South County Retirement Home

Allegation investigated: Resident had to be hospitalized while in care

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol. On 08/25/2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for a resident. The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside. Page 1 out of 3 Substantiated The Department obtained a copy of the facility staff ‘pass-down notes.’ Based on review that on August 21, 2022, or August 22, 2022, at around 6am, a resident R2 informed staff S1 that R1 had fallen. S1 went to check and found R1 on the ground. S1 observed a bowel movement next to R1. S1 asked R1 “did you have an accident out here?” R1 responded, “no, I don’t know.” S1 asked R1 if he/she was in pain, R1 responded that he/she was okay. S1 told R1 to get up after cleaning him/her and R1 requested help. S1 stated R1 has fallen before and rarely asks for help. R1 requested help from S1. When R1 got up and tried to walk R1 said he/she felt pain on his/her upper right leg. On August 22, 2022, S1 asked R1 if he/she was in pain. R1 told S1 that he/she “still had pain.” On August 23, 2022, R1 told staff (S3) that he/she was in a lot of pain and that he/she “hurt so bad”. S3 contacted 911 services. On February 28, 2023, ADM was interviewed. ADM stated he/she reads the staffs notebook of "pass down notes" "mostly every day." ADM stated that on August 21, 2022, was a Sunday and ADM does not read the staff's notebook on the weekends. ADM stated, "no one reported anything to her/him on Sunday." ADM explained the staff are all "trained to call 911 and he/she does not know why the staff did not call 911 this time." On November 18, 2022, R1’s Case Manager (CM) was interviewed. CM stated, “the facility called him/her after R1 had been transported to the hospital…R1 was complaining of pain… had been in a wheelchair for two days”. CM stated he/she did not know that R1 fell at the facility two days before being taken to the hospital. A review of facility documentation did not show any documented evidence that the facility informed R1’s case manager about the fall incident before R1’s hospitalization on August 23, 2022. A review of medical records indicated that R1 was transported and admitted to the hospital on August 23, 2022. While at the hospital, R1 was diagnosed with a right hip fracture. On August 28, 2023, R1 passed away in the hospital due to complications with the surgery required to treat his/her hip fracture. R1's cause of death was due to heart failure complicated by a right hip fracture from an witnessed fall. Page 2 out of 3 A review of R1’s medical discharge records from the hospital from August 23 to 28, 2022 stated the R1 was admitted due to an unwitnessed fall associated with a right leg pain. R1’s right leg shortens and externally rotated. R1’s findings were of right closed displaced intertrochanteric hip fracture. Furthermore, R1 was found to have an acute comminuted intertrochanteric fracture of the right proximal femur. According to Clevelanclinic.org, “a closed intertrochanteric fracture of the hip, right [happens when the upper part of the thighbone breaks, usually from a fall or a car accident].” On February 28, 2023 & March 1, 2023, the Department conducted interviews with facility staff (S1 to S4) and ADM. S1, S4 & ADM stated R1 had fall incidents while in the facility. S4 stated R1 was hospitalized for a broken hip in 2019. (Before the August 23, 2022, hospitalization). During a review of R1’s Appraisal Needs and Services Plan (ANS) and interview with ADM, the facility did not develop and implemented interventions to mitigate R1’s safety. ADM did not update R1’s ANS before and after R1 sustained injury. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator Samuel Apostol and a signed copy of this report was provided along with appeal rights. An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $9,500.00 for violation resulting in serious bodily injury is pending review. Page 3 out of 3the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 26-AS-20220825122345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 20, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff ... to meet their needs. This requirement was not met as evidenced by Based on investigation, R1 did not receive immediate medical assistance after R1 fell and subsequently verbalized having pain. Staff did not adhere to facility’s protocol on medical emergency by calling 9-1-1the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send plan of action on how the facility will meet the residents needs after a resident has fallen. Licensee stated he will send POC by 10/20/2023 to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1) · Plan of correction due date: Oct 20, 2023

87405 Administrator - Qualifications and Duties (d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by: Based on investigation, ADM was not aware of R1’s fall because according to ADM he/she does not read staff notes on the weekend. ADM also did not inform R1’s CM of R1’s fall and R1 being a fall risk was not addressed in 2019 when he/she had his/her initial fall at the facility.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send letter of understanding regaring the regulation and his role and responbilities as ADM and how he will provide care and supervison to the residents. Licensee stated he will send POC by 10/20/2023 to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Oct 26, 2023

87463 Reappraisals (a) The pre admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ...document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidenced by: Based on investigation, R1 was a fall risk with an associated fall history. R1 had a fall in 2019. A review of R1’s LIC624 Appraisal Needs and Services Plan (ANS) dated Feburary 2, 2019, the facility did not update R1’s ANS to address fall prevention.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send Plan of action on how the facilty will updates residents needs and services plans when residents have changes in conditioin. Licensee stated he will send POC by 10/26/2023 to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 26, 2023

87468.1 Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evicenced by; Based on investigation, R1’s responsible party and/or Case Manager was not immediately informed when R1 had a fall and current health condition before he/she was admitted to the hospital.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Licensee stated he will send plan of action on how the facilty will regulary inform residents representatives about their care, ongoing evaluations. Licensee stated he will send by POC date, 10/26/2023 to LPA.

Allegation investigated: Resident fell and sustained an injury Staff did not seek timely medical attention for resident

