose of the visit. LPA reviewed physician’s report for resident1 (R1), incident report dated 5-30-23, functional capability assessment for R1, and discharge paperwork for R1. LPA also interviewed S1as part of this investigation. Based on interviews and record review it was determined that R1 was sent to the hospital by facility staff on 5-26-23. It was further determined through record review that R1 was accepted back to facility on 6-1-23 Additional record review revealed R1discharged self from facility on 6-2-23 at 3:20pm. As a result, of this investigation, there is a not a preponderance of evidence to conclude that R1 was abandoned by facility staff after being sent to the hospital. Therefore, this allegation is UNFOUNDED. An exit interview was conducted with Lucky Kaur and a copy of this report was provided to Lucky Unfoundedthe state’s words, verbatim · CDSS document, Jun 8, 2023 · control 27-AS-20230531115408

Allegation investigated: Staff did not safeguard resident's personal belongings Staff did not provide resident with an extension cord Staff are cutting off resident's phone calls Staff are not able to communicate and understand resident's needs Staff are not meeting resident's needs

On 5-17-23 at 12:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with interim Executive Director Mark Baddas and explained the purpose of the visit. During this investigation, LPA interviewed 4 residents and 8 staff members. LPA also reviewed facility file documentation including dietary notes for Resident1 (R1), care notes for R1, facility menu, inventory sheet for R1, medication logs and orders for R1, individualized service plan for R1, and shower scheduled and notes for R1. Additionally, LPA conducted facility observations on 4-27-23, 5-10-23, and 5-17-23 as part of this investigation. Allegation: Staff did not safeguard resident’s personal belongings. LPA reviewed inventory sheet and conducted interviews as stated above. Based on record review and interviews, it was determined that R1 placed music CDs on the inventory list upon admission on 4-12-23. It was further determined that a set of writing pens were not noted on the inventory sheet, however, observed by LPA during an observation visit to R1’s room conducted on 4-27-23. {Cont. on LIC 9099C} Unsubstantiated Inventory sheet further indicates music CDs were safeguarded and returned to R1 after a hospital stay on 4-14-23. Observation and interviews did not reveal decisively whether music CDs contained scratches or other form of damage to indicate ill safekeeping occurred. Interviews conducted did not reveal staff mishandled items of R1. Additional interviews did not reveal corroborated statements of staff members not practicing the safeguarding of residents’ personal belongings. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation: Staff did not provide resident with an extension cord. LPA conducted facility observations and interviews as stated above. Based on interviews conducted, it was determined that an extension cord was present in the room in addition to other wall sockets for resident use. Additionally based on interviews it was revealed that facility staff was asked by R1 for an additional extension cord and informed R1 of other options available including a multi-plug outlet. An observation of R1s room determined 5 outlets are available for use. Based on interviews and observations, there is not a preponderance of evidence to conclude an extension cord, or alternatives were not offered and available for R1. Therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are cutting off resident phone calls. LPA conducted interviews and facility observations as stated above. During facility observation, LPA attempted to utilize phone service in R1’s room and additional resident rooms. Observations revealed staff answered phone within 2-3 rings and under one minute without interrupting conversation. Interviews conducted did not reveal corroborated statements revealing staff interrupting or terminating resident private phone calls and conversations. As a result, there is not a preponderance of evidence to conclude staff are cutting off resident phone calls, therefore, this allegation is UNSUBSTANTIATED. Allegation: Staff are not able to communicate and understand resident’s needs. LPA conducted interviews as stated above and reviewed facility file documentation as stated above. Allegation refers to communication regarding dietary needs for R1. LPA interviewed dietary staff including on-duty cooks. Interviews revealed staff were able to effectively verbalize and follow instructions regarding dietary needs and instructions for residents in care. Additionally, staff interviewed were able to answer interview questions appropriately. Additional interviews conducted did not reveal corroborated statements of staff unable to communicate and understand resident needs. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. {Cont. on 9099C} Allegation: Staff are not meeting resident’s needs. LPA conducted interviews and facility observations as stated above. LPA also reviewed physician’s report for R1, individualized service plan for R1, and medication log sheets and physician’s orders for R1, and care notes for R1. Allegation refers to medication orders not followed as referenced in a previous complaint #27-AS-20230419101259. Based on records reviewed, it was revealed that facility attempted to address medication concerns with R1 on 4-13-23, 4-20-23, and 4-23-23, including a physician’s visit to facility on 4-21-23 to clarify and finalize orders. Additionally, care notes reviewed revealed staff was in communication with pharmacy for R1’s medication needs since admission date of 4-12-23 to clarify and receive any new medication. Based on care notes, a hospital visit was arranged on 4-14-23 to ensure resident receive appropriate medication regimen. It was further revealed through interviews and record reviews that facility was following medication orders as written and received during R1’s admission. Additional interviews conducted did not reveal corroborated statements of facility staff unable to meet medication and other resident needs at this time. As a result, there is not a preponderance of evidence to conclude facility staff did not meet the needs of R1 or other residents in care, therefore this allegation is UNSUBSTANTIATED. An exit interivew was conducted with Mark Baddas and a copy of the report was provided to Mark. Appeal rights provided.the state’s words, verbatim · CDSS document, May 17, 2023 · control 27-AS-20230427082454

Allegation investigated: Staff do not ensure resident is accorded privacy during phone calls Staff does not ensure resident has a comfortable mattress Staff do not ensure resident's dietary restrictions are followed

On 5-17-23 at 11:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegations noted above. LPA met with interim Executive Director Mark Baddas and explained the purpose of the visit. During this investigation, LPA conducted interviews with 4 residents and 7 staff members. LPA also conducted facility observations on 4-27-23 and 5-10-23. Additionally, LPA reviewed facility file documentation including physician’s report for resident1 (R1), individualized service plan for R1, facility menu, receipt of items purchased, care notes, and dietary notes. Allegation #1: Staff do not ensure resident is accorded privacy during phone calls. LPA conducted facility observations and interviews as stated above. Based on observations, it was revealed that residents in care have phones installed which are utilized to make private calls and direct calls to care staff for assistance. It was further revealed through interviews that care staff are not able to intercept or manipulate phone calls and associated conversations based on the current system used. {Cont. on LIC 9099C} Unsubstantiated Additional interviews conducted did not reveal corroborated statements indicating staff are purposely listen in on or disrupting private calls. As result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation #2: Staff does not ensure resident has a comfortable mattress. LPA conducted interviews and facility observations as stated above. LPA also reviewed a receipt of items purchased submitted by Administrator. Based on interviews and record reviews, it was revealed that resident1 (R1) was admitted to facility on 4-12-23, prior to admission, R1’s previous skilled nursing facility ordered a mattress which was delivered, yet not utilized due to R1’s request. Prior to admission, based on interviews, it was further revealed that facility staff attempted to process a physician’s order for a gel mattress which was on back order. Receipt of purchased items indicated facility purchased a 3-inch mattress topper to be place on R1’s current mattress to aid in R1’s comfort. LPA observed ordered mattress at facility awaiting pick up by delivery company. As result, it is revealed that facility made attempts to assist R1 with comfort in relation to mattress. The preponderance of evidence standard is not met to indicate facility did not ensure a comfortable mattress; therefore, this allegation is UNSUBSTANTIATED. Allegation #3: Staff do not ensure resident’s dietary restrictions are followed. Allegation states R1 was given onions and garlic in meals served on 4-15-23 and 4-16-23 as well as oranges and bananas. LPA reviewed dietary notes, physician’s report, individualized service plan, and menu as stated above. LPA also conducted interviews as stated above. Based on records reviewed, it was revealed that onions, garlic, and squash were among the food items R1 was not to receive. It was further revealed that dietary had in possession dietary notes indicating restriction for R1. Based on interviews conducted it was revealed that dietary staff are aware of restrictions and utilize a procedure to ensure residents in care receive food items per requests and established restrictions which includes resident names labeled on trays to ensure accurate delivery of meals. A review of facility’s menu did not indicate food items containing onions or garlic were served on the dates specified above. Interviews conducted did not indicate corroborated statements of staff not following residents’ dietary restrictions or requests. As a result, there is not a preponderance of evidence to conclude facility staff is not making efforts to ensure R1’s or other resident dietary restrictions are followed. Therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Mark Baddas and a copy of this report was provided to Mark. Appeal rights provided. An exit interview was conducted with Mark Baddas and a copy of this report was provided to Markthe state’s words, verbatim · CDSS document, May 17, 2023 · control 27-AS-20230424134903

Allegation investigated: Staff does not ensure resident is administered medications in a timely manner. Staff is providing unprescribed medications to resident. Staff does not attend to resident when requested. Staff does not ensure resident's showering needs are met. Staff does not ensure resident's room and bathroom is cleaned. Staff does not answer facility phone.

On 5-17-23 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss complaint findings for the allegations noted above. LPA met with interim executive director Mark Baddas and explained the purpose of the visit. During this investigation, LPA interviewed 4 residents and 5 staff. LPA also conducted facility observations on 4-27-23 and 5-10-23. Additionally, LPA reviewed facility file documentation including shower schedule, care notes, individualized service plan, housekeeping schedule, physician’s report, medication lists and orders, housekeeping sign off sheets, and medication logs. Allegation #1: Staff does not ensure resident is administered medications in a timely manner. LPA conducted interviews as stated above and reviewed medication orders and log sheets for resident1 (R1). LPA compared medication orders on file with medication log sheets. LPA also reviewed physician’s report for R1. Facility records medication given to residents in care via electronic format. {Cont. on 9099C} Unsubstantiated Based on record reviews and interviews, it was revealed that facility staff assisted R1 with medications within the appropriate time frames per current physician orders and orders received upon R1’s admission on 4-12-23. As a result, there is a not a preponderance of evidence to conclude medications are not administered in a timely manner, therefore, this allegation is UNSUBSTANTIATED. Allegation #2: Staff is providing unprescribed medications to resident. LPA conducted interviews as stated above and reviewed medication orders and log sheets for resident1 (R1). LPA compared medication orders on file with medication log sheets. LPA also reviewed physician’s report for R1. Facility records medication given to residents in care via electronic format. Based on interviews and record reviews, it was revealed that medication orders for R1 matched the medication log sheets used to determine what medications are given and when. Medications which were discontinued were indicated on the medication log sheets and discontinued accordingly per physician’s orders. As a result, there is a not a preponderance of evidence to conclude resident was provided unprescribed medications, therefore, this allegation is UNSUBSTANTIATED. Allegation #3: Staff does not attend to resident when requested. LPA conducted interviews and care notes as stated above. LPA also conducted facility observations as stated above. Based on interviews, care notes and observations, it was revealed that resident needs were attended to within an appropriate time frame necessary meet specific needs of residents in care. Interviews conducted did not reveal any corroborated statements to indicate resident needs are not attended to when requested. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation #4: Staff does not ensure resident’s showering needs are met. LPA reviewed shower schedule associated care notes, and individualized service plan as stated above. LPA also conducted interviews as stated above. Based on interviews and record reviews, it was revealed that showers were given per schedule with exception of one date which indicated R1 exercising right to refuse shower assistance. Shower schedule revealed showers for R1 are to be completed at least 2 times per week. Interviews conducted did not reveal corroborated statements of showers not received as scheduled. As a result, there is not a preponderance of evidence to conclude residents’ showering needs are not met, therefore this allegation is UNSUBSTANTIATED. {Cont. on 9099C} Allegation #5: Staff does not ensure resident’s room and bathroom is cleaned. LPA conducted facility observations and reviewed housekeeping schedule and associated sign off sheets as stated above. Additionally, LPA conducted interviews as stated above. Based on observations conducted, it was revealed that residents’ rooms and bathrooms were clean and sanitary and did not contain foul odors to further indicate uncleanliness. Housekeeping schedule revealed established dates and days of the week for cleaning of various rooms in specific sections of facility. Completion of tasks were revealed based on review of housekeeping sign off sheets. Interviews conducted did not reveal corroborated statements of rooms and bathrooms not cleaned appropriately and per housekeeping schedule. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation #6: Staff does not answer facility phone. LPA conducted facility observations as stated above. LPA also conducted interviews as stated above. Based on observations, it was revealed that facility phones located in various resident rooms were answered within 2-3 rings and under one minute by care staff on duty. It was further revealed that phone call signified location of room calling for assistance. Interviews conducted did not reveal corroborated statements of staff not answering facility phone when calling for assistance. As a result, there is not a preponderance of evidence to conclude staff does not answer facility phone, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Mark Baddass and a copy of this report was provided to Mark. Appeal rights provided.the state’s words, verbatim · CDSS document, May 17, 2023 · control 27-AS-20230419101259

Type of visit: Case Management - Incident

On 5-17-23 at 2:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a complaint investigation regarding incident reports received on 3-23-23, 4-18-22, 4-22-23, and 5-10-23. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed incident reports with Administrator and conducted interview with Administrator. LPA also reviewed needs and service plans for Resident1 (R1), R2, R3, R4, and R5. Incident #1: LPA reviewed incident report dated 3-23-23 which states R1 and R2 were witnessed by facility staff to be pushing each other while in the dining room, including R1 pulling R2’s hair. Based on interview and record review, facility staff intervened and separated residents. A light bruise was discovered around R1’s eye. Facility staff attempted emergency personnel contact and R1 refused. Record review further indicates local law enforcement was called and event was reported on a SOC 341 form and sent to licensing department and ombudsman within regulatory time frames. Interviews and record reviews revealed interventions are in place to include increased supervision and monitoring of residents’ behaviors. Interventions are noted on an updated needs and service plan for R1 and R2. Incident #2: LPA reviewed incident report dated 4-18-23 which states R4 was engaging in disruptive type behavior including yelling at other residents, staff, and visitors at random. Based on interview and record review, it was revealed that staff intervened appropriately to redirect R4. Updates were observed on needs and service plan for R4 to reflect new interventions put in place including increased supervision and redirection techniques. Interviews further revealed Administrator is in contact with R4’s responsible person for additional options. Incident was reported per regulatory requirements. Incident #3: LPA reviewed incident report dated 4-22-23 which states R4 informed facility staff that R3 hit him in the back of the head while in the dining room. Based on interviews and record reviews, an internal investigation was conducted which did not reveal any witnessing of said event, however, did reveal a witness to R4 scratching R3’s arm. {Cont. on 809C} As a result, R3’s arm was treated by facility staff with standard first aid. Incident was reported per regulatory requirements. Interventions for behaviors have been updated on needs and service plan for R4 and R5. Incident #4: LPA reviewed incident report dated 5-10-23 which states R5 and R3 were engaged in an altercation in which R5 threw a food item at R3. No injury reported. Facility reported incident per regulatory requirements. Based on interviews and record reviews, it was revealed that facility staff was present and redirected residents from altercation. Interventions are in place to reflect behavior patterns and needs and service plans are updated at this time. Based on today’s case management visit, no deficiencies are observed. An exit interview was held with Anuradha Saini and a copy of this report was left with Anu.the state’s words, verbatim · CDSS document, May 17, 2023

Allegation investigated: Staff does not ensure resident's showering needs are met. Staff does not ensure resident's needs are being met.

