The Gables of Ojai

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) De Leon arrived at 10:29 am to conducted a 1 year annual visit to the facility above. LPA met Administrator Matteo Digrigoli and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Infection Control Plan. The facility has a sign in and out area for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. Trash can and wastebaskets have tight fitting lids. Infection control and PPE training for staff is completed. Operational Requirements: The facility has a current plan of operation. The facility is approved for a capacity of 118 capacity with 54 Ambulatory, 60 Non-Ambulatory, which 4 may be bedridden in the memory care building rooms 302, 306, and 307. Facility has a current Hospice wavier granted for 15. The Facility is operating in compliance with the granted fire clearance. Physical Plant & Environment Safety: The facility has 14 buildings on the licensed property. The facility has 90 apartments with bathrooms and 7 public restrooms currently occupying 82 residents and employs 41 staff. The facilities common areas were clean, safe and sanitary. Memory Care Building N is located across the street and all exiting doors and gates have alarms. LPA was authorized to enter and inspect facility. The lighting and lamps are sufficient for the use of the facility and for residents comfort. The facilities main kitchen is clean, safe and sanitary. Apartment rooms were clean and comfortable for residents use, showers have non-skid textured floors, and grab bars were secured. Toilet, hand washing and bathing facilities were operational. The pathways were clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and kept locked. The facility has sufficient space inside and outside for activities and visiting. The facility is fenced with 3 open areas and 1 gate. The outside courtyard has plenty of shade for resident use. The facility has a pool fully fenced with 2 locked gates for entry. The facility has telephone and internet service for all residents in care. LPA toured 10 resident rooms. Toured rooms 8, 17, 33, 47, 88, 60, 302, 301, 307, and 312, all rooms met regulation requirements. Continued 809-C Staffing: The facility employes 40 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate expired 09/2023, Administrator has sent in renewal paperwork and is currently pending with CCL. Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and staff met most requirements with some not meeting exact hours and or subjects requirements. Administrator will make sure all staff finish annual training for 2023 with all required subjects and topics covered. Staff handling medications had annual training of 8 hours of medication training. Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals were on file. The facility does not handle cash resources for residents in care. Facility does submit incident reports to the department when required. Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, and Theft and Loss policy. CCL Complaint poster was 20x26 in size. Administrator agreed to have the Memory Care poster made into a 20x26 size. The LTCO poster was posted in the common area of the facility. The current license was posted in common entryway. Planned Activities: The facility offers activities to all residents in care. The facility employs an Activities Director and a monthly calendar with all activities is posted. The facility also offers additional activities to include books, magazines, newspapers, television, daily walks, group discussions and communications, games and puzzles. The facility has sufficient space to allow for activities indoors and outdoors as well as an activity room. Continued 809-C Food Service: The facility employs food service staff. The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food was covered, stored and marked appropriately in the main kitchen. A menu is posted for residents in care. Cleaning solutions and equipment were stored separately than food supply. Main Kitchen areas were clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices. Incidental Medical & Dental: The facility has 2 medication rooms both are kept locked. Facility provides or arranges transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication room for prescription and PRN medications, medication were reviewed for expirations dates. No medications labels were altered. The facility has a mini locked refrigerator. The facility has a red sharps container for disposal of syringes. Medication Destruct is done by the facility with Administrator and Medication Supervision. Disaster Preparedness: The current emergency disaster form is posted. The fire extinguishers were charged and last inspected on 06/05/2023. Emergency exits and telephone numbers were posted. Facility is conducting quarterly disaster drills. The facility is currently having the annual fire inspection today and administrator will send certification once completed. Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have delayed egress in the Memory Care Building. The MC building has exiting doors alarms as well as exiting gate alarms on the courtyard gate. The facility does not currently have residents with oxygen. Exit interview completed, copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Oct 18, 2023

The state marks this report as 9 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not keep facility free from vermin Staff do not properly store food