Licensing Program Analyst (LPAs) Manuel Monter conducted an unannounced visit to deliver findings regarding the allegation listed above. LPA met with facility Administrator (ADM) Samuel Apostol. On October 24, 2022 the department received a complaint alleging that a resident fell and sustained an injury. It has also been alleged that staff did not seek timely medical attention for resident. The investigation revealed either 08/20/2022 or 08/21/2022 during the night shift, a resident living at the facility (R1) was searching for cigarette buds in the facility’s backyard and had an unwitnessed fall around 0600 hours. A staff member (S1) brought R1 inside of the facility and placed him/her in a wheelchair. S1 assessed R1 for pain wherein R1 stated he/she was fine. S1 stated R1 was able to lift his/her left leg while the right leg hurts. S1 informed staff S2 that R1 fell outside. Page 1 out of 3 Substantiated The Department obtained a copy of the facility staff ‘pass-down notes.’ Based on review that on August 21, 2022, or August 22, 2022, at around 6am, a resident R2 informed staff S1 that R1 had fallen. S1 went to check and found R1 on the ground. S1 observed a bowel movement next to R1. S1 asked R1 “did you have an accident out here?” R1 responded, “no, I don’t know.” S1 asked R1 if he/she was in pain, R1 responded that he/she was okay. S1 told R1 to get up after cleaning him/her and R1 requested help. S1 stated R1 has fallen before and rarely asks for help. R1 requested help from S1. When R1 got up and tried to walk R1 said he/she felt pain on his/her upper right leg. On August 22, 2022, S1 asked R1 if he/she was in pain. R1 told S1 that he/she “still had pain.” On August 23, 2022, R1 told staff (S3) that he/she was in a lot of pain and that he/she “hurt so bad”. S3 contacted 911 services. On February 28, 2023, ADM was interviewed. ADM stated he/she reads the staffs notebook of "pass down notes" "mostly every day." ADM stated that on August 21, 2022, was a Sunday and ADM does not read the staff's notebook on the weekends. ADM stated, "no one reported anything to her/him on Sunday." ADM explained the staff are all "trained to call 911 and he/she does not know why the staff did not call 911 this time." On November 18, 2022, R1’s Case Manager (CM) was interviewed. CM stated, “the facility called him/her after R1 had been transported to the hospital…R1 was complaining of pain… had been in a wheelchair for two days”. CM stated he/she did not know that R1 fell at the facility two days before being taken to the hospital. A review of facility documentation did not show any documented evidence that the facility informed R1’s case manager about the fall incident before R1’s hospitalization on August 23, 2022. A review of medical records indicated that R1 was transported and admitted to the hospital on August 23, 2022. While at the hospital, R1 was diagnosed with a right hip fracture. On August 28, 2023, R1 passed away in the hospital due to complications with the surgery required to treat his/her hip fracture. R1's cause of death was due to heart failure complicated by a right hip fracture from an unwitnessed fall. Page 2 out of 3. A review of R1’s medical discharge records from the hospital from August 23 to 28, 2022 stated the R1 was admitted due to an unwitnessed fall associated with a right leg pain. R1’s right leg shortens and externally rotated. R1’s findings were of right closed displaced intertrochanteric hip fracture. Furthermore, R1 was found to have an acute comminuted intertrochanteric fracture of the right proximal femur. According to Clevelanclinic.org, “a closed intertrochanteric fracture of the hip, right [happens when the upper part of the thighbone breaks, usually from a fall or a car accident].” On February 28, 2023 & March 1, 2023, the Department conducted interviews with facility staff (S1 to S4) and ADM. S1, S4 & ADM stated R1 had fall incidents while in the facility. S4 stated R1 was hospitalized for a broken hip in 2019. (Before the August 23, 2022, hospitalization). During a review of R1’s Appraisal Needs and Services Plan (ANS) and interview with ADM, the facility did not develop and implemented interventions to mitigate R1’s safety. ADM did not update R1’s ANS before and after R1 sustained injury. The Department has investigated the above allegation. Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 3 out of 3the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 26-AS-20221024102823

Allegation investigated: Mental/verbal abuse to resident.

Licensing Program Analyst (LPA) Manuel Monter & Mita Partoza conducted an unannounced visit to deliver findings regarding the allegation listed above. LPAs met with facility Administrator (ADM) Samuel Apostol. On 10/02/2023 the department received a complaint alleging that a resident sustained mental/verbal abuse from staff and residents. On 10/10/2023, LPA's interviewed R1. R1 stated the staff are not teasing, taunting, or saying mean things to him/her. R1 stated the female residents are teasing him/her regarding his/her girlfriend. R1 stated this is due to jealously. LPA asked R1 who was teasing him/her, R1 stated he/she did not know. Page 1 out of 2 Unfounded LPA's interviewed 10 residents. 8 out of 10 residents denied the allegation that staff were teasing, taunting or saying mean things to residents. 7 out of 10 residents denied the allegation that residents were taunting, teasing, or saying mean things to other residents. LPA's interviewed 3 staff members, S1-S3. 3 out of 3 staff members denied the allegation that staff were teasing, taunting or saying mean things to residents. 3 out of 3 staff members denied the allegation that residents were taunting, teasing or saying mean things to other residents. LPA's interviewed ADM regarding the allegations. ADM stated the staff do not tease/taunt/say mean things to residents. ADM stated the residents will sometimes tease/taunt/ say mean things to one another. ADM stated the facility staff will intervene and de-escalate the situation. ADM stated the staff will try to re-direct the residents and encourage to cooperate as they live in the same home. ADM stated R1 accuses ADM of speaking with his/her wife. ADM stated R1 accuses others of talking with his/her wife. A review of R1's Appraisal/Needs and Services Plan states; R1 struggles from paranoid thoughts and behaviors(past characterized by a generalized over concern of others). The form states R1 has delusional thoughts such as thinking his/her "girlfriend" is imprisoned. The form also states R1 is fixated on his/her "fiance" and paranoid of people talking to her or saying bad things. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, an exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 26-AS-20231002152059

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Manuel Monter and Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator(ADM) Sam Apostol. LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, facility restrooms and 10 residents bedrooms. During LPA's tour of the resident bedrooms, LPA's observed residents bed sheet were observed to be recently changed. The medication room of the facility was also inspected. Front yard and backyard were inspected. LPA observed fly traps were observed and ADM stated the facility changes the fly traps once a week. There was no obstruction to block the walkways. LPA observed the front yard free of debris and in good condition. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degree F, and hot water temperature was measured in 3 facility bathrooms. The water temperature ranges from 105 to 110 degrees F. Fire extinguisher was serviced in March 2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. The fire alarm system was last inspected on 07/06/2023. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on October 2023. LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 4 staff (S1 to S4) and 4 residents (R1-R4). No deficiencies cited during today's visit. This report was reviewed with ADM Sam Apostol and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, Oct 10, 2023

Type of visit: Case Management - Incident

LPA Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on 7/28/2023. LPA met with administrator (ADM) Samuel Apostol. On 7/28/23 the department received an incident report regarding resident R1 assaulting resident R2 around 12pm. R2 was taken to the hospital and has returned to the facility. R1 was arrested by the sheriff. ADM stated he will not accept resident R1 back to the facility. ADM was interviewed regarding his plan of action on keeping his residents safe and the facility's procedures for when residents begin to argue/fight with each other. ADM stated that the facility was actively watching resident R1 due to he/she no longer taking his/her medication. ADM stated on 7/24/23, resident R1 was beginning to refuse medication and claiming to staff that he/she fired the facility's staff as he/she is the owner. ADM stated he contacted the case manger, conservator and psychiatrist regarding resident R1 refusing to take his/her medication. ADM stated he informed his staff to keep an eye on R1 who was not taking his her medication. ADM stated R1 and R2 are not roommates. ADM stated the facility will encourage resident who do not get along to avoid interacting with each other to avoid conflicts. LPA asked for the following documents. The facility staff schedule, R1's progress notes, police report case number card. LPA also requested R1 and R2's updated appraisal needs and services plan. LPA advised ADM to put his plan of action on future incident reports. LPA toured the facility. No deficiencies cited during todays visit. A copy of the report was provided to ADMthe state’s words, verbatim · CDSS document, Aug 1, 2023

Allegation investigated: Resident was sexually abuse while in care.

