Valle Verde

Type of visit: Required - 1 Year

On 09/26/2023 Licensing Program Analyst (LPA) Brian Phillips arrived at the facility announced for a scheduled visit to conduct a required 1-Year Annual facility site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator Susie Ponce, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility is a Continuing Care Retirement Community that consists of assisted living, memory care, independent living, and a dementia unit. The facility has waivers for Hospice and Dementia, housing both non-ambulatory and ambulatory residents. KITCHEN(S): The facility has a main kitchen for residents of the facility in the main kitchen/dining room building. The main kitchen serves residents in the assisted living and memory care segments of the facility, as those areas have dining rooms, but no full kitchens. There is a separate kitchen in a facility restaurant building connected to the resident pool area. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in the kitchen are inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last 7 days. Additional perishable food items were maintained on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. Heating devices such as stoves are inaccessible to residents, as are sharps/other items that could constitute a danger to residents. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C COMMON AREAS: At the time of the visit, the main lounge(s) and dining room(s) were observed to be appropriately furnished, with all furniture in good condition. There are lounge areas/breakout areas for residents in the different facets of the facility including assisted living, independent living, memory care, and dementia care that are appropriately furnished, with all furniture being in good condition. There are multiple fireplaces on the premises, which were all covered and inaccessible. There are pianos in the common areas of the facility in good repair and operating condition. There are operating aquariums in different portions of the facility that are in good operating condition. The facility maintains a resident mailroom, resident operated thrift store open to the public, a resident store, fitness center for residents, and resident clinic. The facility maintained a comfortable temperature in all individual buildings inspected. Smoke detectors and carbon monoxide detectors were tested and operational at the time of the visit in each of the buildings inspected. The fire extinguishers in all buildings inspected were fully charged and were last serviced in 2023. The LPA observed required postings throughout all common spaces including Resident Personal Rights and Resident Council Rights. There are activity supplies and equipment, including reading materials for the residents in all common areas inspected. All window screens were in good repair in all of the buildings comprising the facility. There is appropriate lighting in all of the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all stairways are well-lit with sturdy hand railings/stair chair accessibility devices. As the facility has more than 16 residents and is multiple stories, there is a signal system in place which was functional at the time of the inspection by the LPA. OUTSIDE/LAUNDRY/MISCELLANEOUS: The facility is comprised of a large number of separate buildings for multiple uses, including a fitness center, pool with jacuzzi, resident clinic, mailroom, thrift store, and resident convenience store. There is a main entrance road into the facility and an administrative entrance area for visitors. The facility has walls of concrete surrounding the backyard area of the memory care portion of the facility, with electronic combination delayed egress entrances/exits. The facility has an outdoor patio area for residents outside of the resident restaurant next to the pool area. The pool/body of water and jacuzzi comply with all safety instructions per the regulations. Currently the pool is undergoing construction so there are no bodies of water on the facility premises. Outdoor activity spaces and the dining patio for residents are equipped with furniture for resident use. Electronic devices are in place to monitor exits of the memory care building in the facility, if exiting presents a hazard to any resident. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, are well-lit, and have hand railings/grab bars. This is a facility with over 16 residents, therefore there are multiple designated laundry rooms where cleaning products are stored, which are kept locked. Continued on 809-C The laundry rooms are accessible through the different segmented buildings in the facility including memory care, assisted living, and independent living. There was emergency food and water in a storage room/area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There are multiple first aid kits that include sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. BEDROOMS: The facility has resident bedrooms in the memory care, assisted living, and independent living segments/buildings. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There are hundreds of designated resident rooms in the facility, with the LPA inspecting multiple rooms in each building that houses residents. The bedrooms for residents consists of a restroom in the room, a closet area for storage, a bed, and room for a couch and/or television with furniture. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device such as a wheelchair or a walker. Each room has at the least a chair, night stand, chest of drawers, and sufficient lighting. Each resident bedroom in the independent living segment of the facility is furnished with a smoke alarm/fire alarm system, emergency call system, and appliances for the residents. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are non-private restrooms in the common areas of the facility as well as private restrooms in the resident’s bedrooms in specific buildings of the facility. All restrooms inspected by the LPA had assisting equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets and tubs/showers per resident in the facility. Night-lights are installed in the hallways outside of the common area restrooms. INFECTION CONTROL: Upon entry to each building, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. Continued on 809-C The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate isolation rooms if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The facility maintains a COVID-19 Health Care System Mitigation Playbook from the California Department of Public Health as well as an Emergency Preparedness Informational Form and Interim Guidance for Outbreak Management in Long-Term Care and Post-Acute Care Facilities. The facility maintains an Infection Control Plan as well as an Emergency Operations Program and Plan Manual with aspects pertaining to infection control. This facility also has signage postings in the entry areas of individual buildings for for a COVID-19 Vaccine Clinic taking place in October of 2023. This required annual 1-year facility site inspection visit will need a continuation visit to conclude the aspects of the visit constrained by time limitations. These aspects include Facility Records compromising Staff member files for LIC 501 personnel records, LIC 503 health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, LIC 9052 Employee Rights, LIC 508 criminal record Statements, criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. Additionally, Resident records need to be reviewed for LIC 603 Pre-Admission/Placement appraisals, LIC 602 Physicians Reports, Consent Forms, Personal Rights for Residents, LIC 601 Emergency Information, LIC605A Release of Medical Information, PRN Authorization, Needs and Services Plan (ANS), Resident Assessments, Mini-Mental State Exam (MMSE) for residents with dementia, Self-management of medications if applicable, Medication Orders, Medication Logs, Advance Directives, Conservatorship Documentation, and Physician Orders for Life-Sustaining Treatment (POLST). Facility medications also need to be audited for a locked centralized storage area for resident medications as well as the Centrally Stored Medication and Destruction Record for residents. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 26, 2023