On 5-10-23 at 10:22am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings related to the allegations noted above. LPA met with Director of Nursing Lucky Kaur and explained the purpose of the visit. During this investigation, LPA interviewed resident1 (R1) R2, R3, and R4. LPA also interviewed staff1 (S1), S2, S3, and S4. Additionally, LPA reviewed shower schedule for R1, physician’s report for R1, and conducted a facility observations. Allegation #1: Staff does not ensure resident showering needs are met. LPA conducted interviews and reviewed records as stated above. LPA also conducted a facility observations on 4-19-23 and 5-10-23. Based on observation, interviews, and record review, it was determined that R1 received showers per shower schedule with an exception of one day in which R1 exercised her right to refuse a shower. Additionally, interviews revealed showers are given on a consistent bases per shower schedule. As a result, based on interviews, record reviews, and observation of R1’s living environment, there is a not a preponderance of evidence to conclude facility is not meeting residents showering needs. Therefore, this allegation is UNSUBSTANTIATED. {Cont. on 9099C} Unsubstantiated Allegation #2: Staff does not ensure resident needs are met. This allegation states R1 has difficulty sleeping due to noise and requests to be moved to a skilled nursing facility. LPA conducted interviews and reviewed records as stated above. LPA also conducted a facility observation. Based on observation, interviews, and record review, it was determined that facility is meeting R1’s showering needs as stated above in Allegation #1. Additionally, based on interviews and facility observation, it was revealed that excessive noise was not observed or correlated with lack of residents sleep. As a result, there is not a preponderance of evidence to conclude that facility is not ensuring resident needs are met. Therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Anuradha Saini and a copy of this report was provided to Anuradha. Appeal Rights provided.the state’s words, verbatim · CDSS document, May 10, 2023 · control 27-AS-20230418084718

Type of visit: Case Management - Other

On 5-5-23 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an eviction notice presented to resident1 (R1) and a current episode of scabies regarding R2. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed eviction letter with Administrator and attempted interview with R1. Based on review of eviction letter, it was determined that letter was presented to R1 on 4-17-23, and a copy was not sent to Licensing department within required regulatory time frame. LPA conducted facility tour and observed isolation carts outside of resident2 (R2) room who is diagnosed with scabies. LPA reviewed incident report with Administrator. Isolation cart contained appropriate personal protective equipment (PPE) available for staff and visitor use. LPA also observed staff members utilizing the PPE during today's tour. LPA also reviewed medication order for R2 and determined that physician's prescribed treatment is being followed by staff. Based on today's case management visit, a citation issued under Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator and a copy of this report was left with Administrator. Appeal rights provided.the state’s words, verbatim · CDSS document, May 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: May 15, 2023

Eviction Procedures. (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: Based on record review and interview, licensee did not ensure an eviction notice issued to R1 on 4-17-23 was sent to licensing department within regulatory time frame as noted above.the state’s words, verbatim · CDSS document, May 5, 2023

Plan of correction: Licensee will rescind previous written eviction notice and so inform R1. Licensee will send proof of rescinded notice to LPA by POC due date.

Allegation investigated: Staff allowed resident to remain in soiled clothing for extended period Staff does not ensure resident has adequate storage space for personal possessions

On 4-7-23, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a complaint investigation for the allegations noted above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. During this investigation, LPA interviewed 6 staff members, Administrator, and 4 residents. LPA also conducted facility observation on 3-24-23 and 4-7-23. Additionally, LPA reviewed care logs and physician report for resident1 (R1). Allegation #1: Staff allowed resident to remain in soiled clothing for extended period. LPA conducted interviews as noted above as well as facility observation, and records review as noted above. During facility tours on 3-24-23 and 4-7-23, LPA observed facility staff interacting with residents in care and meeting toileting, bathing, and other care needs. Record reviewed revealed care needs including resident changing of soiled clothing, showers, and hygiene performed within adequate time. Interviews conducted with residents and staff did not reveal consistent corroborated statements of residents remaining in soiled clothing for extended periods of time. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. {Cont. 9099C} Unsubstantiated Allegation #2: Staff does not ensure resident has adequate storage space for personal possessions. LPA conducted facility tour and conducted interviews as noted above. During facility tour, LPA observed storage space adequate for residents in care and meeting regulatory compliance. Additionally, LPA observed items belonging to residents in care to be appropriately stored in storage spaces. Interviews conducted did not result in corroborated statements of facility not ensuring adequate storage space for resident’s personnel possessions. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Based on this investigation, no citations are issued. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 7, 2023 · control 27-AS-20230320082353

Allegation investigated: Staff are not ensuring resident is bathed Staff did not ensure toilet paper was available for residents Staff are not providing adequate food service to residents

On 4-7-23 at 10:00am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a complaint investigation for the allegations noted above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. During this investigation, LPA interviewed 6 staff members, Administrator, and 4 residents. LPA also reviewed current facility menu and conducted a facility observation. Additionally, LPA reviewed shower schedule for resident1 (R1). Allegation #1: Staff are not ensuring residents are bathed. LPA interviewed Resident1 (R1), R2, R3 and R4 as well as Staff1 (S1), S2, S3, S4, S5, and S6. LPA also reviewed shower schedule as noted above. Based on interviews and record reviews, it was determined that showers are attempted and completed consistently. It was further noted based on interviews and record reviews that residents also refuse showers periodically. A facility observation conducted on on 3-24-23, and 4-7-23 revealed no foul odors in facility, and LPA observed staff members interacting with residents for care needs including showers. As a result, there is not a preponderance of evidence to conclude that residents are not being bathed. Therefore, this allegation is UNSUBSTANTIATED. {Cont. on 9099C} Unsubstantiated Allegation #2: Staff did not ensure toilet paper was available to residents. LPA conducted facility observation on 4-7-23 and 3-24-23, and 3-9-23, and interviewed residents as noted above. Based on observation and interview, it was determined that facility has an adequate supply of toilet paper on hand. Additionally, LPA observed toilet paper in various rooms during facility tours to contain toilet paper available on holders as well as additional toilet paper stored in bathrooms. Interviews conducted revealed supplies including toilet paper are available consistently. As a result, there is not a preponderance of evidence to conclude that toilet paper is not available to residents. Therefore, this allegation is UNSUBSTANTIATED. Allegation #3: Staff are not providing adequate food service to residents. LPA conducted facility observation on 4-7-23, 3-24-23, 3-9-23 and interviewed staff and residents as noted above. LPA also reviewed facility’s menu. Based on record review, interviews, and observation, it was determined that facility is serving food consistent with published menu. Additionally, interviews conducted did not reveal corroborated statements of inadequate food service. As a result, there is not a preponderance of evidence to conclude that staff are not providing adequate food service to residents, therefore, this allegation is UNSUBSTANTIATED. As a result of this investigation, no citations are issued. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 7, 2023 · control 27-AS-20230303140934

Allegation investigated: Staff are not keeping facility free of odor Staff did not maintain the facility in clean and sanitary condition

On 3-24-23 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the allegations noted above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. During this investigation, LPA conducted facility observation on 3-9-23 and 3-24-23. LPA also conducted interviews with Administrator, Staff1 (S1), S2 and S3. Allegation #1: Staff are not keeping facility free of odor. Based on observations conducted, LPA observed a foul odor around room 107 on 3-24-23. It was further determined that odor was strongest and more easily detected upon LPA entering room 107. As a result, there is a preponderance of evidence to conclude facility was not maintaining an area free of odor, therefore, this allegation is SUBSTANTIATED. Allegation #2: Staff did not maintain the facility in clean and sanitary condition. Based on observations conducted, LPA observed room 107 to contain a used adult diaper on the floor near the foot of the bed belonging to R1. It was further determined that this item contributed in part to foul odors within the room. {Cont. on 9099C} Substantiated As a result, there is a preponderance of evidence to conclude facility did not maintain a clean and sanitary condition, therefore this allegation is SUBSTANTIATED. As a result of this investigation, citations are issued under Title 22, Division 6. A civil penalty in the amount of $250 was issued in addition to citation due to repeat violation within 12 month period. An exit interview was conducted with Anurahda Saini and a copy of this report was provided to Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 24, 2023 · control 27-AS-20230303140934

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Apr 4, 2023

87625(b)(3). Managed Incontinence. (b) ...the licensee shall be responsible for the following: (3) Ensuring that...facility remains free of odors from incontinence. This requirement was not as evidenced by: Based on observation, licensee did not comply with this regulation in that LPA observed a strong urine odor in and around room 107 on 3-24-23. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee will submit a plan to ensure incontinent residents are kept clean and dry, and rooms, along with surrounding areas are kept odor free. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 4, 2023

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by: Based on observation, licensee did not comply with this regulation in that LPA observed a used adult diaper on the floor of room 107 near the foot of R1's bed. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee will submit a plan to ensure rooms, common areas, and other areas used by residents remain clean and sanitary. Plan to be submitted to LPA by POC due date.

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

Allegation investigated: Staff does not ensure facility is kept in good repair Staff does not ensure resident medical information is kept confidential

On 3-24-23 at 9:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate a complaint for the allegations noted above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA interviewed Administrator, staff1 (S1), S2, S3, and S4. LPA also conducted facility observation and reviewed additional documentation including photographs related to above allegations. Allegation #1: Staff does not ensure facility is kept in good repair. LPA conducted interviews as stated above, facility observation, and reviewed photographs. Based on observation and interviews it was determined that a window seal in room 107 was damaged for a period of 2-3 weeks and not yet repaired. Window seal contained cracks and paint peeling from multiple areas. As a result, there is a preponderance of evidence to conclude faclity sustained an item in ill repair, therefore, this allegation is SUBSTANTIATED. {Cont. 9099C} Substantiated Allegation #2: Staff does not ensure resident medical information is kept confidential. LPA conducted staff interviews as stated above and reviewed additional documentation. Based on interviews and record review, it was determined that staff member sent a photograph of a medication bottle for Resident2 (R2) to the wrong intended recipient resulting in medical information exposed. Interviews conducted confirmed information was sent in error and was corrected as required. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. As a result of this investigation, citations are issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within 12 month period. An exit interview was conducted with Anuradha Saini and a copy of this report was provided to Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 24, 2023 · control 27-AS-20230320082353

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 4, 2023

Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by: Based on observation and interview, window seal in room 107 contained damage for 2-3 weeks after occurrance. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee has repaired damage to window seal and send photo proof of repair to LPA. Licensee will submit a plan outlining how future repair items will be addressed timely. Plan to submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Apr 4, 2023

Additionial Personal rights...(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Based on record review and interview, Licensee did not ensure confidential medical information for R2 in that a photograph of medication information was sent to the wrong receipient. This posed a potential health, safety and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee will read regulation 87468.2(a)(2) and submit a signed declaration of understanding to LPA by POC due date. Licensee will submit plan outlining procedures for safely and effectively communicating private information to the appropriate parties. Plan to be submitted to LPA by POC due date.

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

Type of visit: Case Management - Incident

On 3-24-23 at 4:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 2-28-23. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report dated 2-28-23, as well as physician's report for R1. Based on interview and record review, it was determined that on 2-28-23 at approximately 7:15am, resident1 (R1) was sitting outside of the facility. A med tech (S1) encourage R1 to come inside due to cold weather. R1 stated he will come back after his routine walk. At 8:15am, S1 attempted to check on R1 and was unable to locate R1. S1 and other facility staff checked R1's room and surrounding areas of facility as well as areas across the street from facility, but unable to locate R1. At approximately 9:00am, R1 arrived back at facility accompanied by local law enforcement. Based on review of physician's report for R1, R1 is unable to leave building unassisted. Facility staff reported incident within regulatory time frames. Facility staff is currently in process of assessing R1 for placement within secured unit of facility. Due to facility unaware of R1's whereabouts, citation is issued under Health and Safety code 1569.312(d). An immediate civil penalty in the amount of $1000 is issued to facility in addition to citation due to repeat violation within 12 month period. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 24, 2023

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Mar 27, 2023

Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts… This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure facility’s knowledge of R1’s whereabouts on 2-28-23 leading to an absence of supervision. This posed an immediate health, safety, and resident rights risk to resident in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Licensee to conducted staff training on elopement policy and procedures. Training date to be submitted to LPA by POC due date. Training to be completed and proof of completed training sent to LPA no later than 2 weeks from citation issued date. Licensee will submit a plan outlining procedures for maintaining knowledge of residents whereabouts at all times. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Incident