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-Day complaint visit to the facility at 09:20 a.m. the LPA was greeted by Marketing Director Christine Fenn and discussed the reason for the visit. Administrator Matteo Digrigoli arrived later during the visit. During today's visit the LPA toured the facility with Marketing Director Christine, obtained copies of pertinent documents, interviewed eight (8) staff, five (5) residents, one (1) residents private caregiver and marketing director between 09:40 a.m. and 02:30 p.m. Report will continue on LIC9099-C. Substantiated On the allegation that Staff do not keep facility free from vermin, it is the reporting party’s concern that there have been rats in the facility for the past month and management has not done anything about it. It was further alleged that the fruit that is being left out for the residents is getting eaten by the rats. To investigate the allegation, the LPA conducted a facility tour, observed the kitchen in the main campus and the dining rooms in memory care (The Gardens) and assisted living (The Cottages). At 10:04 a,m. the LPA observed rodent droppings on the floor of the kitchen in the main campus and at 10:55 a.m. inside a drawer in the dining room of Memory Care. Staff interviews revealed that the facility has had rat sightings for the past two to three weeks and one staff saw one last week. Staff interviews revealed that sticky traps have been placed by maintenance and are periodically checked. Lastly, staff interviews revealed that if the facility cannot control the situation Orkin, a pest control service would be called, however they have not called Orkin to assist with the vermin. Based on observation and interview, the allegations that " Staff do not keep facility free from vermin " is deemed SUBSTANTIATED at this time. On the allegation that Staff do not properly store food, it is the reporting party’s concern that staff do not put start dates on opened food and containers are left open when they are put away. It was further alleged that uncovered frozen meat is left out in the sink overnight to defrost. To investigate the allegation, the LPA conducted a facility tour, observed the kitchen in the main campus and the dining rooms in memory care (The Gardens) and assisted living (The Cottages). At 9:49 a.m. the LPA observed an opened can of whole jalapenos peppers with no start date labeled. At 9:58 a.m. the LPA observed an undated container of sauce, one undated dish of cooked meat, and one undated plate of cooked bacon all inside the fridge. At 10:00 a.m. the LPA observed four (4) uncovered hamburger patties not stored properly with visible freezer burn and a box of hamburger patties left open inside the freezer. At 11:16 a.m. the LPA observed staff grab apple sauce from a closed container inside the fridge in memory care and not properly closing the container. One of the corners of the apple sauce container was left open. Based on observation, the allegation that “Staff do not properly store food” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were issued to Administrator Matteo Grigoli. On the allegation Staff are not providing adequate food service to residents, it is the reporting party’s concern that the cooks in the kitchen do not take the temperatures of the food and are not properly washing the fruits and vegetables. It was further alleged that the residents were served chicken that was not fully cooked because it had been put in the oven while it was still frozen. To investigate the allegation, the LPA conducted a facility tour, observed the kitchen staff in the main campus while preparing lunch and interviewed staff and residents. At 11:27 a.m. the LPA observed kitchen staff washing lettuce using a colander, properly storing and labeling leftover food and periodically changing their gloves. In addition, the LPA observed kitchen staff checking the temperature of the chicken dish they had just cooked. Resident interviews revealed that the food service at the facility is excellent and that they had no concerns about the food service. Staff interviews revealed that fruits and vegetables are washed thoroughly and that they make sure the meat is fully cooked before serving it to the residents. Based on observations and interviews the allegation “Staff are not providing adequate food service to residents” is deemed UNSUBSTANTIATED at this time. On the allegations Staff do not ensure carpet is kept clean and sanitary and Staff do not ensure that the facility remains free of odors, it is the reporting party’s concern that on 9/28/23 a resident (R1) had a diarrhea accident and the carpet got dirty. It was further alleged that R1’s room smelled due to staff placing a floor mat on top of the feces instead of cleaning it. To investigate the allegation, the LPA visited R1’s room and random resident rooms with carpets, reviewed pertinent documents, and interviewed staff and residents. Record review revealed R1’s private caregiver had washed off what they could from the carpet and that the facility placed a work order on 9/28/23 for the carpet to be cleaned. Administrator Matteo stated R1’s carpet was washed by maintenance staff the same day or the day after. During today’s visit, R1’s room had no odor. In addition, R1’s interview revealed that the accident “got cleaned up nicely” and had no concerns of odors and that it was cleaned in a timely manner. Administrator Matteo stated that depending on the situation, carpets are either washed in house by maintenance staff with an extractor or are professionally cleaned by Regency, a carpet cleaning company. All three residents that were asked if they had any concerns regarding odors or carpet cleaning issues stated that they have no concerns and that they can place work orders if needed. Staff interviews also revealed that they have not smelled any odors coming from resident rooms. Based on the information gathered, although the allegation may have happened or is valid, there was insufficient evidence to confirm "Staff do not ensure carpet is kept clean and sanitary and Staff do not ensure that the facility remains free of odors. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.Exit interview conducted and report issued to Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 29-AS-20231002090407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Oct 10, 2023