Allegation investigated: Staff do not provide proper medication assistance to residents in care Staff do not attend to residents in a timely manner Staff do not properly maintain resident's prescription medication records

Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA met with Christina Burton, Infection Preventionist, as well as Jeremiah Hovsepian Bearce, Director of Health Services, and explained the purpose of the visit. On the allegation: Staff do not provide medication assistance to residents in care. It is alleged that Staff members have given wrong medications to residents in care. The allegation states four incidents have occurred between 9/6/22 through 9/22/22 in which multiple residents in different rooms were given incorrect medications. On 09/27/2022, LPA interviewed staff members and residents in the facility. No staff member nor resident confirmed the allegation. Staff interviewed stated they had not observed any resident being given incorrect medications. LPA did not observe any evidence of the allegation while at the facility. Continued on 9099-C Unsubstantiated On 09/27/2022, LPA received documentation of daily medications given to residents, as well as the Centrally Stored Medication & Destruction Record. On 05/12/2023, separate LPA conducted record review of the records/documentation of medication for residents and the Centrally Stored Medication and Destruction Record received by separate LPA from the facility on 09/27/2022. No errors or questionable staff marking were found in any of the resident medication documentation. LPA saw no incidents between 09/06/2022 through 09/22/2022 in which wrong medications had been documented being given to any resident. While investigating a separate complaint at the facility on 05/12/2023, LPA interviewed residents who stated that they had never been given any wrong medication at the facility or heard or any other resident receiving any incorrect medication. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. On the allegation: Staff do not attend to residents in a timely manner. It is alleged that Staffing at the facility is in a constant state of flux, and that staff members do not respond to radio calls, so residents are left unattended for long periods of time. The allegation does not know the exact amount of time the residents are left unattended for, but that it was a constant issue. On 09/27/2022, LPA observed the Staff of the facility while at the facility for the complaint investigation visit. The LPA observed all staff members answering radio calls and attending to residents on a consistent basis. While investigating a separate complaint at the facility on 05/12/2023, separate LPA interviewed witnesses who indicated that staff members are attentive to the needs of residents in a timely manner at the facility. LPA did not observe any received radio call by facility staff members go unanswered or ignored. On 08/10/2023, LPA observed staff members answering radio calls in a timely manner and assisting residents when/if needed. LPA did not observe any staff refusing or neglecting to answer a radio call at the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. On the allegation: Staff do not properly maintain resident’s prescription medication records. It is alleged that there are documentation errors on narcotic medication including multiple bottles with various amounts of medication and incorrect pill counts. The allegation does not know if there is any medication missing. Continued on 9099-C On 09/27/22, LPA interviewed staff members and obtained records/documentation of medication for residents and the Centrally Stored Medication and Destruction Record. Medication records for September 2022 are documented appropriately with no inconsistencies or absence of documentation. There is no documented evidence to corroborate the allegation. No witnesses interviewed stated seeing or receiving any incorrect medications. On 08/10/2023, separate LPA reviewed the Centrally Stored Medication and Destruction Record for the assisted living portion of the facility. LPA also obtained copies of resident medication records and physician order reports for residents, maintained in each resident’s record/file. LPA observed that all the correct/proper medications were logged as having been given to each resident, and an audit of the actual medications stored in the assisted living portion of the facility matched the records maintained by the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, it is deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report issued to the Administrator.the state’s words, verbatim · CDSS document, Aug 10, 2023 · control 29-AS-20220922112716