On 2-2-23 at 1:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management on various incidents occurring between 11-16-22 and 1-25-23. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed the following incidents and related facility file documentation as well as conducted additional interviews: On 11-16-22, an incident report submitted by facility stated resident1 (R1) and R2 were involved in a resident to resident altercation in which R2 allegedly placed an object in R1’s mouth due to R1’s snoring episodes. Facility reported incident to department, local law enforcement, and ombudsman. R1 and R2 are own responsible persons. Interviews were conducted with facility nurse, R1, and R2. Based on interviews conducted, it was determined that residents are no longer sharing a room and interact adequately. Interviews also revealed that no injuries occurred. Furthermore, interviews revealed incident was denied by R2. Appraisal needs and service plans for R1 and R2 have been updated to reflect above incident and monitoring for residents needs. On 12-27-22, an incident report was submitted stating on 12-27-22, R3 was double dosed on medication Lasix. According to R3’s orders, R3 was to receive 40mg of Lasix, and received 80mg of Lasix. It was determined through interview with facility nurse that medication technician was new during the time of incident and has since been in-serviced on proper procedures for assistance with medication administration including six rights of medication. Interview and incident report also revealed that R3 was closely monitored for additional signs and symptoms. Additionally, facility contacted R3’s physician and responsible person. On 1-5-23, facility reported and incident occurring on 1-4-23 in which R4 experienced a behavior episode which included wandering into other resident rooms and hitting facility walls. Additionally, incident report states R4 also hit staff in the stomach as well as another resident in care. R4 is a resident of memory care. Facility reported incident to licensing department, ombudsman, responsible parties, and local law enforcement within regulatory time frames. {Cont. on 809C} Needs and service plan for R4 is updated to reflect behaviors with interventions in place including monitoring for increased behaviors. Based on interviews conducted with facility nurse, there have been no further episodes of behavior seen in R4. Facility will refer R4 to psychiatric services. On 1-8-23, facility reported an incident occurring on 1-6-23 in which R6 sustained a fall after becoming agitated during a shower assist by staff. Additionally, this report stated R5 sustained an unwitnessed fall on 1-7-23. Facility reported R5’s room contained alcohol and suspected R5 was intoxicated leading to her fall. R5 and R6 were transported to hospital. Additionally, responsible parties for R5 and R6 were notified of incidents. R5 and R6 returned from hospital without injury and no new orders. R5 and R6 are monitored by staff at this time for increased behaviors and potential injuries. Facility will refer R5 and R6 to psychiatric services. On 1-21-23, facility reported an incident occurring on 1-21-23 in which R7 engaged in aggressive behavior towards staff and residents. R7 is a resident of memory care. According to interview with facility nurse, R7 became verbally disruptive, including yelling at various staff and residents. Interview further revealed that due to R7’s behaviors, R7 was sent to hospital for further evaluation and staff and resident were not struck by R7. At this time, R7 remains in hospital attempting to be stabilized. Facility reported incident to responsible party and licensing department within regulatory timeframes. R7s service plan reflects interventions for behaviors. R7 has also been referred to psychiatric services for follow up. On 1-27-23 facility reported an incident occurring on 1-23-23 in which R8 was sent to local hospital due to discovery of an open area on the coccyx area. Based on interview and record review, facility ordered home health for further evaluation, but R8 requested to be sent out to the hospital for evaluation. Discharge orders reviewed revealed R8 was diagnosed with skin abscess and sent back to facility on 1-27-23 with home health services. On 2-1-23, home health services determined R8 to now have a stage 3 wound and facility arranged for R8 to be sent to local hospital for additional follow up and treatment on 2-2-23. Licensing department and R8’s responsible party were notified within regulatory time frames. On 1-25-23, facility reported an incident occurring on 1-25-23 in which R9 sustained a fall resulting in a closed fracture of left foot. Based on incident report, R9 lost balance in room and fell. R9 was sent to local hospital on 1-25-23 and returned same day with orthopedic follow up requested. Progress notes reviewed stated facility arranged an appointment with R9’s physician on 2-8-23 for purposes of receiving an orthopedic follow up based on insurance, however, R9 declined appointment. Next available orthopedic appointment available is 3-8-23 according to facility progress reports. R9 is noted as own responsible party. Facility sent report to licensing department within regulatory time frames. Staffing schedule reviewed revealed 7 caregivers on duty during the date and time of incident, including care giving department supervisor. As a result of today’s case management, citation are issued under Title 22, Division 6, Chapter 8. An immediate civil penalty in the amount of $250 is issued in addition to the citation due to repeat violation within 12-month period. An exit interview was conducted with Anuradha Saini and a copy of this report was given to Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Feb 2, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 10, 2023

Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: Licensee did not ensure a proper medication order was followed for R3 in that R3 was given 80mg of Lasix instead of the physician ordered 40mg of Lasix on 12-27-22. This posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Feb 2, 2023

Plan of correction: Licensee and facility nurse have provided additional staff inservice on medication administration and will provide proof of completed inservice to LPA by POC due date. Licensee will read regulation 87465(a)(4) and submit a signed declaration of understanding to LPA by POC due date.

Type of visit: Case Management - Health Checks

On 2-2-23 at 10:11am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 92. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 77 bedrooms and 77 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Staff were wearing masks while on duty. Hand sanitizer was readily available. There were 10 caregivers and 3 med techs on duty, 3 kitchen staff, 2 housekeepers, assistant administrator, nurse, and Administrator on duty. Facility has 30-day supply of PPE on hand. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. The facility has an approved a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside area including smoking area. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Signal system in place and functional. {Cont. on 809C} Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 76*F.upstairs and downstairs. LPA toured kitchen and observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 7/1/22. Five resident charts reviewed and contained all required documentation including updated needs and service plans and physician's reports. Facility is reporting incidents per regulatory time frames and has a current updated plan of operation in place. Staffing schedule reflect Administrator on duty at least 40 hours per week. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini.the state’s words, verbatim · CDSS document, Feb 2, 2023

Allegation investigated: Facility staff member stole checks from resident and forged them to himself.

On 12-6-22 at 1:17pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the complaint allegation noted above. LPA met with Director of Nursing (DON) Lucky Kaur and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPA’s visit and gave permission for Lucky to sign in her absence. During this investigation, LPA interviewed Administrator, Staff1 (S1), Resident1 (R1) R2, and attempted interview with S2. LPA also reviewed physician’s report for R1, copies of various checks written, and staffing record for S2. Based on interviews and record reviews, it was determined that various checks with various amounts were written on 6/14/22, 8/26/22, 9/2/22, and 9/10/22, made out to S2 which contained a signature and printed name of R1 on the checks, and cashed. It was further determined that R1 did not write such checks and discovered suspicious bank activity on 10/3/22 during a visit to R1’s bank which was after R1's discharge from facility on 9/29/22.. A review of S2’s staffing record revealed S2 was terminated from employment on 4-1-22. {Cont. on 9099C} Unsubstantiated Interviews further revealed that it was unclear how S2 would have had access to R1’s checks prior to or after S2’s termination. Additionally, based on interviews and record reviews, there were no reports recorded of R1 missing checks while a resident at facility. Incident described as above was reported accordingly and appropriately by facility upon discovery on 10-3-22. Based on interviews and record reviews, although the incident may have occurred, there is not a preponderance of evidence to conclude that S2 was a facility staff member at the time R1’s checks were allegedly taken and written. As a result, this allegation is UNSUBSTANTIATED. DON left facility prior to completing this note, and gave permission for assistant administrator Alicia Carranza to sign in her absence. An exit interview was conducted with Alicia Carranza and a copy of this report was left with Alicia. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 6, 2022 · control 27-AS-20221026104559

Type of visit: Case Management - Incident

On 11-4-22 at 3:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for health and safety. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA interviewed Administrator and staff1 (S1). LPA also reviewed incident reports for resident1 (R1) dated 10-16-22 and additional care notes for R1. Based on interview and record reviews, it was determined that R1 was admitted to the hospital on 10-16-22 due to thrombosis. On 10-20-22, facility received information from hospital that R1 was diagnosed with scabies on 10-19-22. Based on interview, it was revealed that no further cases of scabies have been reported or diagnosed within facility at this time, and facility continues to take necessary precautions including regular monitoring of residents for signs and symptoms of scabies since learning of R1’s diagnosis. Incident on 10-16-22 was reported per regulatory requirements. No citations issued today as a result of this case management. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.the state’s words, verbatim · CDSS document, Nov 4, 2022

Type of visit: Case Management - Other

On 11-4-22 at 1:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding staffing and lift assists. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA interviewed Administrator and reviewed staffing schedule for 10-29-22 night shift. LPA also reviewed incident report for resident1 (R1). Based on interviews and record reviews, it was determined that R1 sustained an unwitnessed fall without injury on 10-29-22, and staff notified fire department for a lift assist. It was further determined that R1 refused to go to the hospital. Staffing on 10-29-22 night shift included 1 med tech and 3 caregivers. LPA offered technical assistance on when facility shall call 9-1-1 and additional resources utilized for assistance with lifts including but not limited to: Use of mechanical lifts or other means provided appropriate documented training is in place. Administrator stated additional training will be put in place for staff to recognize need for 9-1-1 calls versus needed internal assistance for residents in care. No deficiencies cited today as a result of this case management. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.the state’s words, verbatim · CDSS document, Nov 4, 2022

Allegation investigated: Staff failed to provide adequate food service Staff are not taking precautions for COVID-19 Due to lack of supervision residents engaged in inappropriate interactions Staff handle residents in a rough manner and yell at residents Residents are left in soiled clothing Facility is malodorous Facility has an infestation of insects Facility has an outbreak of scabies

On 10-14-22 at 2:45pm, Licensing Program Analysts (LPAs) Michael Bilger and Renee Campbell arrived unannounced to continue investigation and deliver complaint findings for the allegations listed above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. During this investigation, LPA interviewed 7 staff, Administrator and 3 residents. LPA also reviewed facility file documentation including Actual hours worked for August 2022, staffing schedule for August of 2022, Physician’s reports for Resident1 (R1) and R2, functional capabilities assessment, med tech communication form, footcare wellness form, pest control service agreement, and additional documentation including training verification and menu. Additionally, LPA conducted facility observation of memory care and kitchen. Allegation #1: Staff failed to provide adequate food service. This allegation stated facility did not provide adequate amounts of snacks to residents during night shift. LPA interviewed Staff1 (S1), S2, S3, S4, S5, S6, and S7 in addition to Administrator. LPA also conducted kitchen observation and observation of memory care on 8-26-22 and 10-14-22. LPA also interviewed Resident1 (R1), R2, and R3.. {Cont. on 9099C} Unsubstantiated LPA also reviewed facility’s menu. Based on interviews, record reviews, and observation, it was determined that facility has available snacks and other food items available for residents during night shift including a surplus of items as noted during observation on 8-26-22 including various sandwiches. Interviews conducted did not reveal a shortage of food item availability or inadequate delivery of food to residents during the night. As a result, there is not a preponderance of evidence to conclude staff failed to provide adequate food service, and this allegation is UNSUBSTANTIATED. Allegation #2: Staff are not taking precautions for COVID-19. LPA conducted facility observation of memory care on 8-26-22 and 10-14-22, and reviewed additional documentation from facility. LPA observed isolation carts stocked with adequate amounts of personal protective equipment (PPE) outside of COVID designated rooms, and observed COVID room designated appropriately with use of color coding. Unit was observed to be clean and sanitary. Staff on duty was observed to be wearing appropriate PPE. Additionally, COVID signage was observed to be posted and resident’s with COVID were observed to be appropriately isolated. Training documentation revealed COVID-19 precautionary training conducted on multiple dates between June and August of 2022. Interviews conducted with S1-S7 as well as Administrator and R1-R3 revealed COVID precautions are followed or not observed to be inappropriately followed. Based on observations, interviews, and record reviews there is not a preponderance of evidence to conclude this allegation is true, therefore this allegation is UNSUBSTANTIATED. Allegation #3: Due to lack of supervision residents engaged in inappropriate interactions. LPA conducted observation of memory care on 8-26-22 and 10-14-22, and reviewed additional facility documentation. LPA also interviewed S1-S7, Administrator and R1-R3. LPA observed residents interacting appropriately during meal and other activities. {Cont. on 9099C} Records reviewed could not clearly determine if any inappropriate interactions were conducted by residents in care. Based on interviews, record reviews, and observation, it was determined that since there have been no clear observations of inappropriate interactions between residents as a result of a lack of supervision through record review and observation, the preponderance of evidence standard is not met and this allegation is UNSUBSTANTIATED. Allegation #4: Staff handle residents in a rough manner and yell at residents. LPA conducted facility observation on 8-26-22 and 10-14-22, and interviewed staff and residents as noted above, and reviewed additional documentation. Based on observation and interviews, it was determined that there has been no recollection of confirmed rough handling or yelling at residents in care. Additionally, based on record review, it was determined that rough handling or yelling at residents was not decisively revealed. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. Allegation #5: Residents are left in soiled clothing. LPA interviewed staff and residents as noted above. LPA also reviewed additional documentation and conducted facility observation on 8-26-22 and 10-14-22. Based on interviews and record reviews, it was determined that residents in care have not reportedly been left in soiled clothing for inappropriate lengths of time. Observation of facility revealed no foul odors. Based on interviews, record reviews, and observation, the preponderance of evidence standard is not met and this allegation is UNSUBSTANTIATED. Allegation #6: Facility is malodorous. LPA conducted facility observation on 8-26-22 and 10-14-22, and conducted interviews with staff and residents as noted above. Based on observation, it was determined that memory care unit did not contain foul odors. Furthermore, based on interviews, it was determined that there has been no recollection of a malodorous environment within memory care unit. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. {Cont. on 9099C} Allegation #7: Facility has an infestation of insects. LPA conducted facility observation on 8-26-22 and 10-14-22, and conducted interviews with staff and residents as noted above, and reviewed additional documentation. Based on observation and interviews, it was determined that although cockroaches were reportedly observed on the outside of facility they were not observed within the inside of facility. Additionally, record review revealed one insect crawling on the floor which was undetermined to be that of facility’s. A pest control service agreement reviewed revealed an on-going pest control service in place for facility. As a result, there is not a preponderance of evidence to conclude that facility has had an infestation of insects, therefore this allegation is UNSUBSTANTIATED. Allegation #8: Facility has an outbreak of scabies. LPA conducted interviews with staff and residents as noted above, and reviewed facility file documentation. Based on interviews and record reviews, it was determined that although a rash was existent on resident1 (R1) it was undetermined and unconfirmed through an appropriate skilled professional that said rash was scabies. Additionally, record review revealed treatment practices were in place for the diagnosed skin rash, and that no cases of scabies have been diagnosed at this time. Based on interviews and record reviews, there is not a preponderance of evidence to conclude that residents in care contained scabies, and this allegation is UNSUBSTANTIATED. No citations are issued today as result of this investigation. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal rights provided.the state’s words, verbatim · CDSS document, Oct 14, 2022 · control 27-AS-20220818164143

Type of visit: Case Management - Incident

On 10/14/22, Licensing Program Analyst (LPA) Renee Campbell arrived at A1 Del Monte Assisted Living and Memory Care at approximately 12:15 pm to conduct a case management visit regarding an incident report submitted to CCLD 09/08/22. LPA was greeted by Administrator Anu Saini, and explained the purpose of the visit. Based on the incident report, while in their shared room Resident1, (R1) slapped Resident (R2) three times because R2 would not lower the volume on the television. Both residents were separated and sent to different rooms. 911 was called so that a report could be filed and a SOC 341 was completed. Based on observations, documents and interviews, facility followed procedure. A report was filed with the police, an incident report was submitted to licensing and R1's behavior was updated in her Behavior Progress notes. After the police were called, residents were moved to separate rooms to address the situation. The administrator and staff were interviewed as well. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 14, 2022

Type of visit: Case Management - Health Checks

On 10-14-22 at 10:05am, Licensing Program Analysts ( LPAs) Michael Bilger and Renee Campbell arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA was greeted by Business Office Manager Eddie Itilong and LPA explained the purpose of the visit. Administrator Anuradha Saini arrived at approximately 10:30am. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 92. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 77 bedrooms and 77 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Staff were wearing masks while on duty. Hand sanitizer was readily available. There were 7 caregivers and 3 med techs on duty, 3 kitchen staff, 2 housekeepers, assistant administrator and Administrator on duty. Facility has 30-day supply of PPE on hand. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. The facility has an approved a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside area including smoking area. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Signal system in place and functional. Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 74*F.upstairs and downstairs. LPA toured kitchen and observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 5/16/22. Five resident charts reviewed and contained all required documentation including updated needs and service plans and physician's reports. Facility is reporting incidents per regulatory time frames and has a current updated plan of operation in place. Staffing schedule reflect Administrator on duty at least 40 hours per week. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini.the state’s words, verbatim · CDSS document, Oct 14, 2022