On 6/22/23, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. On 6/22/23, LPA's interviewed R1 regarding the alligation above. R1 stated intially did not want to talk about it. R1 then stated that it may have been S1 or may have been his/her room mate. When ever LPA attmepted additional questions, R1 would digress and talk about something unrelated. R1 when asked her/his thoughts on S1, R1 stated they are fine. S1 was interviewed and denied the alligation. When questioned further, R1 stated S1 didnt inapprotriatley touch him/her, but their roomate did. R1's roomate was interviewed and R2 stated touching never occured with R1. R2 stated S1 does not assit with shower or enters their room. Page 1 out of 2 Unsubstantiated During interview with ADM. ADM stated R1 did not come forward with the allegation. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 2 out of 2the state’s words, verbatim · CDSS document, Jun 22, 2023 · control 26-AS-20220623103245

Allegation investigated: Facility staff does not take residents to scheduled medical appointments

On 6/22/23, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. Facility staff does not take residents to scheduled medical appointments: LPA's observed facility log regarding medical appointments. Photographs were taken regarding medical appointments for the month of November & December 2021. During a previous visit, over 10 residents were interviewed and asked if the facility takes them to their appointments. 10 out of 10 residents stated the facility does take them to their medical appointments. Page 1 out of 2 Unfounded The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 2 out of 2 Based on the interviews conducted with clients and staff, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited, Exit interview conducted with ADM, Sam Apostol and a copy of the report was provided. Page 2 out of 2 Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided. Page 2 of 2the state’s words, verbatim · CDSS document, Jun 22, 2023 · control 26-AS-20211213152254

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a) · Plan of correction due date: Jun 29, 2023

1569.69(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements. this requirment was not met at evidenced by; Based on Interview & record review. S1 admitted assiting with medication without medication training. Medication training records did not show S1 recive medication training in 2021 and 2022. ADM also confirmed this. This poses a potential health , safety and personal rights risk to residents.the state’s words, verbatim · CDSS document, Jun 22, 2023

Plan of correction: ADM stated they will write written plan of action when designated medication staff is unavaliable to dispense medications.

Allegation investigated: Facility administrator falsifies training records Staff did not notify resident's authorized representative of residents fall

On 6/22/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. On 10/24/2022, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 10/24/2023, the initial investigation visit was conducted. The Department obtained staff training documents, a staff and resident roster, and staff schedule for the months of September and October of 2022. Page 1 out of 2, see continuation on LIC 9099-C (Page 2). Unsubstantiated Facility administrator falsifies training records The allegation stated the facility administrator falsifies the staff training records and puts the fake records in the staff files. During record review of staff files and training logs, LPA observed the training logs from 2013-2023. LPA observed either an RN, Administrator Sam Apostle or a third party vendor was providing facility staff training. The training logs which captured the staff signatures were made with different color ink and different signatures. Staff did not notify resident's authorized representative of residents fall The allegation stated the Resident (R1) had a fall on 8/13/22 and the staff also did not notify the resident's authorized representative that the resident fell. A staff member called the resident's authorized representative on or around 8/15 or 8/16/22 to let the authorized representative the resident was being sent to the hospital. During today's visit 6/22/2023, LPAs interviewed ADM and ADM stated the family was notified about the fall via phone call and does not have written record of the call. The Department has investigated the above allegations. Based on LPA inspection, observations, records review, interviews with AD, staff, and residents, the preponderance of evidence standard has not been met therefore the allegations are UNSUBSTANTIATED. Meaning although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Samuel Apostol and a copy of the report was provided. Staff administer medication without medication training The allegations stated a staff member (S1) without training is providing medications to the residents. Per interview with Administrator (ADM) Sam Apostol, facility staff did not have training due to the pandemic. LPAs reviewed the medication logs from September and October 2022 which includes the resident's medications, date and time the staff initials stating when and who gave the medications to the resident. ADM reviewed the initials on the medication record and they did not belong to S1. Per staff interviews and resident interviews, S1 gives residents medications in the morning. LPAs interviewed S1, S1 stated S1 has given medications in the past couple of years when Med-Tech is on vacation or calls off sick. S1 stated did not receive medication training. Per S1, the medication is in little brown envelopes which are prepared in advance. Per record review, S1 has not received medication training in prior years, the only training record for S1 is for the year 2023. Staff did not report incident involving resident to CCLD The allegation stated the resident's fall which occurred on 8/13/2022 was not reported to CCLD by submitted an incident report. During today's visit, 6/22/2023, LPAs interviewed ADM and ADM could not produce the incident report for the resident's fall. ADM did report the hospitalization of the resident which occurred a couple of days later. The Department has conducted an investigation of the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Administrator, Sam Apostol. A copy of this report, along with the facility's appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 22, 2023 · control 26-AS-20221024102823

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Jun 29, 2023

1569.69(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements. this requirment was not met at evidenced by; Based on Interview & record review. S1 admitted assiting with medication without medication training. Medication training records did not show S1 recive medication training in 2021 and 2022. ADM also confirmed this. This poses a potential health , safety and personal rights risk to residents.the state’s words, verbatim · CDSS document, Jun 22, 2023

Plan of correction: ADM stated they will write written plan of action when designated medication staff is unavaliable to dispense medications.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: POC