Allegation investigated: Facility does not serve food of good quality

Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced 10-day complaint visit and met with Andy Sheen-Turner, Director of Dining Services. LPA explained the purpose of the visit. LPA requested documents pertaining to the investigation and conducted observations of the pertinant areas of the facility. On the allegation: Facility does not serve food of good quality. It was alleged that the meat is dry, burnt, and vegetables are sometimes of poor quality. The reporting party indicated that the quality of food is too salty. Reporting party also indicated an unwillingness to receive custom food orders accommodated by the facility. LPA observed the dining room areas in separate sections of the facility and found the food items on the menu to be of good quality while served to residents. LPA toured the kitchen and observed the food supply. All foods observed were of good quality. There was no indication of any expired/stale food items and all food items were stored properly at correct temperatures. Contd. on 9099-C Unsubstantiated During the LPA's touring of the kitchen area, policies and procedures on the handling of food were observed and food items had the dates that they were received by the facility labeled on the food product. There were no observable deficiencies in the quality of the food at the facility. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview, report was printed and emailed.the state’s words, verbatim · CDSS document, May 12, 2023 · control 29-AS-20230509113301

Allegation investigated: Facility does not serve food of good quality.

Licensing Program Analysts (LPAs) Olson and Phillips conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPAs met with Adam Kopras, Assisted Living Manager, Jeremiah Hovsepian Bearce, Director of Health Services, and Andy Sheen-Turner, Director of Dining Services and explained the purpose of the visit. On the allegation: Facility does not serve food of good quality. It was alleged that the meat was tough and “low quality”, custom orders (such as holding sauce) are not available, and vegetables are sometimes of poor quality and salty. The reporting party indicated that the quality of food has decreased from how it used to be. LPA Olson interviewed residents and staff on 1/10/2023 from 4:45pm to 7:10pm and observed the dinner meal service. During the dinner service, LPA took photographs of the food served to the residents and interviewed 27 residents about the food. Continued on 9099-C Unsubstantiated LPA Olson observed the food to be of good quality during the meal service. On 03/07/2023, LPAs toured the kitchen and observed the food supply. All foods observed were of good quality. Most residents interviewed indicated the food was of good quality, the meat was cooked to the level of doneness ordered, there was a good variety of foods, and healthy options are available as well as “less healthy” options. Some residents interviewed, who had been at the facility for several years, indicated food quality has improved over the years and they had no complaints about the food. Some residents interviewed indicated the vegetables are overcooked at times, and multiple residents indicated the food has a lot of salt. Some residents interviewed indicated they would like better quality meats and would like additional choices. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview, report was printed and emailed.the state’s words, verbatim · CDSS document, Mar 7, 2023 · control 29-AS-20230105144728

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Olson conducted a case management visit to check on the status of Resident 1 (R1), after R1 recently relocated to this facility. LPA met with Susie Ponce, Administrator and Adam Kopras, Assisted Living Manager and explained the purpose of the visit. LPA toured the facility and met with R1 in R1’s room. LPA interviewed R1 about their experience at the facility. R1 confirmed all their needs were met by the facility and had no concerns. Exit interview, report given via email.the state’s words, verbatim · CDSS document, Dec 20, 2022