Type of visit: Case Management - Incident

On 10-14-22 at 1:30pm, LPAs Michael Bilger and Renee Campbell arrived unannounced to conduct a case management visit due to an incident which occurred on 9-10-22. LPAs met with Administrator Anuradha Saini and explained the purpose of the visit. LPA Bilger conducted interview with Administrator and reviewed incident report dated 9-12-22. Based on interview and record review it was determined that on 9-10-22, resident1 (R1) caused damage to the ceiling sprinkler in R1’s room resulting in water damage and flooding within the room which also caused the alarms to sound. The damage resulted in air conditioning unit to malfunction for a brief period of time and the temporary relocation of memory care residents to another location of the facility. Based on interview, memory care residents were relocated to the dining room area temporarily with sufficient staffing numbers for supervision including monitoring of all exit doors until returning to room same day. Residents in care were provided fans and hydration as necessary. Resident room temperature was monitored by on duty staff to ensure sufficient temperature range. Air conditioning unit was functioning fully on 9-12-22, then slightly malfunctioning on 9-14-22 due to the 9-10-22 incident, and repaired same day to fully functional status. No disruption in care or other resident activity reported. Meals remained served on time and fans continued to be provided for all residents in memory care. Incident was reported to licensing department within regulatory guidelines. No deficiencies cited as a result of today’s visit. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.the state’s words, verbatim · CDSS document, Oct 14, 2022

Type of visit: Case Management - Incident

On 8-26-22 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident which occurred on 8-19-22. LPA met with Lucky Kaur and explained the purpose of the visit. Administrator Anuradha Saini was contacted by phone and LPA explained purpose of the visit. Administrator gave permission for Lucky to sign in her absence. LPA reviewed incident report dated 8-19-22 and interviewed staff1 (S1). Based on interview and record review, it was determined that resident1 (R1) eloped from facility on 8-19-22 at approximately 7:10pm. Facility staff searched surrounding areas, but unable to locate R1. Facility staff filed police report and were later notified by police that R1 had been found and taken to hospital. Incident report and interview also revealed that a staff member was sent to hospital to sit with R1 once learning of R1’s whereabouts. Based on interviews and record review, it is determined that facility was unaware of R1’s whereabouts on 8-19-22 between 7:10pm and approximately 4:00pm on 8-20-22, resulting in an absence of supervision for R1. As a result, deficiencies are cited under Health and Safety Code, Chapter 3.2. In addition to citation issued, an immediate civil penalty in the amount of $500 is issued due to violation resulting in absence of supervision. An exit interview was conducted with Lucky Kaur and a copy of this report was left with Lucky. Appeal rights provided.the state’s words, verbatim · CDSS document, Aug 26, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Aug 29, 2022

Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts… This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure facility’s knowledge of R1’s whereabouts on 8-19-22 leading to an elopement episode and absence of supervision. This posed an immediate health, safety, and resident rights risk to resident in care. An immeidate civil penalty in the amount of $500 is being issued on today's visit due to the violation of absence of supervision Additional civil penalty may be assessed upon further department review.the state’s words, verbatim · CDSS document, Aug 26, 2022

Plan of correction: Licensee wil submit a plan to ensure residents whereabout are accounted for by staff. Plan to be submitted to LPA by POC due date. Licensee to conducted staff training on elopement policy and procedures. Training date to be submitted to LPA by POC due date. Training to be completed and proof of completed training sent to LPA no later than 2 weeks from citation issued date of 8-19-22.

Allegation investigated: Staff are denying visitations for the residents while in care.

On 08-10-2022 at 9:30 am, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Anuradha Saini and explained the purpose of today's visit. During this investigation, LPA Martinez conducted interviews, inspected the facility, and reviewed facility documents. Throughout the investigation, it was learned the facility had visitors entering the facility in August of 2022. However, on one occasion, a couple of visitors were denied entry. The visitors arrived at the facility during visitor hours although they were not granted entry. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility. Substantiatedthe state’s words, verbatim · CDSS document, Aug 10, 2022 · control 27-AS-20220805155944

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Aug 24, 2022

87468.1 (a)(11)Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours. This requirement was not met as evidence by:Based on interviews it was learned resident's visitors were not granted entry during reasonable hours. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: The facility agrees to conduct Covid-19 and visitation training for all staff by POC Date 08/24/2022. Facility staff will email training documentation and sign in sheet to LPA Martinez by POC date 08/24/2022.

Allegation investigated: Resident's room is in disrepair

On 08-10-2022 at 9:30 am, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegation. LPA Martinez met with Anuradha Saini and explained the purpose of today's visit. During this investigation, LPA Martinez conducted interviews and observed resident rooms. Resident 1's (R1) had dead flies on the floor and window sill, which were removed by facility staff. In addition, R1's room had food debris on the floor. I R1's closet rails had dirt build up and dirt on the closet floor. Also, resident 2's closet rails had dirt build up and dirt on the closet floor, which their blankets were placed on the closet floor next to dirt. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility. Substantiatedthe state’s words, verbatim · CDSS document, Aug 10, 2022 · control 27-AS-20220809162235

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 24, 2022

87303 (a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: based on observation and interview review, LPA Martinez observed R1 and R2 bedroom were unsanitary and not in good repair. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Facility staff agrees to conduct a housekeeping and facility maintenance and operation training for all housekeeping staff by POC date 08/24/2022. Facility will email LPA Martinez copies of training sign in sheet and training materials by POC date 08/24/2022. Facility has installed bug zappers in the facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Anuradha Saini and explained the purpose of the visit. Today's case management visit is in response to: facility staff did not treat resident 1 (R1) with dignity, and R1 was not free from humiliation by staff. LPA Martinez observe staff 1 (S1) speak to resident 1 (R1) in a deeming manner. Staff 1 yelled at R1 due to their health issues and having to clean their bedroom floor due to a health condition. Moreover, Staff 2 (S2) questioned R1 on how they spend their money in an unprofessional manner. S2 further stated R1 was spending their money on drugs, and S2 had no substantial evidence or basis to accuse R1 of this expenditure. As a result, the facility was cited personal rights deficiency, which can be found on the 809-D Page. The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.the state’s words, verbatim · CDSS document, Aug 10, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 24, 2022

Personal Rights of Residents in All Facilities 87468.1(a)(1) residents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded dignity in their personal relationships with staff...This requirement was not met as evidence by: Based on observation: staff 1 and staff 2 did not provide R1 with dignity. This posed a potential health and safety risk to resident 1 (R1).the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Facility staff agrees to conduct a training on personal rights for the administrator and all staff by POC date 08/24/2022. Facility will email LPA Martinez copies of training sign in sheet and training materials by POC date 08/24/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(5) · Plan of correction due date: Aug 24, 2022

Administrator - Qualifications and Duties 87405(d)(5) The administrator shall have the qualifications specified in Sections 87405...Good character and a continuing reputation of personal integrity. This requirement was not met as evidence by: Based on observation facility administrator did not implement personal integrity. this posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Administrator agrees to complete a training on personal rights and integrity by POC date 08/24/2022. Facility will email LPA Martinez copies of training sign in sheet and training materials by POC date 08/24/2022.

Allegation investigated: Resident did not receive a copy of the admission agreement

On 7-28-22 at 11:55am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Anuradha Saini and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and Resident1. LPA also reviewed facility file documentation including admission agreement for R1. Based on interviews and record reviews, it was determined that R1 received a copy of her signed admission agreement on 6-20-22. During interview with R1 on 7-28-22, LPA observed admission agreement on R1's nightstand. Additionally, it is indicated in the admission agreement that R1 acknowledged receipt of admission agreement on 10-29-2021 which contains a fee schedule and acknowledgment of handbook received. Based on interview and record review, the preponderance of evidence standard is not met, and this allegation is UNFOUNDED. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Unfoundedthe state’s words, verbatim · CDSS document, Jul 28, 2022 · control 27-AS-20220725143916

Allegation investigated: Facility is in disrepair Staff did not meet resident's needs

On 7-28-22 at 10:13am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations listed above. LPA met with Alicia Carranza and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPA's visit and gave permission for Alicia to sign in her absence. During this investigation, LPA interviewed two staff members and four residents. LPA also reviewed admission agreement for Resident1 (R1) and care notes from June 2020 for R1. In addition, LPA conducted a facility observation on 6-20-22. Allegation #1: Facility is in disrepair. LPA interviewed R1 and R2 as well as Staff1 (S1) and Administrator. LPA also conducted facility observation. Based on interviews, the allegation of facility in disrepair specifically noted the in R1’s room window unable to open, as well as the air conditioning unit and bathroom fan in R1’s room. Based on observation by LPA, the window in R1’s room was able to open, close and lock without difficulty. In addition, LPA observed air conditioning unit to be producing cold air. LPA further observed R1’s room to be of adequate temperature with overall facility temperature 75*F on 6-20-22. LPA observed bathroom fan to be malfunctioning in bathroom. {Cont. on 9099C} Unsubstantiated Based on interviews, this malfunction was not reported to maintenance by R1, but was reported on day of LPA’s visit on 6-20-22 and repaired same day. Based on interviews conducted, there were no other items noted of concern in terms of disrepair. As a result, there is not a preponderance of to conclude facility is in disrepair at this time, therefore this allegation is UNSUBSTANTIATED. Allegation #2: Staff did not meet resident's needs. LPA interviewed R1, and R2 as well as S1 and Administrator on 6-20-22. On 7-28-22, LPA interviewed R3 and R4.. LPA also reviewed care notes for R1 and Admission agreement for R1. Additionally, LPA conducted a facility observation on 6-20-22. Based on interviews, this allegation stated R1 was not receiving timely assistance for incontinence needs, personal items including medication not secured upon R1’s return on 6-20-22, and R1 not receiving a copy of her admission agreement. Based on interviews and observation, it was determined that R1 had left facility on 6-20-22 with an intention to discharge to another facility but returned same day. LPA observed boxes of R1’s personal items at 2:10pm and based on interviews, R1 returned to facility at approximately 1:30pm. LPA observed staff members entering room to offer assistance during LPA’s visit. Additionally, based on interviews, R1’s medication was secured and locked upon her return within approximately 15 minutes. LPA observed R1’s medication secured during observation. Based on record review of care notes, it is indicated that R1 has been receiving activities of daily living (ADL) care including incontinent care needs. Based on interviews and record reviews, it is indicated that R1 and other residents’ care needs are being addressed timely. Upon review of R1’s admission agreement, LPA observed an acknowledgment of receipt signature from R1 in the appropriate sections of Admission agreement. Based on interviews, record reviews and observation, there is not a preponderance of evidence to conclude that R1’s needs are not met by staff, therefore, this allegation is UNSUBSTANTIATED. No citations issued as a result of this investigation. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Appeal Rights provided.the state’s words, verbatim · CDSS document, Jul 28, 2022 · control 27-AS-20220620090633

Type of visit: Case Management - Health Checks

On 7-12-22 at 9:40am, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA was greeted by Business Office Manager Eddie Itilong and LPA explained the purpose of the visit. Administrator Anuradha Saini arrived at approximately 10:00am. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 85. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 77 bedrooms and 77 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Staff were wearing masks while on duty. Hand sanitizer was readily available. There were 5 caregivers and 2 med techs on duty, 3 kitchen staff, 2 housekeepers, assistant administrator and Administrator on duty. Facility has 30-day supply of PPE on hand. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. The facility has an approved a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside area including smoking area. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F. Signal system in place and functional. {Cont. on 809C} Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 72*F.upstairs and downstairs. LPA toured kitchen and observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 5/16/22 Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini.the state’s words, verbatim · CDSS document, Jul 12, 2022

Type of visit: Required - 1 Year

On 7-12-22 at 12:45pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside area of the facility to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility for the elderly with a current census of 85. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. Facility has 89 bedrooms and 89 bathrooms. There is a formal dining room off the kitchen area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. "See something, Say something" poster was in place. Staff were wearing masks while on duty. Hand sanitizer was readily available. Facility has 30-day supply of PPE on hand. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. LPA reviewed 8 resident charts and 5 staff charts. All staff charts contained updated first aid and COVID-19 vaccinations . All resident charts contained regulatory contents. Infection control tool completed. The facility has an approved COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside area including smoking area. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. {Cont. on 809C} Water temperature reads between 105*F-120*F upstairs and downstairs and room temperature reads 72*F.upstairs and downstairs. LPA toured kitchen and observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished with floors and walls clean and odor free throughout. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. Fire extinguishers are fully charged and last inspected 5/16/22. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Anuradha Saini.the state’s words, verbatim · CDSS document, Jul 12, 2022

Type of visit: Case Management - Incident

On 7-12-22 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to recently submitted death reports. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA reviewed death reports for Resident1 (R1), and R2 and accompanying documentation with Administrator. Death Report #1: Death report stated R1 was sent to acute hospital on 5/6/22 due to a fall and facility was notified or R1's passing on 6-10-22. LPA reviewed accompanying death certificate submitted by facility staff indicating R1 passed away due to Alzheimer's Disease on 6-1-22. Incident report relating to R1's fall was received timely on 5-7-22 and death report was received timely on 6/14/22. Death Report #2: Death report stated R2 was found unresponsive on 6-19-22 and passed away on the same date. and had a Do Not Rescussitate (DNR) on file. LPA interviewed Administrator regarding events prior to death. Based on interviews, it was determined that R2 was considered for hospice care by R2's physician, but unable to be admitted due to lack of responsible party signature for authorization per hospice agencies. It was further determined through interview that physician for R2 instructed facility to provide comfort measure in lieu of traditional hospice care. Death report was received timely on 6-23-22. No deficiencies issued as result of today's visit. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha.the state’s words, verbatim · CDSS document, Jul 12, 2022

Allegation investigated: Staff do not ensure that residents are adequately fed

On 6-20-22 at 12:41pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue an complaint investigation for the allegation listed above. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. LPA conducted interviews and reviewed diet orders for Resident1 (R1), R2, R3, R4, R5, an R6. LPA also reviewed blood sugar reading for R1-R6. Based on interviews and record reviews, it was determined that adequate food items and amounts were provided to residents. It was further determined that blood sugars for R1-R6 were stable during the period of 5/30/22 to 6/3/22. LPA also reviewed food receipts submitted by Administrator on 6-16-22 which revealed adequate food supply available for residents in care. Based on interviews and record reviews, there is not a preponderance of evidence to conclude that residents in care were not fed adequately. Therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Anuradha Saini and a copy of this report was left with Anuradha. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 20, 2022 · control 27-AS-20220608144500