LPAs Rai and Monter and LPM Manzano conducted an unannounced case management visit-plan of correction (POC) visit. Met with Administrator Sam Apostol. The purpose of this visit is to ensure that the facility administrator and staff are adhering to the Plan of Corrections submitted to the department as a result of citations and deficiencies issued on the following inspection/investigation visits: LPAs and LPM also met with 3 Rehab Counselors from Santa Clara County Behavioral Health (SCCBH). SCCBH has 36 residents at this facility. SCCBH counselors, LPAs/LPM and Administrator had a meeting wherein the importance of 'collaboration and accountability'' between the facility and SCCBH is vital to ensure that needs and supervision of residents in the facility are discussed and individual assessment or plan of care is in place. SCCBH agreed to initiate 'care conference' quarterly and as needed to note significant changes in physical, medical, mental and social condition of each resident. Administrator will reach out to case manager/social worker of residents which are not under SCCBH. SCCBH joined LPAs/LPM during tour of the facility and random checks of residents' bedrooms. Administrator agreed and understood that collaboration with SCCBH and other agencies is important. Based on today's inspection visit, the Administrator and staff have corrected all of the above citation/deficiencies. POC clearance are issued and provided to Mr. Apostol. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Jun 22, 2023

Allegation investigated: Facility faling to safeguard residents property

On 06/07/2023, the Department conducted investigation/infection of the facility and staff on the alleged complaint. Facility faling to safeguard residents property On 06/07/2023, Based on investigation, LPM interviewed Staff (S1), S1 stated that he/she works every Sunday, Tuesday and Wednesday as one of the laundry staff. S1 stated that he/she along with other two staff responsible for the laundry are labeling residents' clothings. S1 stated that there are clothes in the laundry room wherein with no labels. During inspection of the laundry room along with S1, LPM noted that there were more than 20 men and females clothes from sweater, tee-shirts, and pants with no labels. Substantiated According to ADM, the facility had a bed bug issue in the past, but have taken active measures to address the bed bug issue. ADM provided copies of receipts that they are actively working with Terminex to prevent the propagation of bed bugs and pest. The receipts are dated 12/19/22 and 3/18/23. Staff is not giving medications properly On 06/07/2023, Based on interview with Staff and residents, staff (S1 and S2) denied allegation that staff are not giving medications properly. A random interviews with residents (R1 to R2) also stated that staff are not administering their medications in a timely manner while other residents (R3 to R10) stated their medications were being administer to them timely. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be UNSUBSTANTIATED. On 06/07/2023, ADM was interviewed. ADM also acknowledge that staff were instructed to label residents' clothing. ADM acknowledged awareness of missing items being reported by residents. On 06/07/2023, a random interviews with residents were conducted wherein R1 to R3 reported that they had missing items and clothes. R1 stated that they were asked by staff to put labels on their clothes but missing items continue to be an issue at the facility. R1 stated that later on staff will let her/him know that the missing items were found. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20230518132420

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jun 12, 2023

87217(b) Safeguards for Resident Cash, Personal property and valuables: (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met evidence by: During investigation on 5/19 and 6/7, staff and residents were interviewed and acknowledged missing items such as clothing. LPAs and LPM observed on 5/19 and 6/7 residents' clothing with no name or labels in the laundry room. This pose a potential health, safety and personal rights risk.the state’s words, verbatim · CDSS document, Jun 7, 2023

Plan of correction: Administrator stated Administrator stated will send memo to responsilbe parites to label new items they bring to facility. Make sure the residents cloths are labeled. And will submit plan action by June 12 2023 to safeguard residents belongings.

Allegation investigated: Resident's hygiene needs are not being met Resident's bed was not properly maintained Resident was unable to shower while in care Residents medication is not given appropriately

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. On 12/1/2021, Community Care Licensing Division (CCLD) received a complaint with the above allegations. On 12/9/2021, the initial investigation visit was conducted. The facility interior and exterior including the TV room, shower rooms, resident rooms, hallways, kitchen, laundry room, smoking area, and backyard was inspected. Medication Audit for R1 - R2 was conducted and MedTech on duty was interviewed. The facility provided a copy of facility's resident roster, staff schedule, resident shower log, visitor log sign-in sheet, and R1-R2s medication log. Page 1 out of 3, see continuation on LIC 9099-C (Page 2). Unfounded Resident was left soiled During previous inspection 5/19/2023, an interview with staff and ADM stated that bedsheets are changed every once a week except when a resident has an accident such incontinence. LPA inspected R1's bedroom #19, R1's linen had dry urine stain & R2's pillow had dry blood due to severe acne. R1 is incontinent. During today's visit, staff stated they were in the middle of assisting residents and changing everyone's linens during our inspection. LPAs and LPMs did not observe staff who were soiled. Resident's hygiene needs are not being met According to the allegation, the residents were seen strangely filthy at the facility. During today's tour of the facility , residents were observed during meal time, and around the property. There were no complaints regarding the staff not attending to their needs. The residents were observed not to be disheveled. LPAs and LPM observed the residents to be wearing clothes without stains and unintentional rips. During interview with residents, all 4 residents were independent with their grooming and asked staff for help if they need it. During inspection, there was an odor in Room #12. The resident (R1) does not get up and resident is incontinent with bladder. According to the ADM, they were cleaning the resident and the room and they will follow up with social worker. The resident refuses to wear incontinent pad and a plastic cover has been placed over the mattress. Resident's bed was not properly maintained LPAs randomly inspected residents bedrooms. Residents' were also interviewed. Residents provided responses that bedsheets are washed during different times of the week. During today's inspection, 6/7/2023, the resident rooms were made with blankets tucked in and was clean of dirt and debris. Resident was unable to shower while in care During today's inspection, 3 Out of 4 residents interviewed stated they take a shower themselves and 1 out of the 4 residents interviewed stated they need help while taking a shower. All 4 residents interviewed stated the staff administer the medication during scheduled time. During inspection, LPAs and LPM observed the shower room to be unlocked and a schedule of the resident showers was posted outside. Page 2 out of 3, see continuation on LIC 9099-C (Page 3). Page 3 out of 3. Residents medication is not given appropriately ADM and staff stated that R1's medications were administered to R1 in a timely manner, nor they have any knowledge of the incidents where medication was not given. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20211201154803

Allegation investigated: Facility did not have enough staff to meet resident's needs

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. Based on allegation, facility did not have enough saff to meet resident's needs since appears they are just housing people and not actually caring for them. During today's inspection, Administrator and 5 staff members were observed on the premise. Based on random interviews with residents and staff, staff are available to help and assist with tasks. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Nothe state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20211201154803