Allegation investigated: Staff do not provide adequate food service

Licensing Program Analysts (LPAs) Olson and Kontilis conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPAs met with Suzie Ponce, Administrator and explained the purpose of the visit. On the allegation: Staff do not provide adequate food service. It was alleged that the vegetables are old and that food was not cooked properly. It was also alleged that some of the meat and vegetables were “tough” and difficult to chew, and that the food was too salty for residents’ tastes and for residents on a low-salt diet. On 3/22/2022, LPA Kontilis interviewed Executive Director and Director of Dining Services. LPA toured the kitchen and observed the kitchen was clean and sanitary. LPA observed an adequate amount of food and the food appeared to be of good quality. Continued on 9099-C Unsubstantiated Director of Dining Services stated they have changed their food ordering system and vendors. On 6/24/2022, LPA Olson interviewed Dining Room Manager, who stated they offer a low sodium soup every day, and any items on the menu can be made with lower salt. On 9/20/2022, LPA Kontilis toured the kitchen and observed it to be clean and sanitary. LPA observed an adequate amount of food and the food appeared to be of good quality. On 9/20/2022, LPA Kontilis interviewed the Director of Dining Services again, as well as a chef at the facility. Director of Dining Services indicated they will accommodate any special diets indicated on doctor’s orders. They use a computer system and if a resident has a special diet ordered, once the resident’s food order is put into the system, a red box appears with a warning about the allergy or special diet. Dining Services Director stated only one resident has a low sodium diet, and it is a preference, not a doctor’s order. However, they still try to accommodate this preference. LPA attempted to interview the one resident in the computer system who has an indicated preference of a low-salt diet. However, the resident did not respond to LPA’s requests for interview. LPA interviewed residents about the food. The concerns about the food were based on personal preference and did not indicate any food was of a poor quality. Dining Services Director indicated the dining room also implemented comment cards for residents to provide feedback on the food. The dining committee reviews them together and tracks the comments on a spreadsheet, starting in May 2022. Dining Services Director stated they review the comments cards to see what areas can be improved. One example provided was they purchased a Sous vide machine to cook the steaks and other meats very gently, which results in a tender product. Dining Services Director stated they have increased their spending on food, including switching from frozen fish to fresh fish. Based on comments cards, they informed their kitchen staff to cut back on salt a little, and the staff have complied. Another comment mentioned was the portions were small. However, other comments mentioned the portions were too large and food went to waste, so they cut down the portion size for the initial meal, and residents can ask for more. Executive Director noted there are about 50 to 60 items on the menu to provide ample choice to residents. Executive Director stated their menu changes seasonally, and they incorporate fruits and vegetables that are locally available and in season. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. However, the LPA recommends the facility continue to make adjustments to the menu and food preparation process based on the resident feedback in the interviews and on the comment cards. Exit interview conducted, report issued via email.the state’s words, verbatim · CDSS document, Sep 27, 2022 · control 29-AS-20220315115521

Allegation investigated: Food is too high in sodium.

Licensing Program Analysts (LPAs) Olson and Kontilis conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPAs met with Suzie Ponce, Administrator and explained the purpose of the visit. It was alleged the facility serves food that is high in sodium, such as Reuben sandwiches, BBQ shrimp, grits and soup. On 3/22/2022, LPA Kontilis interviewed Executive Director and Director of Dining Services. LPA toured the kitchen and observed the kitchen was clean and sanitary. LPA observed an adequate amount of food and the food appeared to be of good quality. Director of Dining Services stated they have changed their food ordering system and vendors. On 6/24/2022, LPA Olson interviewed Dining Room Manager, who stated they offer a low sodium soup every day, and any items on the menu can be made with lower salt. Continued on 9099-C Unsubstantiated On 9/20/2022, LPA Kontilis toured the kitchen and observed it to be clean and sanitary. LPA observed an adequate amount of food and the food appeared to be of good quality. On 9/20/2022, LPA Kontilis interviewed the Director of Dining Services again, as well as a chef at the facility. Director of Dining Services indicated they will accommodate any special diets indicated on doctor’s orders. They use a computer system and if a resident has a special diet ordered, once the resident’s food order is put into the system, a red box appears with a warning about the allergy or special diet. Dining Services Director stated only one resident has a low sodium diet, and it is a preference, not a doctor’s order. However, they still try to accommodate this preference. LPA Kontilis attempted to interview the one resident in the computer system who has an indicated preference of a low-salt diet. However, the resident did not respond to LPA’s requests for interview. LPA interviewed residents about the food. The concerns about the food were based on personal preference and did not indicate any food was of a poor quality. Dining Services Director indicated the dining room also implemented comment cards for residents to provide feedback on the food. Based on comments cards, they informed their kitchen staff to cut back on salt a little, and the staff have complied. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. However, the LPA recommends the facility continue to make adjustments to the menu and food preparation process based on the resident feedback in the interviews and on the comment cards. Exit interview conducted, report issued via email.the state’s words, verbatim · CDSS document, Sep 27, 2022 · control 29-AS-20220617165147