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent an outbreak of illness

On 6-10-22 at 10:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate a complaint regarding the allegation noted above. LPA met with Director of Nursing (DON) Lakhbir Kaur, LVN and explained the purpose of the visit. LPA also spoke with Administrator Anuradha Saini via phone and explained the purpose of the visit and discussed the above allegations. During this investigation, LPA interviewed Resident1 (R1), R2, and R3. LPA also interviewed Administrator, DON, Staff1 (S1), S2, and S3. LPA also requested staffing roster, resident roster, and conducted a facility observation. LPA also reviewed facility file documentation for R4, R5, R6, and R7. Based on interviews and record reviews it was determined that R4, R5, R6, and R7 experienced symptoms of flu resulting in a suspected outbreak of flu. It was further determined through interviews, record reviews, and facility observation on 6-10-22 that appropriate precautions were put in place to address the suspected outbreak upon discovery including isolation procedures, alternative meal service procedures, ensuring handwashing, and social distancing practices. {Cont on 9099C} Unsubstantiated Testing was performed to rule out additional cases of suspected flu outbreak. As a result, there is a not a preponderance of evidence to prove facility did not prevent an outbreak of illness, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Lakhbir Kaur, and a copy of this report was left with Lakhbir.the state’s words, verbatim · CDSS document, Jun 10, 2022 · control 27-AS-20220608144500

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

Type of visit: Case Management - Incident

On 6-10-22 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incident reports received on 6-10-22. LPA met with Director of Nursing (DON) Lakhibir Kaur, LVN and explained the purpose of the visit. LPA also spoke with Administrator Anuradha Saini via phone and explained the purpose of the visit. LPA reviewed incident reports and test results for Resdient1 (R1), R2, R3, and R4. LPA also interviewed Administrator and DON. Based on interviews and record reviews, it was determined that an occurrence resulting in a suspected flu outbreak occurred on 6-5-22 and not reported to licensing department within 24 hours of occurrence. Based on today’s visit, deficiency is cited under Title 22, Division 6, Chapter 8. An exit interview was held with Lakhbir Kaur and a copy of this report was left with Lakhbir. Appeal rights provided.the state’s words, verbatim · CDSS document, Jun 10, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jun 20, 2022

Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(2) Occurrences...which threaten the welfare, safety or health of residents...shall be reported within 24 hours...to the licensing agency and to the local health officer... This requirement is not met as evidenced by: Based on record review and interviews: A suspected outbreak of flu occurred on 6-5-22 involving multiple residents, resulting in the threat to welfare, safety, and health of residents in care. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2022

Plan of correction: Licensee will conduct staff training on regulation 87211(a)(2) and submit proof of completed training to LPA by POC due date. Licensee will submit a signed declaration of understanding of regulation 87211(a)(2) to LPA by POC due date.

Type of visit: Office

On 5-2-22 at 3:00pm, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Ombudsman Kathryn Thomas, Licensee Sunny Saini, Administrator Anuradha Saini, and Regional Executive Director Jenna Silva. Topics in this meeting included the following: (1) Evictions, (2) Personal Rights, (3) Signal System, (4) Reporting Requirements, (5) Re-appraisals, and (6) Administrator Qualifications. On 4-13-22 three eviction notices were given to Resident1 (R1), R2, and R3 which stated reasons for eviction to include drug and alcohol use as well as overdue rent payments. Eviction notices have since been rescinded and re-issued to reflect overdue rent as the sole reason for eviction. During this meeting, it was revealed by regional executive director that room searches did not occur, instead a "well-being check" occurred to ensure safety of residents. Regional executive director stated that alcohol bottles were found in "plain site". LPM and LPA discussed eviction notices and regulations, and personal rights with Licensee, Administrator and Regional Executive Director. LPM informed licensee that bottles and other materials cannot be confiscated without clear permission from residents. Additionally, in regards to evictions, LPA and LPM informed Licensee that appropriate documentation must be in place to justify an eviction and that internal documentation should be in place in addition to required incident reporting to licensing department. Licensee expressed concern regarding residents who are not following house rules and continue to drink and produce and unsafe environment for themselves. LPA and LPM informed Licensee that all such events should be documented and reported to licensing department. Licensee was made aware by LPA and LPM that personal rights must be honored when entering rooms and confiscating items. Licensee acknowledged understanding. Licensee stated facility is an alcohol and drug-free facility. LPM requested an update to plan of operations and admission agreement reflecting this and requested documents be sent to licensing department for approval prior to implementation. LPM made Licensee aware that an updated plan of operation must be submitted to licensing department if facility moves forward with a new transitional memory care unit. LPM discussed procedures including LIC 200 and fire department approval prior to such implementation. {Cont. on 809C} In regards to facility's signal system, signal system has not been functioning properly since LPAs discovery on 3-8-22 and hand held bells have been in place. Licensee informed LPA and LPM that call system is now currently functioning. Regional executive director demonstrated call button during meeting which indicated an alarm sound and signal to caregiver's device alerting them to the room number requesting assistance. Licensee stated a permanent solution is in process which includes phone units in each resident room, however, parts of been delayed due to supply shortage indicated by Licensee. Licensee stated that an additional permanent solution to the signal system beyond the required signal system currently in place should be completed within 60-90 days as re-programming of system will also need to occur once parts are delivered. LPM asked Licensee how signal systems are monitored to ensure proper functionality. Regional executive director responded and stated that each new caregiver is given a device and each shift check units to ensure they are functioning. Additionally, maintenance department checks weekly to ensure units are working properly. Licensee will ensure process continues. Reporting requirements were addressed with Licensee, Administrator, and regional executive director. LPA discussed recent citations issued regarding medication errors not reported in addition to drug use and room searches. Regional executive director stated facility continues to use a communication form caregivers fill out to inform physician of any medication changes. Additionally, Licensee ensured LPA and LPM this process will continue and report additional instances relating drug and alcohol use as well as other instances which may affect the health, safety, or mental well-being of residents in care. Re-appraisals were discussed. Regional executive director stated that a plan continues to be in place since January 2022 to update all resident appraisal needs and service plans and appraisals annually or if a significant change occurs prior to the annual review. Regional Executive Director also stated daily meeting are held to discuss conditions of residents and makes notes of conditions of changes. LPA informed Licensee and Administrator that if significant changes are identified they should reflect on new appraisals and needs and service plan. Licensee and Administrator acknowledged understanding. LPM informed licensee and Administrator that Anuradha, who is the Administrator of Record must now be on premises 40 hours per week unless until a new administrator of record is in place. Anuradha acknowledged understanding and stated she will be on premises 40 hours per week. LPA requested an updated LIC 500 to reflect Anuradha's 40 hour schedule. No deficiencies cited today. An exit interview was conducted with Anuradha Saini and a copy of this report was given to Anuradha with request for signature and return via email to licensing department.the state’s words, verbatim · CDSS document, May 2, 2022

Allegation investigated: Questionable Death Staff did not respond to resident in a timely manner Facility not following COVID-19 guidelines

On 4-22-22 at 10:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the complaint allegations noted above. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified and gave permission for Jenna to accommodate LPA and sign in her absence. During this investigation, LPA interviewed 5 residents, 4 staff and executive director. LPA also conducted facility observation on 3-8-22 and 4-22-22. Records reviewed included COVID-19 mitigation plan, COVID-19 screening log, incident report for Resdient1 (R1), and functional capability assessment for R1. Investigation Bureau (IB) conducted assignment to obtain death certificate for R1 and acute hospital records for R1 which were reviewed by LPA. Allegation#1: Questionable Death. Based on records reviewed and interviews conducted, it was determined that R1 was sent to the hospital on 1-7-22 due to symptoms including dizziness, runny nose, weakness, and high blood pressure. {Cont. on 9099C}. Unsubstantiated Hospital records reviewed also revealed that R1 tested negative for COVID-19 at facility on 1-6-22 and positive for COVID-19 on 1-7-22 at the hospital. Hospital records reviewed also state R1 was sent to a skilled nursing facility from hospital on 1-10-22 and weakness began to progress. Hospital records further state that R1 was sent back to the acute hospital on 1-15-22 and returned to skilled nursing facility on 1-16-22. Death certificate reviewed states R1 passed away on 1-31-22 due to Parkinson’s disease with a contributing factor of COVID-19. Based on interviews and record reviews, it was determined that R1 was sent to acute hospital after an identified emergency need was addressed by staff at facility and reported to licensing department per regulations. Interviews and record reviews also revealed that R1’s needs were addressed in an appropriate time frame. A diagnoses of COVID-19 was reported on 1-7-22 at hospital. Interviews revealed that even though a COVID-19 outbreak was occurring during the time period of R1’s hospital admission, COVID-precautions were followed at facility. Facility observations on 3-8-22 and 4-22-22 revealed COVID-19 precautions were followed. Based on interviews, record reviews, and observations, it is determined that there is not a preponderance of evidenced to conclude that R1 passed away as a direct result of facility’s actions, therefore this allegation is UNSUBSTANTIATED. Allegation #2: Staff did not respond to resident in a timely manner: Based on record reviews and interviews, it was determined that R1 was experiencing symptoms including high blood pressure, runny nose, dizziness, and weakness at facility on 1-7-22 and was sent to acute hospital on 1-7-22. Record review of incident report reveals symptoms were noticed on 1-7-22 and sent to acute on 1-7-22 by facility staff. Additional interviews revealed that R1 tested negative for COVID-19 on 1-6-22 with no observed symptoms described above. Interviews further revealed that on 1-7-22, R1 originally refused to be sent to acute hospital but later agreed to be sent. Record reviews from hospital state upon hospitalization, R1 stated weakness as a complaint but denied other symptoms including fever, chills, nausea, vomiting, chest pain, and shortness of breath. Interviews with resident2 (R2), R3, R4, and R5 revealed needs are consistently met timely by staff. Based on record reviews and interviews, it is determined that there is not a preponderance of evidence to conclude R1’s needs were not met timely, therefore this allegation is UNSUBSTANTIATED. Allegation #3: Facility not following COVID-19 guidelines (UNSUBSTANTIATED): LPA conducted facility observations on 3-8-22 and 4-22-22, and interviewed R2, R3, R4,, R5, and R6. LPA also interviewed regional executive director, staff1 (S1), and S2. Based on interviews and observations, it was revealed that facility is following general COVID precautions including available hand sanitizer in appropriate locations, COVID-19 signage in appropriate locations, available Personal Protective Equipment (PPE) for 30 days, COVID-19 symptom screening at front door, appropriate COVID-19 record keeping, on-going COVID-19 testing as required, and staff compliance with mask while on facility premises. LPA also observed designated COVID-19 rooms available as needed and observed staff following PPE procedures and precautions. LPA also observed facility dining room to contain signage indicating 1 or 2 persons to a table depending on table size and promotion of social distancing. LPA also observed social distancing promoted at outside smoking patio. Based on interviews and observation, it is determined that there is not a preponderance of evidence to conclude that facility is not consistently following COVID-19 guidelines, therefore this allegation is UNSUBSTANTIATED. No deficiencies cited today. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Apr 22, 2022 · control 27-AS-20220223130051

Type of visit: Case Management - Other

On 4-22-22 at 2:10pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding previous eviction letters sent to Resident1(R1), R2, and R3 on 4-13-22. LPA met with Regional Executive Director (RED) Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini made aware and gave permission for Jenna to accommodate LPA and sign in her absence. LPA reviewed eviction letters and discussed supporting documentation content with RED. A review of an updated admission agreement with attachments was reviewed and discussed including policy on alcohol and drug use by residents. Recommendation from LPA to RED regarding policies was discussed. During case management visit, RED stated that previous eviction letters will be rescinded, revised, and re-issued to R1, R2, and R3 at a later date. Reporting requirements regarding eviction letters, changes in plan of operation, and admission agreements discussed with RED. No deficiencies cited today. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Apr 22, 2022

Type of visit: Case Management - Other

On 4-22-22 at 3:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding facility’s signal system status. LPA met with Regional Executive Director (RED) Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified and gave permission for Jenna to sign in her absence and accommodate LPA. LPA observed new phones to be put in place for residents which will send a signal to care staff altering them to location of resident for purposes of addressing care needs. LPA interviewed RED during case management and conducted facility observation. Based on interviews, it was revealed that necessary parts have been delivered and a programming technician necessary to conduct programming for the new system is delayed due to internal staffing issues with supplier. LPA observed a technician in facility attempting to program pendants previously used to provide a temporary signal system before new phone system is functional. LPA also observed various residents continuing to utilize handheld bells as a temporary signal alert system. RED made aware that signal system must be in place and functional 4/29/22. No deficiencies observed today. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Apr 22, 2022

Allegation investigated: Medication- Facility not following Physicians order. Medication- Facility staff failed to notify resident's Physician regarding medication.