Allegation investigated: Staff do not properly maintain the facility

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. During complaint investiagtion on 05/19/23, LPA toured the faciltiy and observed cigarette buds scattred in the front yard and backyard smoking area. Broken chair was observed in the front yard. LPAs and LPM observed broken blinds in residents' rooms. LPA Monter observed the floor of R1's room #5 to have a slight indentation directly at the entrance which may pose as a tripping hazard for the resident. During today's complaint investigation, LPA's observed broken chairs and appliances (stove) in the front yard. The garbage bin in the front yard was not covered, exposing the garbage which attrached a swarm of 10-12 flies to the container. LPAs and LPM observed a pile of flattened cardboard boxes next to the garbage bin. Page 1 out of 2, see continuation on LIC 9099-C (Page 2). Substantiated Page 2 of 2. LPAs and LPM continued to see cigarette buds scattered in the front yard and backyard smoking area. The wood on the handrails at the front of the facility leading to the front door was brittle and worn out. LPM observed rotten red onion near the cardboard boxes which was not properly disposed and attraced a swarm of files. During today's inspection, LPA Monter observed the floor of R1's room #5 uneven and unbalanced at the entrance. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20211201154803

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 8, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met evidenced by: Based on observation and interviews, multiple areas of cigarette buds found on floor, broken chairs and appliances at the front area, multiple areas with swarms of flies, including front door& smoking area which poses an immediate threat to the Health, Safety and Personal Rights risk to the persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2023

Plan of correction: Administrator will clean the facility and submit a written plan on keeping the facility clean, safe, sanitary and in good repair by POC date.

Allegation investigated: Facility locked in two positive residents in their bedrooms Facility did not report COVID-19 outbreak within CCLD's COVID-19 protocol.

On 06/07/23, LPA's conducted a complaint investigation regarding the alligations above. LPA's interviewed resident R1 and R2 regarding residents being locked in their rooms during covid out break. R1 stated the faciility did close the door, but does not remember if they locked it. R2 stated they were not locked in their bedroom. ADM stated the facility sent incident report to CCL reporting covid outbreak. CCL recived an incident report regarding the covid outbreak on 02/04/2022. Based on the interviews conducted with clients and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20220208091354

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: Facility in disrepair

On 6/7/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation and met with Administrator, Sam Apostol. During complaint investiagtion on 05/19/23, LPA toured the faciltiy and observed cigarette buds scattred in the front yard and backyard smoking area. Broken chair was observed in the front yard. LPAs and LPM observed broken blinds in residents' rooms. LPA Monter observed the floor of R1's room #5 to have a slight indentation directly at the entrance which may pose as a tripping hazard for the resident. During today's complaint investigation, LPA's observed broken chairs and appliances (stove) in the front yard. The garbage bin in the front yard was not covered, exposing the garbage which attrached a swarm of 10-12 flies to the container. LPAs and LPM observed a pile of flattened cardboard boxes next to the garbage pin. Page 1 of 2. Continuation, see page 2, LIC9099-C Substantiated Page 2 of 2. On 06/7/2023, Based on interviews with residents (R1 to R11), 10 Out of 11 residents stated that they do not require assistance in showering except for 1 resident (R1) who requires assistance. Staff stated that they assist residents if they requested. R1 was interviewed wherein he/she said that he/she needs assistance in showering and is receiving assistance from two staff (S1 and S2). Facility staff yell at resident On 06/07/2023, Based on interviews with residents (R1 to R7), 7 Out of 11 residents stated that staff did not yell at them, and the other 4 residents (R8 to R11) stated that staff yell at them when they smoke at night and make the fire alarm goes off by the ADM. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 2 of 2. Facility staff not assisting resident with showering During today's inspection, 3 Out of 4 residents interviewed stated they take a shower themselves and 1 out of the 4 residents interviewed stated they need help while taking a shower. All 4 residents interviewed stated the staff administer the medication during scheduled time. During inspection, LPAs and LPM observed the shower room to be unlocked and a schedule of the resident showers was posted outside. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided. Page 2 of 2. LPAs and LPM continued to see cigarette buds scattered in the front yard and backyard smoking area. The wood on the handrails at the front of the facility leading to the front door was brittle and worn out. LPM observed rotten red onion near the cardboard boxes which was not properly disposed and attraced a swarm of files. During today's inspection, LPA Monter observed the floor of R1's room #5 uneven and unbalanced at the entrance. The Department has received an allegation prior to this complaint on 12/1/2021 where the allegation stated staff did not properly maintain the facility. The Administrator will complete a Plan of Correction which will address both deficiencies. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20220422141525

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 8, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... procedures for the safety and well-being of residents, employees and visitors. This requirement is not being met evidenced by: Based on observation and interviews, multiple areas of cigarette buds found on floor, broken chairs and appliances at the front area, multiple areas with swarms of flies, including front door& smoking area which poses an immediate threat to the Health, Safety and Personal Rights risk to the persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2023

Plan of correction: Administrator will clean the facility and submit a written plan on keeping the facility clean, safe, sanitary and in good repair by POC date.

Allegation investigated: Facility temperature is uncomfortable for residents.

On 06/07/2023, LPA's conducted a complaint investigation regarding the alligations above. Based on allegation that on 6/15/2022 the facility indoor was at 82 degrees F. Some residents alleged it was hot that night and asked staff if they could turn on AC but staff refused. Based on San Martin weather.com on 6/15/2022, the tempreture of the area was a high of 91F and a low of 54 degrees F. LPA's interviewed more or less 10 residents. No resident complained about the facility's tempreture. R1 stated the temperature can get hot but prefers to keep window closed. R2 stated the facility temperature does get hot but they have a fan to mitigate the temperature. ADM stated that if the tempretures get hot; the facility will turn on the AC and provide waters to the residents. ADM stated if a resident complained about the tempreture, then they will adjust the thermostat. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20220623103245

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.

Allegation investigated: Staff did not report incident involving resident Resident sustained injury while in care Staff did not prevent resident from attacking another resident Staff are not providing a comfortable envionment for resident

On 6/7/2023, Based on interview with ADM and Staff (S1), R1 and R2 had a verbal and physical altercation on 07/13/2022 regarding R2's watch. R1 grabbed R2's watch causing a cut on his/her right arm. ADM stated that LIC624 was submitted to CCLD on 7/14/2022. ADM stated that R2's responsible party was notified was notified of this incident according to ADM. Based on record review, CCLD received an incident report of this incident between R1 and R2. Based on investigation, R2 did sustained an injury during an unwitness altercation with R1. ADM stated that first aid was applied but does not require hospitalization. Unsubstantiated On 06/07/2023, ADM was interviewed. ADM also acknowledge that staff were instructed to label residents' clothing. ADM acknowledged awareness of missing items being reported by residents. On 06/07/2023, a random interviews with residents were conducted wherein R1 to R3 reported that they had missing items and clothes. R1 stated that they were asked by staff to put labels on their clothes but missing items continue to be an issue at the facility. R1 stated that later on staff will let her/him know that the missing items were found. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided. Page 2 of 2the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20220718115833

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jun 7, 2023

87217(b) Safeguards for Resident Cash, Personal property and valuables: (b) Every facility shall take appropriate measures to safeguard ...personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met evidence by: During investigation on 5/19 and 6/7, staff and residents were interviewed and acknowledged missing items such as clothing. LPAs and LPM observed on 5/19 and 6/7 residents' clothing with no name or labels in the laundry room. This pose a potential health, safety and personal rights risk.the state’s words, verbatim · CDSS document, Jun 7, 2023

Plan of correction: Administrator stated will send memo to responsilbe parites to label new items they bring to facility. Make sure the residents cloths are labeled. And will submit plan action by June 12 2023 to safeguard residents belongings.