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

Licensing Program Analysts (LPAs) Olson, Cortez, and Kontilis conducted an unannounced subsequent complaint visit to issue final findings on the above allegation. LPAs met with Administrator Susie Ponce and explained the purpose of the visit. LPAs arrived at the facility at 11:15 am. During the investigation, LPA Kontilis reviewed an incident report and other facility documents, and interviewed resident’s responsible party and staff. Resident 1 (R1) lived at the facility since 2009, originally in Independent Living, then in Assisted Living, and then in Memory Care since January 2019. LPA Kontilis reviewed an incident report submitted on 6/25/2021 for an incident that occurred on 6/20/2021. The incident report states on 6/20/2021 at approximately 1:00 pm, R1 exited the memory care unit. R1’s WanderGuard bracelet activated the emergency system at 1:03 pm. The resident continued walking through the campus and fell. Please continue to 9099-C, Pg 2. Substantiated The fall was heard by a visitor who notified a nurse. At approximately 1:20 pm, the nurse responded and saw R1 was sitting on their walker and was unable to bear weight due to left hip pain. 9-1-1 was called and R1 was transported to the hospital. Due to the fall, R1 sustained a fractured pelvis. The incident report indicates an in-service training with memory care staff regarding emergency procedures, including an elopement drill, was scheduled. According to the Administrator, Staff 1 (S1) failed to fulfill their assigned duties and did not have their pager during the incident and S1 did not respond to the WanderGuard activation. S1 was terminated as a result of this incident. Based on the information obtained, a lack of supervision resulted in R1 wandering out of the memory care unit and throughout the facility grounds. Additionally, due to the lack of supervision, R1 sustained an injury as a result of the lack of supervision. Therefore the allegation that lack of supervision resulting in resident wandering away from facility is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted. Civil Penalty issued. Copy of report and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Sep 20, 2022 · control 29-AS-20210623155841

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 20, 2022

87468.2(a)(4) PERSONAL RIGHTS …Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section when R1 eloped from the facility sustaining a fall and injury which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2022

Plan of correction: Staff were re-trained on emergency/elopement procedures on 7/7/2021. POC cleared during visit.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Kontilis, Olson, and Cortez conducted an unannounced infection control annual inspection. LPA's were greeted by Concierge around 11:18 and Administrator around 11:30 AM. Currently, there are 369 residents living within the community. There are 327 residents residing in Residential Living, 26 residents residing in Quail Lodge, the Assisted Living area of the community, and 16 residents residing in The Grove, the memory care unit of the community. LPA's reviewed staff roster from 11:40 AM to 1:10 pm LPA's Olson and Cortez took a physical plant tour of the facility with Assisted Living and Memory support Manager from 1:30 to 3pm. This facility consists of Independent Living section, Quail Lodge Resident, and The Grove Memory Care. Medications are kept in a locked medication room. Main kitchen, dining rooms, various activity rooms were toured. The facility has a swimming pool. Swimming pool is secured. The kitchen was inspected for cleanliness and sanitary condition. The facility has multiple areas spaced to accommodate as much space as possible for social distancing. The staff screen residents for symptoms and temperature at least once a day and documentation is kept on file. Increased monitoring is conducted if any change of condition are noted or any residents are showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Continued on 9099-C Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents. Facility have areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility has plans for delivering medications and meals to any quarantined/isolation resident rooms. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies.Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked offices. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies. Administrator Certificates are valid. Fire extinguishers were charged and inspected annually. The facility has hardwired smoke detectors thorough the facility. At approximately 11:40 am, LPAs reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there are 3 staff members currently working in the facility and have not been associated to the facility prior to their employment. Additionally, one staff member has not received a criminal background and/or fingerprint clearance. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D), Exit interview conducted. Report, Civil penalties and Appeal Rights issued via email.the state’s words, verbatim · CDSS document, Sep 20, 2022