On 4-8-22 at 10:32am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was contacted and gave permission for Jenna to accommodate LPA and sign in her absence. Throughout this investigation LPA interviewed staff1 (S1), S2, S3, and S4. LPA also reviewed medication log sheets and orders for resident1 (R1) and reviewed facility progress notes along with Administrator’s certificate, medication bottle label, and LIC 308 form for Administrator designee. Allegation: Facility not following Physician’s order: LPA reviewed physician orders for R1 which included a blood pressure medication to be given “two times per day.” Interviews conducted and medication log sheets reviewed revealed that R1 did not received this medication as ordered. Further review of blood pressure medication for R1 revealed no hold order from Physician. Based on interviews and record reviews, it was revealed that the blood pressure medication orders were not followed in that facility staff held R1’s medication without an order from R1’s physician to hold or stop giving the blood pressure medication to R1, and did not give the medication to R1 based on stated orders from Physician. As a result, the preponderance of evidence standard exists, therefore this allegation is SUBSTANTIATED. Substantiated Allegation: Facility staff failed to notify resident’s Physician regarding medication: Progress notes for R1 reviewed by LPA revealed three entries regarding a blood pressure medication order discrepancy. An entry on 2-3-22 states pharmacy was called. The following entry was on 2-15-22 which states clinic was called and staff was waiting for a response “within 24 hours.” The last entry was on 2-18-22 which states a staff member notified R1’s responsible person asking for assistance in obtaining a medication list. The progress notes did not specifically state a specific physician was notified to address the medication discrepancy for R1. The above information was also confirmed through staff interviews. Based on interviews and record reviews, it is determined that R1’s physician was not efficiently notified for medication order clarification for R1. As a result the preponderance of evidence standard exists, therefore this allegation is SUBSTANTIATED. Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal Rights provided.the state’s words, verbatim · CDSS document, Apr 8, 2022 · control 27-AS-20220222105340

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Apr 11, 2022

Incidental Medical and Dental Care. (e) For every prescription…medication for which the licensee provides assistance there shall be a signed, dated written order from a physician…This requirement is not met as evidenced by: Based on record reviews and interviews licensee did not ensure physician’s order for blood pressure medication was followed appropriately. Medication for R1 was held by facility staff and not given to R1 without a physician’s approved order to hold or stop medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Licensee will ensure staff complete medication training on assisting residents with medication and following physician orders. Training date to be submitted to LPA by POC due date. Proof of training to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Apr 11, 2022

Incidental Medical and Dental Care.A plan for incidental medical and dental care shall be developed by each facility (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not ensure physician was efficiently notified for medication order clarification for R1. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Licensee will submit a plan which ensures physician’s are efficiently and effectively notified for any resident care needs. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Incident

On 4-8-22 at 12:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 4-3-22. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was made aware of LPA’s visit and gave permission for Jenna to accommodate LPA and sign in her absence. LPA interviewed Administrator, Resident1 (R1) and R2 and reviewed incident report and resident records for R1 and R2. Based on interviews and record reviews it was determined that on 4-3-22, R1 and R2 were noted by staff to engage in an action in facility’s memory care unit which required facility to report. Based on interviews, it was determined that this action was mutual and without violation of resident rights. Record review and interview has determined that increase focus of supervision and updated plans of care are in place for R1 and R2 to address behaviors and safety measures. Facility reported incident to licensing department, ombudsman, and local law enforcement per regulations. LPA conducted facility observation of memory care unit at 12:50pm. Unit alarm doors are functioning and staffing levels were appropriate during observation. All toxins and other dangerous materials are not accessible to residents in care. Temperature of unit was between 68*F and 85*F. Fire extinguishers were fully charged. Unit was clean and sanitary with no foul odors noted. No deficiencies noted. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Apr 8, 2022

Type of visit: POC

On 4-8-22 at 1:55pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a plan of correction visit for a citation issued on 3-8-22 regarding facility’s current signal system. LPA met with Jenna Silva and explained the purpose of the visit. Facility’s signal system was distorted after an interruption in internet service provider which is required for signal system to fully function in facility. At this time, facility is continuing to utilize an alternative signal system using hand held bells and focused supervision for resident safety. LPA interviewed Licensee who stated that new parts are on order and expected to arrive today 4-8-22, which is expected to result in signal system functioning within approximately one week once in place and appropriately tested. Interview with Licensee also revealed that there have been shipping delays for required parts. Additional interviews were conducted with Resident1 (R1), (R2), and (R3). Interviews revealed hand held bells are currently in place. LPA observed hand held bells in place in various resident rooms. No deficiencies cited today. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Apr 8, 2022

Allegation investigated: Medication- Resident not receiving Blood Pressure medication for 3 weeks. Medication- Facility not following Physicians order. Medication- Facility staff failed to notify resident's Physician regarding medication. Administrator- Qualifications

On 3-16-22 at 10:10am Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with regional executive director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was contacted and gave permission for Jenna to accommodate LPA and sign in her absence. Throughout this investigation LPA interviewed staff1 (S1), S2, S3, and S4. LPA also reviewed medication log sheets and orders for resident1 (R1) and reviewed facility progress notes along with Administrator’s certificate and on-duty schedule. Based on interviews and record reviews conducted, it was determined that facility received a blood pressure medication for R1 from R1’s responsible party on 1-31-22 which contained a discrepancy between the physician’s order on file and the label on the bottle. Label on the bottle read “one time per day” and the order on file stated: “two times per day.” It was further revealed through interviews and record reviews that this medication was not given to R1 for a period of longer than 3 weeks. {Cont. on 9099C} Substantiated Furthermore, there was no indication of an order to stop giving the blood pressure medication, or any indication that R1 refused medication. Progress notes for R1 reviewed revealed three entries regarding medication order discrepancy. An entry on 2-3-22 states pharmacy was called. The following entry was on 2-15-22 which states clinic was called and staff was waiting for a response “within 24 hours.” The last entry was on 2-18-22 which states a staff member notified R1’s responsible person asking for assistance in obtaining a medication list. The progress notes did not specifically state a specific physician was notified to address the medication discrepancy. This information was also confirmed through staff interviews. Based on additional interviews it was determined that Administrator did not ensure a practice necessary to aid in resolving the medication discrepancy for R1 described above. Based on the interviews conducted and records reviewed, it is determined that the preponderance of evidence standard it met, therefore the above allegations are SUBSTANTIATED. Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna. Appeal rights provided. This document has been amended to reflect additional citations noted on LIC 9099 dated 4-8-22.the state’s words, verbatim · CDSS document, Mar 16, 2022 · control 27-AS-20220222105340

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 17, 2022

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure R1 receive a prescribed blood pressure medication for a period of more than 3 weeks. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2022

Plan of correction: Licensee will submit a plan to ensure residents are receiving medications as ordered. Plan to be submitted to LPA by POC due date Licensee will ensure staff training on medication regarding physician’s orders and working with pharmacies is completed. Proof of training to be sent to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(5) · Plan of correction due date: Mar 17, 2022

Administrator-Qualifications and Duties. (h) The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs…This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure Administrator communicate effectively with designee, other staff, and outside entities to resolve a medication order discrepancy for R1’s blood pressure medication resulting in R1 not receiving medication for a period longer than 3 weeks. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2022

Plan of correction: Licensee will submit a plan to ensure Administrator staff effectively communicate to meet residents’ needs.

Type of visit: Case Management - Incident

On 3-14-22 at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 3-12-22. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. Regional Executive Director Jenna Silva was present and was given permission by Anuradha to sign on her behalf and accommodate LPA. LPA interviewed Administrator, regional executive director resident1 (R1) and Staff1 (S1). LPA also conducted observation on the facility’s memory care unit. On 3-14-22, facility reported to regional office an incident which occurred on 3-12-22 which involved resident1 (R1) exiting premises resulting in an absence without leave (AWOL). LPA reviewed R1’s physician report, and needs and service plan. Based on interviews and record reviews it was determined that R1 exited premises at approximately 9:30pm on 3-12-22 and returned to facility at appropriately 10:30am on 3-13-22 unharmed. According to physician’s report, R1 is not to leave facility unsupervised. LPA also reviewed staff schedule and actual hours worked for 3-12-22. Staff schedule and actual hours worked revealed 5 caregivers were on duty during the time of this incident. Interview with S1 revealed that S1 and another caregiver were attending to another resident and did not hear the door alarm sound to indicate a resident exiting. During facility observation, it was determined that alarm system is functioning properly. A review of the incident report dated 3-13-22 stated facility staff did not determine the reason for R1s AWOL. A review of physician’s report for R1 revealed that R1 has a history of wandering and indicates R1 has dementia.. Based on today’s visit. Deficiencies are cited under Title 22, Division 6. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 14, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Mar 15, 2022

Care of Persons with Dementia. (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on interviews and record reviews, Licensee did not ensure the staff present appropriately coordinate to address R1s wandering behavior resulting in R1 exiting facility unattended on 3-12-22. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 14, 2022

Plan of correction: Licensee will develop a plan to ensure wandering and exit seeking behaviors are addressed to prevent any future attempted elopements. Plan to be submitted to LPA by POC due date. Licensee to assess current alarm system and submit a tested audit of alarm system functionality to determine appropriate resident safety.

Type of visit: Case Management - Other

On 3-14-22 at 10:10am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding personal rights of residents. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. Regional Executive Director Jenna Silva was present and was given permission from Anuradha to sign on her behalf and accommodate LPA. LPA interviewed regional executive director and interviewed resident1 (R1), R2, R3, R4, and R5. LPA also reviewed facility file documentation regarding notices of permission to enter resident rooms and facility house rules. Based on interviews and record review, it was determined that searches occurred in rooms for R1-R5 on 2-8-22 due to suspicion of illegal drug use and house rule violation. Interviews and record reviews revealed that permission was given by residents prior to entry and all residents were present during search. Interviews also revealed that an eviction letter was given to R1 and R3 but were rescinded after department review. R2, R4, and R5 did not receive eviction notices based on interviews conducted. At this time, facility is not actively pursuing eviction notices for R1-R5 and currently in process of organizing intervention services for residents in need. Based on today’s visit, no deficiencies are cited. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jennathe state’s words, verbatim · CDSS document, Mar 14, 2022

Type of visit: Case Management - Other

On 3-14-22 at 11:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding potential room changes. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. Regional Executive Director Jenna Silva was present and was given permission by Anuradha to sign on her behalf and accommodate LPA. LPA interviewed Administrator and Regional Executive Director. LPA also reviewed notices of potential room changes given to resident1(R1) and R2 . LPA also interviewed R1 and R2 and reviewed additional notices given to other residents in care. Based on interviews and record reviews, it was determined that facility is planning to convert the downstairs unit to memory care and hospice. A notice dated 2-3-22 was given to residents in care stating the intention of potential room changes due to this conversion and the reason for the conversion. It was further discovered that total bed capacity will not change as a result of this conversion, however, residents currently occupying a downstairs unit may be relocated upstairs, given the option to rent the entire room out at a private room rate, or opt to have a roommate occupying the shared portion of said room. Contents of the letter and potential revisions were discussed with regional executive director and resident rights were reviewed. Additional processes such as the required LIC 200 form and fire clearance requirements were discussed. At this time, facility does not have a firm date of when the conversion will take place and has given pre-emptive notices to residents to make them aware of the future plans for the conversion. No deficiencies were cited. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jennathe state’s words, verbatim · CDSS document, Mar 14, 2022

Allegation investigated: Resident not accorded privacy while in care

On 3-8-22 at 9:29am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a complaint investigation for the allegation noted above. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuraha Saini was notified and gave permission for Jenna to accommodate LPA and sign in her absence. On 2-16-22, LPA interviewed staff1 (S1) and S2. On 3-8-22, LPA interviewed resident2 (R2), R3, R4, and R5. LPA also interviewed regional executive director on 2-9-22. A facility observation was conducted by LPA on 3-8-22. Based on the interviews conducted and facility observation, it was determined that there have been no reports of staff or outside individuals entering or attempting to enter resident rooms without permission. Current procedures of knocking on residents’ doors and waiting ample time for a response are reportedly followed based on the interviews and observation conducted. Staff training on resident personal rights is conducted as part of regular staff training. Based on interviews, observation and record review it is determined that there is not a preponderance of evidence to prove resident privacy rights are being violated, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jenna. Unsubstantiated Based on the interviews, record reviews, and observation conducted, it is determined that R1 has reasonable access to a television and the residency fee paid does not include an individual television provided in R1’s room per admission agreement. As a result, the preponderance of evidence standard is not met, therefore, this allegation is UNFOUNDED. An exit interview was conducted with Jenna Silva and a copy of this report was given to Jennathe state’s words, verbatim · CDSS document, Mar 8, 2022 · control 27-AS-20220203132627

Type of visit: Case Management - Other

On 3-8-22 at 3:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit during an investigation on complaint # 27-AS-20220223130051. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was contacted and gave permission for Jenna to accommodate LPA and sign in her absence. During complaint visit it was discovered that facility’s signal system is not functioning properly. LPA tested eight rooms’ signal system by pressing provided emergency pendent located in residents’ rooms with 8/8 rooms unable to send a signal to staff to alert them of resident needs. LPA also interviewed regional executive director and licensee during visit. Deficiencies are issued based on today’s visit. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 8, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(A)(B)(C) · Plan of correction due date: Mar 9, 2022

Maintenance and Operation (i) Facilities shall have signal systems which shall...(1)All facilities licensed for 16 or more...shall:(A)Operate from each resident's living unit.(B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on observation and interview, it was determined that facility's signal system did not function properly per regulatory requirements in 8 out of 8 resident rooms. This poses an immediate health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2022

Plan of correction: Licensee will submit plan to ensure resident needs are met with alternative signal system until current system is repaired or replaced. Plan to be submitted to LPA by POC due date. Licensee has provided hand held bells for residents in care as of 3-8-22. Licensee will repair or replace current signal system to meet regulatory requirements. A time frame for repair or replacement to be submitted to LPA by POC due date.

Type of visit: Case Management - Other

On 3-8-22 at 2:43pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit during an investigation for complaint #27-AS-20220222105340. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified and gave permission for Jenna to accommodate LPA and sign in her absence. During complaint visit, it was revealed that an incident occurred in February 2022 regarding resident1 (R1) not receiving a prescribed blood pressure medication for a period of approximately 3 weeks. LPA interviewed Regional Executive Director. LPA also reviewed facility incident reports for February 2022. Based on interviews and record reviews it is determined that this incident was not reported by facility to licensing agency upon facility learning of difficulty in resolving this occurrence. Deficiencies are issued based on today’s visit. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 8, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 22, 2022

Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports...:(1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified…(D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on interviews and record reviews, R1 did not receive prescribed blood pressure medications for approximately 3 weeks and incident was not reported to licensing agency. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2022

Plan of correction: Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date Licensee will conduct staff training on regulation 87211 and submit proof of completed training to LPA by POC due date. Training from an outside vendor to be utilized.

Allegation investigated: Resident rates increased without proper notification

On 2-23-22 at 11:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Alicia Carranza and explained the purpose of the visit. Administrator Anuradha Saini was notified and gave permission for Alicia Carranza to accommodate LPA and sign in her absence. During this investigation, LPA reviewed Admission agreement for Resident1 (R1), a general rate increase notice furnished by facility, interviewed R1, and interviewed regional executive director. Based on interviews and record review it was determined that the admission agreement for R1 contains a provision which states a 60-day notice will be given for a change in monthly fee. Review of general rate increase notice dated 10-1-21 revealed that the notice was not addressed to a specific resident and did not contain a signature of acknowledgement in order to determine proof of issuance. Additionally, this notice did not state an adequate reason for an increase or a general description of any additional costs as per regulatory requirements. Interview with R1 revealed a notice was issued on 1-24-22 to reflect an effective rate change date of 2-1-22. {Cont on 9099C} Substantiated Based on interviews and record reviews it is determined that the preponderance of evidence standard has been met, therefore, this allegation is SUBSTANTIATED. Deficiencies are cited under Title 22, Health and Safety Code, chapter 3.2. An exit interview was conducted with Alicia Carranza and a copy of this report was given to Alicia. Appeal Rights provided.the state’s words, verbatim · CDSS document, Feb 23, 2022 · control 27-AS-20220203132627

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a) · Plan of correction due date: Feb 28, 2022

Increase in fee rates for elderly residents...60 days' written notice..(a)If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs. This requirement is not met as evidenced by: Based on record review and interviews Licensee did not ensure proper 60-day notification was given to R1 for a rate increase. This poses a potential resident rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2022

Plan of correction: Licensee has re-issued a revised 60-day notice with proper contents to R1 on 2-18-22 to reflect the new rate change on 5-1-22. Licensee will read health and safety code 1569.655 and provide a signed certification of understanding to LPA by POC due date.