Allegation investigated: Staff confiscated resident property. Resident was assaulted by another resident. Staff not intervene in resident on resident altercation. Medication was not given to resident at proper time. Resident was not fed.

On 06/07/2023, LPAs Rai and Monter and LPM Manzano conducted an unannounced complaint investigation of the above allegations and met with Administrator Sam Apostol. Staff confiscated resident property Based on interview with staff, ADM stated that R1 is no longer in the facility. ADM is aware of the incident occurred on 2/22/2023. ADM stated that R1 had a cellphone but staff did not confiscate R1's phone. Staff (S1) stated they do not confiscate resident's personal belongings. ADM denied allegation that R1's cellphone was confiscated. Staff (S1) stated that R1 had a behavior where he/she thew his/her cellphone towards the staff at the facility during the incident on 2/22/2023. Page 1 of 3. Continuation on page 2, LIC9099-C Unsubstantiated Resident was not fed ADM stated that R1's diet was good. ADM stated that his/her staff does not deprived R1 from not eating for 3 days rather the opposite, R1 was throwing his/her food on the floor and milk towards staff when exhibiting behaviors. ADM stated that R1's appetite was very good. Staff (S1) stated that R1 was being given meals and snacks but when exhibiting behavior the resident threw his/her food instead of consuming it. Medication was not given to resident at proper time. Based on allegation, the facility staff did not administer R1's medication timely manner causing his/her to have a stomach pain due to an empty stomach. ADM and staff stated that R1's medications were administered to R1 in a timely manner, nor they have any knowledge of the incident. Resident was assaulted by another resident Based in allegation, the resident was assaulted by another resident at the facility. Staff (S1) stated R1's roommate would complain because R1 would leave the window open and R1's roommate would be cold. The facility documented this incident occurring 2/5/2023 and 2/9/2023. During interview, S1 stated they had verbal agreements but both residents were not physical toward each other or other residents. Staff not intervene in resident on resident altercation ADM stated that R1 and R2 had an altercation wherein it was not witnessed. ADM stated that when R1 was in the facility, R1 had a behavior wherein he/she was not listening when being redirected. ADM stated that R1 threw milk at staff and scattered his/her clothes (clean and dirty) in his/her room and in the facility. Page 2 of 3. Continuation on page 3, LIC9099-C Page 3 of 3. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol.the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20230210140919

Allegation investigated: Unlawful Eviction

On 06/07/2023, LPAs Rai and Monter and LPM Manzano conducted an unannounced complaint investigation of the above allegations. Unlawful Eviction. On 06/07/2023, Based on interview with ADM, ADM stated that facility had an outburst behavior which was out of control. The facility had to call Emergency Psychiatric Services (EPS) and 24 hour care regarding R1's uncontrolled behavioral outburst. ADM stated that EPS came to the facility 2-3 hours later wherein they took R1. R1 was admitted at EPS. Page 1 of 2. Continuation on page 2, 9099-C. Unfounded ADM stated EPS was informed that R1 has to be stable prior to returning back to the facility. ADM stated that R1's social worker and 24 hour care were aware, involved and agreed that R1 need a higher level of care and subsequently admitted to a secured facility in San Jose. Staff (S1) stated that R1 was not picked up by EPS rather they called the Sheriff. Sheriff took R1 to Momentum Crisis Residential. ADM stated that the facility is willing to work with their residents and with their responsible party but when a resident has an uncontrolled behavior and being disruptive in the facility, they ADM denied allegation that R1 was illegally evicted. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited, Exit interview conducted with Administrator, Sam Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 7, 2023 · control 26-AS-20230210140919

Allegation investigated: Staff do not keep the facility free from pests

On 5/19/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation. On 5/19/2023, during today's inspection of the facility, LPAs/LPM observed 10 residents smoking and talking in the backyeard. LPAs and LPM observed swarm of approximately 40 flies forming a large or dense group under the covered patio with patio tables and chairs. Cigarette buds were observed around the cemented ground, an empty can of soda on ground. LPAs observed metled cheese and a peeled orange on the table. An interview with Staff S1 stated the presence of the flies in the facility was due to the horses in the neighborhood. Page 1 out of 2, see continuation on LIC 9099-C (Page 2). Substantiated According to the reporting party (RP), on 12/6/2021, a plate of old food was on the floor and flies were observed around the food. A random interview with residents stated that they utilized the covered patio during socialization where they had meals outside. Residents stated the staff were not observed clearing the outside patio ground and metal tables in a daily basis but if the staff do clean it will be at least once a week. According to a insect/pest control company, Orkin, the company website states, "Common house flies are attracted to decaying organic filth such as feces and rotting meat, whereas fruit flies seek sugary substances and feed more commonly on overripe fruit, spilled soda and alcohol".[https://www.orkin.com/pests/flies/what-attracts-flies]. On 5/19/2023, LPAs and LPM conducted a tour of resident's bedrooms and common areas including kitchen were inspected. During inspection, at least 2 flies were observed in the living area and in the area in front of the exit door (between room #21 and 22) is open. LPM observed at least 1-2 flies outside the front yard. During inspection of the facility grounds, there were a few flies observed in the front yard, side yards, front porch and around the facility perimeter except the covered patio. A horse ranch nearby the facility and is approximately 500 feet away from the facility (on the left side facing the facility) but no horses or other animals were observed during today's visit. A random interviews with a group of 10 residents, residents stated that they have observed mice in the facility but not so much of bedbugs, except 2 residents who stated that bedbugs were in their bedrooms; however, during the inspection, presence of bedbugs were not observed, nor residents complained of bed bug bite. During interview with Administrator (ADM), ADM is aware of the presence of mice in the facility and has contracted with a pest control company to eradicate bed bugs. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, May 19, 2023 · control 26-AS-20211201154803

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

87303(a) Maintenance and Operation: (a) The facility shall be in clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of mainteance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by: Based on observation of the covered patio at the backyard has swarm of at approximately 40 flies above the 10 seated residents who were smoking. The outside table observed with an empty can soda, tables with melted cheese and a peeled orange fruit which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2023

Plan of correction: Administrator will submit a written plan of action on how the facility would eliminiate or irradicate the presence of flies and mice in the facility by POC date 5/20/2023

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: Medication is unlocked.