Allegation investigated: Facility is without a first aid kits in designated areas

Licensing Program Analyst (LPA) Olson conducted an unannounced initial 10-Day complaint visit to the facility above at 12:20 PM. LPA met with Jeremiah Hovsepian Bearce, Director of Health Services and explained the purpose of the visit. Administrator Susie Ponce and Melissa Honig, Executive Director were not available at the time of the visit. LPA conducted a tour of the facility from 1:20 pm to 2:20 pm with Jeremiah Hovsepian Bearce, Director of Health Services and Stephen Freine, Building and Gounds Director. On the allegation that the facility is without First Aid kits in designated areas of the facility, at 1:35 pm, 1:39 pm, and 1:45 pm, LPA observed First Aid kit signage indicating First Aid kits were available in the cabinets in East Laundry Room, #33 (1:35 pm), Rose-Garden Clubhouse #35 (1:39 pm), and The North Gazebo Clubhouse, #36 (1:45 pm) yet no first Aid kids were present. LPA informed Building and Grounds Director and Director of Health Services that there were no First Aid kits in the cabinets where the signage is posted. Based on LPA’s observation, the allegation that the facility is without First Aid kits in designated areas is Substantiated at this time. Continued on 9099-C Substantiated LPA asked if there were first aide kits anywhere else on campus for residents and Director of Health Services stated no but there is a call button in every clubhouse where residents can pull and a clinic nurse will come to address any issue including first aide. Facility placed first aide in every cabinet where it was listed and agreed to audit it daily. Facility will review in the upcoming weeks if they will keep the signs up and offer first aide in those locations in the future. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of today’s report and appeal rights were reviewed and emailed to Executive Director and Director of Health Services. Due to Computer issues a wet signature is on file.the state’s words, verbatim · CDSS document, Jun 24, 2022 · control 29-AS-20220617165147

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 25, 2022

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on LPA’s observation, the licensee did not comply with the section cited above as LPA observed 3 out of 4 laundry room cabinets with First Aid kit signage posted but no First Aid kits were observed in the cabinet(s) which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2022

Plan of correction: Facility Immediately placed new first aid kits in cabnets. The POC was cleared during the visit.

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 did not safeguard residents personal belongings Staff denied resident their personal belongings