Type of visit: Case Management - Incident

On 2-9-22 at 2:52pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a case management visit for an incident reported on 1-5-22. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified of LPAs visit and gave permission for Jenna to accommodate LPA and sign in her absence. According to incident report dated 1-5-22, an encounter between two male residents was witnessed by Staff1 (S1) on 1-4-22 which required separation of residents. LPA reviewed incident report with Regional Executive Director and interviewed Regional Executive Director and (S1). LPA also conducted a health and safety case management check. LPA was screened for COVID upon entry. Social distancing was practiced and COVID-19 signage was in place. Facility temperature was at 75*F. Facility was clean and sanitary with no foul odors. Sharp objects, toxins, and other dangerous items were inaccessible to clients in care. LPA screened facility for COVID questions upon entry. Based on interviews conducted today, it was determined that knowledge of suspected abuse occurred but was not reported timely per regulatory reporting requirements. Incident report and interview revealed Resident1 (R1) sustained redness of a body part after an encounter with R2. Citations are issued today based on Title 22 regulations, division 6, chapter 8. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.the state’s words, verbatim · CDSS document, Feb 9, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Feb 10, 2022

c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by: Based on interviews conducted an incident of suspected abuse occurred on 1-4-22 and was not reported timely to local law enforcement and ombudsman. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2022

Plan of correction: Licensee will report the incident to local law enforcement and ombudsman by POC due date and submt proof of completed reporting to LPA by POC due date. Licensee will schedule training on Elder Abuse reporting and submit scheduled training date to LPA by POC due date.

Type of visit: Case Management - Incident

On 1-24-22 at 3:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open a case management visit for an incident reported on 1-5-22. LPA met with Regional Executive Director Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified of LPAs visit and gave permission for Jenna to accommodate LPA and sign in her absence. According to incident report dated 1-5-22, an encounter between two males residents was witnessed by staff on 1-4-22 which required separation of residents. LPA reviewed incident report with Regional Executive Director and interviewed Resident1 (R1) and R2. LPA interviewed RED. LPA attempted to interview Staff1 (S1) who was not available at this time. LPA also conducted a health and safety case management check. LPA observed residents and staff to be wearing masks, hand sanitizer was available at appropriate locations throughout facility. LPA was screened for COVID upon entry. Social distancing was practiced and COVID-19 signage was in place. Facility temperature was at 75*F. Facility was clean and sanitary with no foul odors. Sharp objects, toxins, and other dangerous items were inaccessible to clients in care. LPA screened facility for COVID upon entry. Additional time is needed to complete this case management. LPA will contact Administrator at a later time for completion. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Jan 24, 2022

Allegation investigated: COVID-19 precautions are not being followed

On 1-19-22 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the allegation noted above and deliver findings. LPA met with Director of Nursing Marievec Andrade and explained the purpose of the visit. Administrator Anuradha Saini was notified of LPA’s visit and gave permission for Marievec to accommodate LPA and sign necessary paperwork. Throughout this visit and other visits pertaining to this investigation LPA interviewed five staff members, four residents, and conducted facility observations on 1/4/22, 1/11/22, and 1/19/22. LPA also reviewed facility’s COVID-19 mitigation plan. LPA observed residents and staff wearing appropriate personal protective equipment (PPE) throughout facility. LPA also observed facility designating various rooms for quarantine including quarantined section with dedicated staff bathroom and breakroom. Dining room and smoking areas were observed by LPA to promote social distancing. Appropriate COVID precaution signage was observed to be in place. LPA was screened upon entry for temperature and symptoms, and hand sanitizer was available at the sign in desk upon facility entry. {Cont. on LIC 9099C} Unsubstantiated Based on interviews with residents, it was stated that precautions are being followed and masks as well as other PPE are being provided as necessary. Based on interviews with staff, it was stated that precautions are followed, with necessary on-going training on precautions to reinforce on-going practice of COVID-19 precautions. Based on observations and interviews conducted, it was determined that there is not a preponderance of evidence to prove COVID-19 precautions are not followed on a routine basis. Therefore, the allegation noted above is UNSUBSTANTIATED. An exit interview was conducted with Marievec Andrade and a copy of this report was left with Marievec. Appeal rights provided.the state’s words, verbatim · CDSS document, Jan 19, 2022 · control 27-AS-20220103131036

Type of visit: Office

An Informal Conference was conducted at 10:00am on 1/6/22 at the Sacramento Regional Office virtually via Teams Meeting. Present for the meeting was Administrator, Anuradha Saini, Licensee Sunny Saini , Regional Executive Director Jenna Silva, Licensing Program Manager (LPM) , Liza King and the writer of this report Licensing Program Analyst (LPA), Michael Bilger . The purpose of the informal conference was to address the facility’s compliance issues. The Department has concerns stemming from site inspections on multiple dates during the year 2021. The licensee was told that this Informal conference is a part of the Administrative Action process and that further citations may result in an elevation to a formal non-compliance conference that could then lead to referral to the Department's legal division for possible revocation of license. Issues discussed during the meeting were: 1. 87413(a)(1) Personnel-Operations: In each facility, when regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. (Memory care unit was left unattended during an assist with 911 personnel in the assisted living section) 2. Care and Supervision: The Licensee shall provide care and supervision as necessary to meet the client’s needs. (Licensee did not ensure a proper repositioning and lift was performed for a resident in care for purposes of promoting fall prevention) 3. 80061(b)(1)(D)Reporting requirements: (b) Upon the occurrence...of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day...a written report containing the information...shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include...(D)Any injury to any client which requires medical treatment (Facility did not furnish timely incident reports for incidents occurring on 8/5/21 and 8/7/21) {Cont. 809D} 4. 87211(a)(1)(B) Reporting Requirements: Each licensee shall furnish….reports as the Department may require…(1) A written report shall be submitted…to the person responsible for the resident within seven days of the occurrence…(B) Any serious injury….occurring while the resident is under facility supervision. (Facility did not inform responsible person in writing of a fall occurring on 10-27-21 5. 87411(a) Personnel Operations: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... (Licensee did not ensure R1 received appropriate care and supervision due to inadequate staff coverage and resident sustained a fall with injury) 6. 87468.1(a)(9): Personal Rights: Residents in all residential care facilities for the elderly shall have…the following rights: To have communications to the licensee from their representatives answered promptly and appropriately. (Licensee did not ensure responsible person was answered promptly when requesting records due to a fall). 7. 87463(a). Reappraisals. The pre-admission appraisal shall be updated in writing…as frequently as necessary to note significant changes and to keep the appraisal accurate. (Licensee did not ensure an updated appraisal was completed for a resident due to a fall event on 10-27-21) In an effort to support the facility maintaining substantial compliance with health and Safety Statute and Title 22 regulations, the Department is developing a plan with the licensee to address causes for concerns. Plan to address compliance concerns: Facility will now ensure at least 2 staff are on duty at all times in each assisted living and memory care units. This plan also includes coverage for staff who take scheduled breaks. Additionally, this plan includes the utilization of on-call staff and supervisors to fill in for shifts when necessary. Inservice training was completed to address this plan. This plan was implemented on 12-1-21. Facility has trained staff in regard to repositioning and lifting of residents as necessary. Staff to receive on-going training on when to call 9-1-1 for emergencies and when a proper repositioning may be performed to promote fall prevention. Facility will also be contracting with outside agencies for additional training. Training records to be maintained at facility and available for review by the Department as necessary. LPM requested copy of training schedule for January and February. {Cont. on 809C} Facility shall continue to maintain a binder for all incident reports. The binder will contain blank incident reports and made available to staff. Procedure to include: (1) Staff fills out incident report and places in binder, (2) Binder is brought into facility’s daily meeting for incident report reviews, (3) Management staff to discuss incident reports, (4) Incident reports to be sent to Department. Facility has developed and will continue to implement a reporting template to notify responsible persons in writing of incidents within 7 days. Facility has developed and will continue to implement a checklist to ensure all appropriate parties are notified of incidents including responsible persons, physician, and the Department. Facility to implement cross-training of staff to help ensure all resident needs are met. Plan includes cross training housekeeper as caregiver and night shift coverage. Plan to be implemented on 1-3-22 Reappraisals will now be tracked by date of when they are due. A marked date will be placed on resident binders to alert staff when reappraisal is up for renewal. Case conferences are to be completed on a monthly basis to address high risk residents, and to include review of current appraisal with resident and/or responsible person as applicable. Case conferences are to be implemented by 1-26-22. A Director of Nursing was hired and is currently assisting with this process. The department will provide additional case management visits No deficiencies are cited during today’s meeting. An Exit interview was conducted with Anuradha Saini and Jenna Silva, and copy of this report was provided to Anuradha and Jenna via email with request for return with signature.the state’s words, verbatim · CDSS document, Jan 6, 2022

Type of visit: Case Management - Other

On 12-21-21 at 12:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit related to a previously issued citation on 12-9-21 for complaint #27-AS-20211116124932. LPA met with Jenna Silva and explained the purpose of the visit. Anuradha Saini was notified via phone of LPA's visit and gave permission for Jenna to accommodate and sign paperwork in her absence. The citation previously issued on 12-9-21 has been amended to update the Title 22 regulation number #87411(a). As a result, the previously issued civil penalty has been removed. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal Rights provided.the state’s words, verbatim · CDSS document, Dec 21, 2021

Type of visit: Case Management - Incident

On 12/21/21 at 1:05pm, Licensing Program Analyst (LPA) arrived unannounced to conduct a case management visit regarding recent incident reports received. LPA met with Regional Center Executive (RCE) Jenna Silva and explained the purpose of the visit. Administrator Anuradha Saini was notified by phone and gave permission for Jenna to accommodate LPA and sign paperwork in her absence. LPA reviewed incident reports from 12-10-21 to 12/21/21. LPA also interviewed RCE. Based on record reviews and interviews, it was determined that facility reported multiple falls and other resident events between the dates noted above. Record review determined incidents were reported timely and appropriately. LPA also reviewed charts for Resident1 (R1), R2, R3, R4, and R5. Charts reviewed contained updated appraisal needs and service plans. Facility was toured with RCE. No obstructions to fire exits noted. Facility temperature was 72*F throughout. LPA did not observe any toxins or dangerous items accessible to residents in care. Based on interview, it was determined facility is utilizing an outside service to assist with additional needs of residents as necessary at this time. LPA also reviewed staffing scheduled which shows 4 staff on duty at night, 6 staff on PM, and 8 staff on AM. Based on interviews and record reviews, no deficiencies are cited for today's visit. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna.the state’s words, verbatim · CDSS document, Dec 21, 2021

Allegation investigated: Resident had unwitnessed fall and received injuries Reporting party not notified of fall Reappraisal not completed for change in condition Documents not provided to DPOA upon request

On 12-9-21 at 10:18am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with Jenna Silva, regional executive director and explained the purpose of the visit. Licensee Sunny Saini gave permission for Jenna to sign documents and accomodate LPA. During the course of this investigation LPA reviewed facility file documentation including staffing schedule for October 2021, actual hours worked by staff on October 26-27, 2021, appraisal forms for resident1 (R1), and Incident report for R1. LPA conducted a facility observation on 11-17-21. LPA also conducted interviews with Staff1 (S1) on 1-17-21, S3 on 11-24-21, and S4 on 11-29-21. LPA also conducted interviews with R1 on 11-17-21 and interview with responsible person for R1 on 11-24-21. Based on interviews conducted, facility observation, and records reviewed the findings for the allegations are as follows: Allegation #1: Resident had unwitnessed fall and received injuries: LPA reviewed incident report for R1 dated 10-28-21 which described a fall occurring at 5am on 10-27-21 for R1. This fall was described as an unwitnessed fall with head injury. Based on interview and observation with R1, LPA observed bruise markings on R1s face on 11-17-21. {Cont. on 9099C} Substantiated Amended from original report dated 12-9-21: Based on interview with S1 and observation, it was determined that 32 residents reside in memory care with 12 residents identified as fall risk residents. Upon LPAs review of actual hours worked by caregivers, it was determined that three caregivers were on duty during the night shift on 10-26-21 until the morning of 10-27-21. Upon further review it was determined that S2 began shift at 10:25pm and clocked out at 7:00am, S3 began shift at 8:00pm and clocked out at 3:30am, S4 began shift at 10:15pm and clocked out at 7:00am. LPA reviewed staffing schedule on 11-17-21 and interviewed S1, which reveals 3 caregivers scheduled to work during the hours of 10:30pm to 7:00am on 10-26-21 until the morning of 10-27-21. Based on interviews, observation, and record reviews it is determined that R1 resides in memory care and fell at 5:00am on 10-27-21 and sustained injuries, and upon further review, determined that only one staff was on duty in memory care and one staff was on duty in assisted living at the time of R1’s fall and without the presence of additional staff member previously on duty. Incident report states this fall was unwitnessed. Therefore, this allegation is SUBSTANTIATED. Allegation #2: Reporting party not notified of fall: LPA reviewed incident report for R1 dated 10-28-21. Based on review of incident report, there is no indication of responsible party being notified of fall incident occurring on 10-27-21 at 5:00am. Interviews with responsible person for R1 revealed no contact was made to responsible party in writing after the fall noted above. Interview with S1 revealed that it could not be confirmed if responsible party was notified of all noted above. Based on interviews and record reviews, this allegation is SUBSTANTIATED. Allegation #3: Reappraisal not completed for change of condition: LPA reviewed appraisal forms for R1 on 11-17-21. An appraisal needs and service plan for R1 was observed by LPA to be dated 2-19-21 with no update regarding fall precautions relating to the fall of R1 which occurred on 10-27-21 at 5:00am. A reappraisal form for R1 was requested on 11-17-21 and was not located in R1s record. Based on record review and observation, this allegation is SUBSTANTIATED. Allegation #4: Documents not provided to POA upon request. LPA conducted interviews with S1, and responsible person for R1. Based on interviews conducted, it was determined that a request for records relating to information on R1s fall on 10-27-21 at 5:00am was made by responsible person on 11-1-21 and not received by responsible person for R1 until 11-19-21. Based on interviews conducted, this allegation is SUBSTANTIATED. As a result of today’s visit and the findings noted above, deficiencies are cited under Title 22, division 6. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 9, 2021 · control 27-AS-20211116124932