On 5/19/2023, LPAs Monter and Rai and LPM Manzano conducted an unannounced complaint investigation of the above allegation. During the tour of the facility, LPAs and LPM observed staff storing medications in a kitchen cabinet which does not have lock. Based on interview with staff S1, S1 was the designated medication technician during day shift. S1 stated during interview that medications for PM and weekend was stored in the cabinet in the kitchen. S1 stated that the doors in the kitchen are locked and the staff have keys to access it. Page 1 of 2, please see LIC 9099-C. Substantiated Page 2 of 2. LPA and LPM inspected the kitchen cabinet on the right side top cabinet next to the refrigerator where S1 stored the PM, weekend medications (Sat and Sun) and 1 bag of R1's medication. During inspection, LPA and LPM observed that main door towards the medication room and the kitchen was open and accessible to residents in care. Kitchen staff was busy preparing and serving meals. Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, May 19, 2023 · control 26-AS-20220623103245

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 26, 2023

Incidental Medical and Dental Care (h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met by: Based on interview and observation, the administrator did not comply by storing resident medication in a kitchen cabinet which does not have locking capabilities poses a potential Health, Safety, or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, May 19, 2023

Plan of correction: Administrator will submit a written plan of action on how the facility will store the medication in a locked cabinet and not accessible to persons in care POC date 5/26/2023.

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.

Type of visit: Case Management - Deficiencies

On 5/19/2023, LPAs Monter and Rai and LPM Manzano were in the facility to do an unannounced complaint investigation. During interview with staff (S1), LPAs observed S1 preparing residents' medication in advance for Friday evening, and weekend. The medications in the medication room were prepped ahead of time, more than 24 hours. S1 stated that they started practice of prepping medications since pandemic. The resident's medication was delivered from the pharmacy in bubble pack and facility staff were transferring to small brown packets. LPAs/LPM interviewed Administrator who stated that the medication should only be prepared 24 hours in advance and anything more is not acceptable. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Sam Apostol and a copy of the report was provided. Appeal Rights was provided.the state’s words, verbatim · CDSS document, May 19, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: May 26, 2023

Incidental Medical and Dental Care (h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met by: Based on interview and observation, the administrator did not comply by storing resident medication in small brown envelopes 4 days in advance which poses a potential Health, Safety, or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, May 19, 2023

Plan of correction: Administrator will submit a written plan of action on how the facility would prepare the medication in a timely manner and keep the medication in original bubble pack provided by the pharmacy by POC date 5/26/2023.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Samuel Apostol. During visit, LPA Marrufo toured the facility. LPA Marrufo observed a 30-day supply of PPEs, perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed the facility bathroom had available soap, paper towels, and hand washing signs. The outdoor area exits were clear of obstructions. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2022

Allegation investigated: Resident sustained an unwitnessed fall, causing a fracture. Medical attention for resident was not sought in a timely manner.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with facility Medical Technician Ivonne Chavez (S1). Administrator Samuel Aposto (Admin) was unable to attend the inspection. Admin gave S1 permission to sign and review the report on his behalf. On 11/22/2021, a resident (R1) was discharged from the hospital and referred to a home health agency. The discharge medical records indicate that R1 had difficulty walking, impaired mobility, and issues with activities for daily living. R1 was assessed by home health and was determined to need support during transfers. R1 was noted to have fall precautions put in place, and was noted to only walk while supervised. Witnesses reported that during visits, they attempted to locate staff to provide this information, but were unable to find staff within the facility. During interviews with staff members, staff stated that R1 was able to ambulate by himself, but didn't because he was "lazy." Substantiated Staff reported that R1 had a history of falls but no prevention plan. R1 had only one documented fall at the facility, with the reason for emergency evacuation to the hospital being listed as "weakness." R1 was diagnosed with a fractured femur at the hospital. Information provided by the facility did not match with the transcript of the 911 call nor the ambulance records. Staff that reportedly assisted with the fall claimed that they did not work on the day that the fall took place. Administrative and medical staff at the facility provided information regarding the fall, but were unable to remember the fall when re-interviewed. Administrative and medical staff reported that R1 needed a higher level of care than they were able to provide. On an unknown date, facility staff member (S1) witnessed R1 on their bedroom floor and assisted them up. S1 documented that R1 was unable to move their hand and was unable to sit. A separate staff member (S2) reported that they were concerned about R1 because R1 was not eating. S2 determined that R1 needed medical attention, but R1 refused to go to the hospital. R1 was sent to the hospital 2 days later because they were not able to move, sit, or eat. Ambulance records indicate that R1 had been weak for 2 days. The information reflects that staff were aware and were concerned that R1 needed medical attention, but did not send him to the hospital in a timely manner. The Department has conducted an investigation of the above allegations. Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D. Exit interview conducted with Medical Technician Ivonne Chavez. A copy of this report, along with the facility's appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 22, 2022 · control 26-AS-20220210171405

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Nov 23, 2022

87463 - Reappraisals - (a) The pre-admission appraisal shall be updated... to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical... condition. This requirement was not met as evidenced by: Based on interviews and records review, the facility did not update R1's care plan when it became evident that R1 was a fall risk, resulting in fracture. This posed an immediate threat to the health and safety of residents in carethe state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: Licensee to submit updated written procedures for staff to reappraise residents upon return from the hospital and upon emerging changing health conditions by POC due date

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

87465 - Incidental Medical and Dental Care - (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health... This requirement was not met as evidenced by: Based on interviews and records review, the facility did not contact 911 until two days after R1's injury that resulted in fracture. This posed an immediate threat to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2022

Plan of correction: Licensee to conduct trainings with staff to assist with identifiying circumstances in which calling emergency services is necessary and provide proof of scheduling by POC due date