Licensing Program Analyst (LPA) Olson conducted subsequent visit to deliver final findings. LPA met with Jeremiah Hovsepian Bearce, Director of Health Services and explained the purpose of the visit. Licensing Program Analysts (LPA) Toan Luong and Darlene Chavez conducted initial visit on 4/19/2021 and met with Administrator Susan Ponce. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, the complaint investigation was conducted virtually. LPAs conducted interviews with the administrator and requested documents pertinent to the investigation. LPA Luong conducted interviews with staff, residents, and witnesses on 5/7/21, 5/11/21, 5/13/21, 8/23/21, 8/27/21, 8/31/21, and on 11/05/21. LPA Luong reviewed facility documents. R1 was scheduled to move to assisted living from independent living on 3/23/2020. The resident and resident’s responsible parties would be responsible for the relocation of the resident. Continued on 9099-C Unsubstantiated On 3/19/2020, the Governor of California issued an order for Californian residents to stay at home to reduce the spread of the Corona Virus Disease and allowing only essential outings. Due to the Governor’s order, the facility assigned a staff/social worker (S1) to R1 to facilitate the move to assisted living. R1’s assisted living quarter was smaller in size than that of the independent living. During the initial stages of the pandemic, donations were not being accepted by charities. Allegation #1 Staff did not safeguard resident’s personal belongings: It was alleged that R1’s belongings were not safeguarded between 3/23/2020 and afterwards during R1’s transition from independent living to assisted living. LPA Luong’s interviews reveal that Witness #1 (W1), Witness #2 (W2), and Witness #3 (W3) were packing R1’s belonging into boxes prior to the move to assisted living. W1, W2, and W3 considered themselves as close friends of R1. W3 was also the personal assistant to R1. However, interviews revealed that R1 had a falling out and did not trust W3. Statements made from R1 included, “announced what W3 would wanted of my belonging,” “Don’t come in and tell a 94, who could drop off. Don’t talk to people my age wanting my belonging,” and “No longer friends” with W3. W1, W2, and W3 had arranged for a storage unit for R1’s belongings to be transferred to. The storage unit was paid for by R1 but was listed under W3’s name. R1 did not want to release items into the storage unit. To accommodate R1, the facility used a closet in the administration wing to store R1’s belongings. R1’s independent living was described by interviewees as “Not a hoarder but does have books and newspaper stacked ceiling high.” As a result, not all of R1’s belongings could be brought over from R1’s independent living to assisted living immediately. Items would be stored in the administration closet and moved gradually to the assisted living as space was organized. Not all of R1’s items would fit in R1’s new quarters and some items would have to be donated or discarded. R1 had a book collection that was agreed to be donated to a charity. However, LPA contacted the charity and was informed that between the periods of April 2020 through August 2020, if callers were to request a donation of large quantity of books, then the charity representative would request the caller from refraining from donations at the time. However, the representative also stated that if an individual was to drop off books at the location site, there was not a sign to discourage donations. Books were reportedly donated to another organization. Other furniture items were donated to La Tienda, the facility’s store. La Tienda did not accept all furniture items and some were discarded. Interviews reported that S1 went through items with R1 for consent to be discarded or removed. R1 was also described as having poor short-term memory but good long-term memory, being disorganized, and discombobulated. Continued on 9099-C It was also learned that W3 had given W3 a raise from $15 to $30 per hour without the consent of R1. Interview with R1 revealed that R1 was afraid of jewelry being stolen. R1 would hide jewelry inside medicine bottles and stuff the bottle with hair ties to prevent any rattling sounds. R1 would then hide the medicine bottles in various furniture and beds. R1 stated that R1 wanted to keep W3 out of the moving process. R1 also stated that R1 was paranoid during the move. Interviews also revealed that W1, W2, and W3 were not familiar with each other nor with other R1’s friends until the transition process of R1. LPA reviewed document Resident Intent to Movesigned 3/3/20 by R1. LPA reviewed document Level of Care Transfer Noticedated 3/3/20. Documents recorded that discussion for transfer was made on 7 different days between 2/13/20 through 3/1/20. Both documents were signed by R1 with the representative party left blank. LPA reviewed Storage Rental Agreement dated 3/19/20. Storage unit was under W3’s name, but did not have an indicator of where payment originated from. On 8/27/21, LPA reviewed LIC 621 Client/Resident Personal Property and Valuables signed 3/23/20 by R1. Document indicated that R1 did not want to list any items on the document. LPA reviewed email correspondence between the facility staff and W2. Email correspondence reported that “I have sorted through and am keeping her memorabilia and good jewelry, as well as R1 parents’ wedding clock, for now, until I’m able to return all in person.” LPA reviewed document SB SOS LLC Services Proposal signed by the Administrator Ponce 4/8/20. Document reported service completed were: Clients needs books cleared from property and pack photograph albums into smaller manageable boxes for storage within client’s new residence. Document does not specify details of quantity of books nor location of book donation. R1 did not complete an inventory list of items, and the facility tried to assist R1 with moving and storing their property during the pandemic. Based on the evidence obtained, the allegation is deemed unsubstantiated at this time. Allegation #2 Staff denied resident their personal belongings: It was alleged that R1 did not have access to belongings during the transition moving to assisted living. LPA Luong’s interviews reveal that R1 would request for items. Some items were provided but other items could not be produced. Some of those items included a corral ring and a sapphire ring. Interview also revealed that R1 was described as having poor short-term memory. Interview with R1 revealed that R1 was afraid of jewelry being stolen. R1 would hide jewelry inside medicine bottles and stuff the bottle with hair ties to prevent any rattling sounds. R1 would then hide the medicine bottles in various furniture and beds. R1 stated that R1 wanted to keep W3 out of the move. Continued on 9099-C LPA reviewed internal facility email correspondence dated 8/5/20. Email correspondence was between facility staff and indicated items were difficult to find, but in one instance, a dvd with sentimental value was found and provided. Interviews conducted with administrator indicated that this item was of importance to R1 but was misplaced several times by R1. On 8/27/21, LPA reviewed LIC 621 Client/Resident Personal Property and Valuables signed 3/23/20 by R1. Document indicated that R1 did not want to list any items on the document. LPA reviewed email correspondence between the facility staff and W2. Email correspondence reported that “I have sorted through and am keeping her memorabilia and good jewelry, as well as R1 parents’ wedding clock, for now, until I’m able to return all in person.” R1 did not list any belongings on the LIC 621 Client/Resident Personal Property and Valuables and was hiding valuables in various furniture. W2 was safeguarding some of R1’s valuables but did not provide a list. Based on the evidence obtained, the allegation is deemed unsubstantiated at this time. Exit interview conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 10, 2022 · control 29-AS-20210416110128