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 10, 2021

Ammended from original report dated 12-9-21: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on record reviews, interviews, and observation, R1 sustained a fall with injury...Licensee did not ensure R1 received appropriate care and supervision due to inadequate staff coverage. This poses an immediate health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee will submit staffing schedule to indicate appropriate levels of coverage necessary to meet residents’ needs. Schedule to be submitted to LPA by POC due date. Licensee will conduct staff training on fall precautions and submit a scheduled training date to LPA by POC due date. Licensee will submit plan on providing adequate coverage to meet residents’ needs in the event of staff shortages. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Dec 20, 2021

Reporting Requirements (a) Each licensee shall furnish….reports as the Department may require…(1) A written report shall be submitted…to the person responsible for the resident within seven days of the occurrence…(B) Any serious injury….occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews and record review, responsible person for R1 was not notified in writing of fall that occurred on 10-27-21 at 5:00am within seven days of occurrence. This poses a potential health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee will read regulation 87211(a)(1) and submit a signed statement of understanding and agreeance to follow regulation. Licensee will submit a plan to ensure responsible parties are notified appropriately following incidents as noted in regulation 87211(a)(1)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Dec 20, 2021

Reappraisals. (a) The pre-admission appraisal shall be updated in writing…as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: Based on records review and interviews, facility did not update an appraisal form for R1 to address fall precautions and a fall event of R1 which occurred on 10-27-21 at 5:00am. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee will develop a plan to ensure all resident appraisals are updated as appropriate to meet the needs of residents in care. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(9) · Plan of correction due date: Dec 20, 2021

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have…the following rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidenced by: Based on interviews, Licensee did not ensure responsible person for R1 was answered promptly when requesting documents relating to a fall event for R1. Documents were requested on 11-1-21 and not received until 11-19-21. This poses a potential health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee will read regulation 87468.1(a)(9) and submit a signed understand of regulation indicating agreeance to follow the regulation. Licensee will conduct staff training to ensure communications from responsible persons of resident in care are answered timely. Proof of training to be submitted to LPA by POC due date.

Type of visit: Case Management - Other

On 12-9-21 at 12:12pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management relating to complaint #27-AS-20211116124932. LPA met with Jenna Silva and explained the purpose of the visit. Licensee Sunny Saini gave permission for Jenna to sign documents and accommodate LPA. During a complaint visit on 11-17-21, LPA reviewed Resident1 (R1) record and conducted interview with staff1(S1). During record review it was determined that physician’s report for R1 was not obtained and was absent from R1s chart. As a result of today’s visit, deficiencies are cited under Title 22, Division 6, Chapter 8. An exit interview was conducted with Jenna Silva and a copy of this report was left with Jenna. Appeal rights provided.the state’s words, verbatim · CDSS document, Dec 9, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80069(a) · Plan of correction due date: Dec 20, 2021

Client Medical Assessment. Except for licensees of ARFs, prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client…The requirement is not met as evidenced by: Based on record review and interview, physician’s report from R1’s chart was absent and not obtained. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2021

Plan of correction: Licensee will complete physician’s report for R1 and submit copy to LPA by POC due date. Licensee will develop and submit a plan ensuring all residents will have current and updated physician reports in charts as appropriate. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Other

On 11-30-21 at 1:10pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit due to a recently expressed concern regarding resident rights. LPA met with resident care coordinator (RCC) Ian Phitnoukanh and explained the purpose of the visit. Administrator Anuradha Saini was notified of LPAs visit and gave permission for Ian to sign in her absence. LPA interviewed Resident1 (R1) and R2. LPA also interviewed RCC. Based on these interviews it was determined that R1 and R2 have been sustaining a mutual friendship within the facility including private visitations, meals together, and attending activities together. It was further determined that R1 and R2 are able to interact with one another without interference of facility staff. Based on interviews conducted, R1 and R2 are continuing to maintain a mutual friendship without infringement on resident rights. As a result of today's visit, no deficiencies are cited today. An exit interview was conducted with Ian Phitnoukanh and a copy of this report was left with Ian.the state’s words, verbatim · CDSS document, Nov 30, 2021

Type of visit: Case Management - Incident

On 11-23-21 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit due to incident reports received on 11-19-21. LPA met with Resident Care Coordinator (RCC) Ian Phitsanoukanh explained the purpose of the visit. Licensee was on premises and gave permission for Ian to sign and accommodate LPA during today's visit. LPA conducted a health and safety check during case management visit. LPA's temperature was checked and logged at entry. Sign in procedures were initiated. Facility temperature was 75*F throughout facility. Staffing included 3 caregivers in memory care and 1 med tech, 2 caregivers in Assisted Living and 1 med tech. Resident were eating lunch at 11:50am and served according to mealtimes and menu items. At 10:05am LPA reviewed 14 incident reports received on 11-19-21. 4 out of 14 incident reports were reported as unwitnessed falls. LPA also reviewed facility’s fall prevention program and conducted interviews with Resident1 (R1), Staff1 (S1) and S2. LPA also conducted observation of R1 relating to self-administered medication procedures at 12:45pm and reviewed medication log sheet and physician’s report for R1 at 12:10pm. Based on interviews and record reviews it was determined that R2, R3, R4, R5, and R6 are receiving fall prevention services. Based on review of medication log sheet, incident report, interviews, and observation it was determined that R1 is able to administer own medications accurately. Additionally during review of incident report, it was determined that 6 of 14 incident reports were submitted to regional office beyond seven days of occurrence and not within reporting requirement regulations. As a result of today’s visit, deficiencies are cited per Title 22 regulations, division 6, chapter 8. A civil penalty in the amount of $250 is assessed due to a repeat violation. An exit interview was conducted with Ian Phitsanoukanh and a copy of this report was left with Ian. Appeal rights provided.the state’s words, verbatim · CDSS document, Nov 23, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b)(1)(D) · Plan of correction due date: Nov 29, 2021

Reporting requirements. (b) Upon the occurrence...of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day...a written report containing the information...shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include...(D)Any injury to any client which requires medical treatment. This requirement is not met as evidenced by: Based on record review licensee did not ensure timley reporting of incident in 6 of 14 incident reports reviewed. This poses a potential health and safety risk for resident in care. Civil penalty assessed due to repoeat violation.the state’s words, verbatim · CDSS document, Nov 23, 2021

Plan of correction: Licensee will submit a plan to ensure timely reporting of incidents to licensing department. Plan shall include a procedure for designating an individual in charge of auditing and ensuring accurate and timely reporting. Licensee to submit plan to LPA by POC due date.

Type of visit: Case Management - Incident

On 11/5/21 2:20pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit on recent incident reports of falls. LPA spoke with Administrator Morgan Whinery via phone and explained the purpose of the visit. Morgan was unable to be present and gave permission for Ian Phitsanoukanh, resident care coordinator to accompany LPA and sign in her absence. LPA toured facility with Ian to ensure Title 22 compliance and safety. All sharp objects and toxins were secured. Memory care door was functioning properly including alarm device. Room temperature was 75*F throughout facility. There were no obstructions to fire exit noted. There are 5 caregivers and 2 med techs for AM shift, 4 caregivers and 2 med tech for PM shift, and 2 med tech/caregiver are scheduled for noc shift with on-call available. LPA reviewed fall incident reports and resident files for Resident1 (R1), R2, R3, R4, R5, an R6. Falls were reported between the dates of 9-25-21 and 10-14-21. LPA also interviewed Administrator, and Ian Phitsanoukanh. Of the 6 resident falls reviewed, 4 were unwitnessed falls. All reporting requirements for incident reports received were met per regulations. Based on interviews, it was determined that facility has now implemented a fall prevention program as of 9-25-21 which includes safety protocols and in-service training. LPA reviewed fall prevention program. Fall prevention training was noted to occur on 10-28-21. Needs and service plans for R1, R2, R3, R4, R5, and R6 were reviewed by LPA. LPA observed resident rooms with fall preventions in place. As a result of this visit, no deficiencies are cited. An exit interview was conducted with Ian Phitsanoukanh and a copy of this report was left with Ian.the state’s words, verbatim · CDSS document, Nov 5, 2021

Type of visit: Post Licensing

On 10/6/21 at 12:55pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a post licensing inspection visit. LPA was greeted by Administrator Morgan Whinery and LPA explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry rooms, common TV area, and outside of the facility perimeter to ensure compliance with Title 22 regulations. Facility is a 158-bed assisted living facility with a current census of 79. LPA was screened upon entry for temperature and asked to sign in. Facility has a formal dining room and TV lounge area for residents. Facility also has a separate and secured memory care unit. All door alarms were in functioning order throughout facility. Elevator is functioning properly and last serviced 9/7/21. There is a separate staff break upstairs and downstairs. All knives, toxins, and other chemicals were inaccessible to residents in care. A tour of the outside was conducted. LPA did not observe any obstructions to emergency exits. "See something, Say something" poster was in place. Resident rights and rights of resident council notices posted. Emergency disaster plan and facility sketch updated and posted. Administrator certificate posted and expires 11/21/2022. All active employees are fingerprint cleared. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. {Cont. on 809C} Refrigerator temperature measured at 40*F. Freezer temperature measured at 0*F Water temperature was measured at 119.7*F in resident bathroom and room temperature reads 75*F on first floor and 78*F on the second floor. LPA observed the facility to have adequate food supply in kitchen area. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire alarm is functioning appropriately. Facility has an emergency food and water kit. Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Morgan Whinery.the state’s words, verbatim · CDSS document, Oct 6, 2021

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 9/13/21 at 2:48pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding an incident discussion with Administrator from 9/10/21. LPA met with Administrator (ADM) Morgan Whinery and explained the purpose of the visit. Incident involved Resident1 (R1) obtaining and recording temperatures for visitors upon entry. LPA interviewed Administrator and reviewed Provider Information Notice (PIN) 21-40 stating that a designated staff member shall be responsible for screening visitors upon entry. Upon entry today, LPA was greeted by R1 who took temperature upon observation. LPA observed temperature was written and recorded by designated staff member (Staff1) (S1). Administrator stated that designated staff members are now in place to verify and record all temperatures and perform screening questions for visitors upon entry. LPA observed S1 recording and verifying temperature and asking appropriate screening questions after temperature was taken by R1. LPA also interviewed R1 during today's visit. LPA also toured facility inside and out. Facility temperature was 75*F. Staffing levels were appropriate to meet resident needs. No safety hazards observed during today's visit. Based on today's visit an advisory note LIC 9102 was created and furnished to Administrator to reflect PIN 21-40 and Title 22 regulations, Division 8. No deficiencies observed during today's visit. LPA requested updated COVID Mitigation Plan to reflect the above procedure in place for visitor screening. An exit interview was conducted with Administrator Morgan Whinery and a copy of this report was left with Morgan.the state’s words, verbatim · CDSS document, Sep 13, 2021

Type of visit: Case Management - Incident

On 9/3/21 at 10:30am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 8/5/21. LPA met with Administrator Morgan Whinery and explained the purpose of this visit. LPA reviewed the following documents: Resident1 (R1)'s service plan, hospital records, and previous incident reports. LPA also conducted interviews with Staff1 (S1) and S2. LPA also interviewed Day Program social worker for R1. Based on interviews with day program social worker, S1, and S2 and based on records reviews it was determined that R1 was at the day program on 8/5/21 and was sent to the emergency room (ER) after a registered nurse (RN) at the day program noticed a wound on R1's left leg with oozing puss needing attention. According to record review, RN sent R1 to ER for further evaluation of wound on 8/5/21. Based on interview with S2 and hospital record review, it was revealed that R1's wound was previously addressed by S2 on 7/12/21 and sent to ER for further evaluation and treatment. Based on interview with day program social worker it was revealed that day program attempted to call facility, but attempted the call using an phone number no longer in service and has since learned of the new phone number. As a result and based on additional interviews with S1 and S2, it was revealed that facility did not receive notification from day program on 8/5/21 that R1 had been sent out, and did not learn of R1's hospitalization until hospital notified facility of R1's time for discharge on 8/5/21. Upon further record review of incident reports, it was determined that an incident report for 8/5/21 was not received by licensing department until 9/3/21, and an additional incident report from 8/7/21 was not received by licensing department until 8/18/21. Based on today's visit, deficiencies are being cited under Title 22 regulations, Division 8. An exit interview and a copy of this report along with appeal rights was left with Administrator Morgan Whinery.the state’s words, verbatim · CDSS document, Sep 3, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b)(1)(D) · Plan of correction due date: Sep 17, 2021

Reporting requirements. (b) Upon the occurrence...of any of the events specified in (1)...a report shall be made to the licensing agency within the agency's next working day...a written report containing the information...shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include...(D)Any injury to any client which requires medical treatment. This requirement is not met as evidenced by: Based on record review and interviews, Licensee did not furnish incident reports for R1's hospitalizations on 8/5/21 and 8/7/21 in a timely manner. This posses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2021

Plan of correction: Licensee will conduct staff training on regulation 80061 and submit proof of completed training to LPA by POC due date Licensee will read and provide a signed statement of understanding of regulation 80061.

Type of visit: Case Management - Other

On 7/30/21 at 10:50am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit to address concerns previously expressed by a resident. Concerns expressed were lack of food quality and quantity and insufficient staffing. LPA met with Administrator Anuradha Saini and explained the purpose of the visit. At 11:25am LPA interviewed Resident1 (R1), R2 at 11:45am, R3 at 11:55am, and R4 at 12:10pm. LPA also interviewed Administrator and Administrator designee. LPA also reviewed facility records including current menu and actual hours worked for the period of 7-15-21 to 7-30-21. Based on interviews and record reviews, it was determined that caregivers were on duty as assigned and able to meet the needs of residents in care across morning, evening, and night shifts. LPA reviewed current menu and observed lunch meal at 12:25pm which consisted of sufficient amounts of food to meet regulatory guidelines. Additionally, based on resident interviews, it was determined that quality and quantity amounts of food were suitable, but a variety in menu choices is requested. LPA toured facility inside and out with Administrator designee. LPA observed facility to be clean and sanitary and in good repair. Temperature inside facility was 76*F throughout. LPA toured kitchen area which was clean and sanitary. Food supply was sufficient upon observation. Per California Code of Regulations, Title 22 there were no deficiencies observed or cited during today's case management visit. A exit interview was conducted and a copy of this report was left with Administrator Anuradha Saini.the state’s words, verbatim · CDSS document, Jul 30, 2021