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to conduct a Case Management- Health Checks Visit. LPA met with Samuel Apostol Administrator and Yvonne Chavez Med Tech. LPA toured the facility to include the Medication Room. LPA interviewed Administrator and 4 staff and reviewed training records. Medications are stored in a medication cart located in locked medication room. Overflow medication is stored in locked Medication Closet in the locked facility office. LPA discussed Centrally Stored Medication Storage and Medication Training and provided a copy of Medication Training Requirements. See attached LIC9102 Advisory Note regarding Centrally Stored Medication Storage. LPA reviewed report with Samuel Apostol Administrator and a copy provided.the state’s words, verbatim · CDSS document, Apr 21, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Samuel Apostol. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed a visitor screening area at the entrance. LPA Marrufo toured the facility kitchen, pantries, and refrigerators and observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days. LPA Marrufo observed COVID-19 related posters throughout the facility hallways. The facility bathrooms has available soap and paper towels and hand washing signs. LPA Marrufo toured the outside area and observed the exits to be clear of obstructions. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Samuel Apostol and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 15, 2021

Allegation investigated: Facility did not follow COVID screening protocols Facility equipment is in disrepair Facility did not offer activities for the resident

Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation findings. LPA met with Administrator (AD) Samuel Apostol. On 7/27/2021, Department received complaint with above allegations and on 7/30/2021, Licensing Program Analyst, Marybeth Donovan opened the complaint. On 7/30/2021, LPA Marybeth Donovan, conducted a tour of facility with AD: Observed that facility has a screening protocol that was enforced. Exterior gate signs clearly indicated that all visitor are to call for assistance. Facility is clean. That watering hose was functional. Activity calendar posted on wall in hallway and any changes or modified activity was reflected in second copy next to original. VCR in R1’s room was not connected to TV and R1 stated that resident did not inform facility of interruption of functionality. AD is aware and will have staff member look into VCR status immediately. Unfounded On 9/29/2021, LPA Steve Nguyen, conducted a tour of facility with AD: Observed that screening protocol was enforced and that there was signage for covid mitigation posted throughout facility in prominent vantage points. Facility was clean. Watering hose was functional and were used by staff and residents for gardening activities. Observed VCR in residents’ room was functional. AD stated that, residents like to watch videos in their room. On 7/30/2021, LPA Marybeth Donovan interviewed 2 staff and 1 resident. 2 out of 2 staff denied all allegations. Per staff: Covid Mitigation process strictly enforced, and signage is up. Watering hose is functional. Once informed of VCR status, facility took immediate action. Resident is not sure on any of the allegations and not sure if VCR is not connected or just not working. LPA Marybeth Donovan reviewed the Activities calendar. Noted that any modification is reflected on the copy posted next to original. Per AD, facility tries to follow calendar whenever possible. The Department has investigated the above allegations. Based on interviews, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per the California Code of Regulations, Title 22, as a result of this complaint investigation. This report was reviewed with Administrator Samuel Apostol and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 15, 2021 · control 26-AS-20210727112127

Allegation investigated: Staff withdrew blood from residents Staff administered incorrect medications to residents

Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator (AD) Samuel Apostol. On 10/13/2020, Licensing Program Analyst (LPA) Steve Nguyen interviewed complainant. Complainant denied ever making such allegations and asked allegations to be retracted. On 10/15/2020, LPA conducted a virtual tour of facility with AD: Observed medication is locked, cleaning supplies locked, sharps are locked, all staff wearing masks and the practice of social distancing in use. LPA requested the following documents but not limited to: staff roster, resident roster, MARs, and a list of residents that received blood work for the month October 2020. Unfounded On 10/15/2020, LPA interviewed AD. Per AD: All residents go to County Lab or Home Health for blood work. AD denies any medication error within the facility for the month October 2020. On 10/30/2020, LPA interviewed 4 Staff. 4 out of 4 staff denied that facility carries out blood work on premises. 4 out of 4 staff denied any medication error for the month of October 2020. On 10/30/2020, LPA interviewed 4 residents. 3 out of 4 residents stated that they go to clinic or hospital for blood work. 1 out of 4 stated that he/she don’t need blood work. 4 out of 4 residents stated that they get their medication on time and have no knowledge of any errors. LPA reviewed Home Health Lab Work. Home Health Lab Work indicated that residents get their blood work done at Home Health and not at South County Retirement Home INC. LPA reviewed Medical Assessment Records (MARS): All documents were complete and there were no missing data. The Department has investigated the above allegations. Based on interviews, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per the California Code of Regulations, Title 22, as a result of this complaint investigation. This report was reviewed with Administrator Samuel Apostol and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2021 · control 26-AS-20201012163057

Allegation investigated: Facility staff failed to ensure resident received phone call messages from family Facility staff member physically abused resident

Licensing Program Analyst (LPA) Steve Nguyen conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator (AD) Samuel Apostol. On 10/30/2020, Licensing Program Analyst (LPA) Steve Nguyen interviewed complainant. Complainant denied ever making such allegations and asked allegations to be retracted. On 10/30/2020, LPA conducted a virtual tour of facility with AD: Observed medication was locked, cleaning supplies locked, sharps are locked, all staff wearing masks and the practice of social distancing in effect. Noted a pay phone within the facility that's available for resident to use. LPA requested the following documents but not limited to: staff roster, resident roster, and LIC634 (incident reports from June 2020 through October 2020). Unfounded On 10/30/2020, LPA interviewed AD. Per AD: Facility has a pay phone that is accessible to all clients 24/7. All residents know where the pay phone is located and because it is a pay phone, it does not take any messages. AD goes on to state that, to the best of his knowledge, there had not been any incident of staff abusing any residents. The facility provides training in dementia and elder or dependent abuse, to further enhance skill set to assist with residents on an ongoing basis to ensure the health and safety of residents. On 10/30/2020, LPA interviewed 4 Staff. 4 out of 4 staff stated that there is a pay phone for residents use, and that the pay phone does not take messages. 4 out of 4 staff denied any knowledge of abuse. On 10/30/2020, LPA interviewed 4 residents. 4 out of 4 residents stated that they know there is a pay phone but does not know anything about missed messages. 4 out of 4 residents denied any abuse from staff. LPA reviewed LIC 634 Incident Reports from June 2020 through October 2020, and no indications of abuse reported. LPA also reviewed training certificate and staff are trained in elder or dependent abuse. The Department has investigated the above allegations. Based on interviews, review of records, the Department has found that the complaint allegations are UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. No deficiencies were cited per the California Code of Regulations, Title 22, as a result of this complaint investigation. This report was reviewed with Administrator Samuel Apostol and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2021 · control 26-AS-20201026145206