Allegation investigated: Facility failed to safeguard resident's belongings Facility did not report missing items.

Licensing Program Analyst (LPA) Toan Luong made an unannounced initial 10-Day complaint visit. LPA arrived at the facility at 9:01 am and announced the purpose of the visit. During the visit, LPA conducted a Safety and Welfare tour of the facility. From 9:55 AM – 12:45 PM, LPA Luong conducted in-person interviews and obtained copies of documents pertaining to the investigation. LPA Kristin Kontilis conducted telephone interviews and participated in the investigation. On 6/20/2021, Resident 1’s (R1’s) eyeglasses and wristwatch went missing after R1 sustained a fall in the Independent Living area of the facility. 9-1-1 was called, R1 was transported to the hospital and subsequently admitted into the skilled nursing unit of the facility. Documents reviewed revealed that R1 has limited vision and requires eyeglasses. On 6/30/2021, R1’s Responsible Party was informed that a replacement wristwatch was available after a change of battery. On 7/2/2021, facility staff assisted R1 to a local vendor to replace the eyeglasses. Substantiated To date, the eyeglasses have not been located and R1 has not received a replacement of the eyeglasses and wristwatch. Based on the interviews conducted and records reviewed, the allegation that the facility failed to safeguard Resident’s belongings is Substantiated at this time. On 6/21/2021, R1’s responsible party contacted facility staff to notify them that R1 did not have their eyeglasses or wristwatch. After R1 notified staff of the missing items, staff made various inquiries to locate the items. Based on record review and interviews conducted, facility staff did not notify R1’s responsible party of the missing items and did not notify Community Care Licensing (CCL) of the missing items. Therefore, the allegation that facility staff did not report missing items is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Copy of report issued. Deficiencies issued. Appeal Rights issued.the state’s words, verbatim · CDSS document, Jul 9, 2021 · control 29-AS-20210629102735

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87218(a)(2) · Plan of correction due date: Jul 12, 2021

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program ... (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. ...This requirement is not met as evidenced by: Based on record review and interviews, R1’s personal eyeglass and wristwatch were lost when R1 was sent to the hospital following a fall. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2021

Plan of correction: Administrator will update internal document regarding resident information to indicate resident's care needs allowing others caring for resident to address resident's health, welfare, and safety allowing missing items to be addressed promptly.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 12, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident 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 evidence by: Based on record review and interviews, the loss of R1’s eyeglasses and wristwatch were not reported to R1’s responsible party or to CCL which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2021

Plan of correction: Administrator will update internal document regarding resident information to indicate resident's care needs allowing others caring for resident to address resident's health, welfare, and safety allowing items needed for ADL to be addressed promptly.