87555(b)(27) General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by Based on interviews and observations, the licensee did not comply with the section cited above, as there were rodent droppings observed in the kitchen and staff admitted that the facility has an issue with rodents in the kitchen, which poses and immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: The Administrator agreed to do the following: 1. Submit a written plan of action, detailing how the facility will maintain compliance with the regulation. Indicate the steps the facility is taking to manage the pest concern on a daily basis and submit to CCL by 10/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Oct 16, 2023

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality...Food in damaged containers shall not be accepted, used or retained. Based on observation, numerous food items were observed in the kitchen refrigerator and freezer to be stored with no start label, meats were observed exposed to freezer burn and food not stored properly which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: During today's visit, items identified were disposed of. Administrator agreed to a full audit of all food items, including dry storage, refrigeration and freezer units to ensure all items are properly labeled, stored and within appropriate expiration date range and will provide proof to CCLD by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with an initial complaint visit (Complaint Control#29-AS-20231002090407). The purpose of the visit is to issue citations for deficiency observed during the complaint investigation which is not related to the complaint. The LPA arrived at the facility at 09:20AM and was greeted by Marketing Director Christine Fenn and discussed the reason for the visit. Administrator Matteo Digrigoli arrived later during the visit. At 9:40 a.m. during today's visit the LPA toured the facility with Marketing Director Christine. At 10:58 a.m the LPA observed one (1) full bottle of Dona Sol Merlot, and one (1) full bottle of Barefoot Merlot in an unlocked cabinet inside the dining room of the memory care unit accessible to the residents in care. At 11:01 a.m. the LPA observed a tool box with the following variety of tools: hammer, pliers, screw drivers and other tools inside an unlocked cabinet in the dining room of the memory care unit. At 11:58 a.m. the LPA observed a Clorox spray bottle, a pet stain and odor eliminator spray and disinfectant wipes in the living kitchenette area of room #34 accessible to residents in care. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 9, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Oct 16, 2023

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by Based on LPA's observations, the licensee did not comply with the section cited above as cleaning supplies, bottles of merlot,hammer and other tools were observed accessible to residents which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2023

Plan of correction: Staff locked all items during todays visit Administrator stated that they will provide documentation staff training regarding regulation 87705(f)(1) to CCL by 1/6/22.

Allegation investigated: Untrained staff

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director (ED), Matteo Digrigoli, and explained the reason for the visit. On 03/20/2023, LPAs Kasandra Lopez, Esther Cortez, and Ashley Smith conducted an initial visit. The LPAs toured the memory care campus from 10:14 a.m.-10:50 a.m., conducted five (5) staff interviews from 11:00 a.m. – 2:10 p.m., and conducted a file review and collected documents from 2:45 p.m. – 3:30 p.m. On 07/17/2023, LPA Smith conducted a subsequent visit where the LPA conducted three (3) staff interviews from 10:00 a.m. - 11:30 a.m., and reviewed resident files from 11:30 a.m. - 1:00 p.m. On 7/26/2023, the LPA conducted a physical plant tour, and interviewed ten (10) residents from 10:20 a.m. – 11:45 a.m. Today, the LPA reviewed staff training records for five (5) staff, conducted a medication audit from 11:20 a.m. – 12:30 p.m., and interviewed staff at 10:20 a.m. and 11:10 a.m. Substantiated Regarding the allegation: Untrained staff It was alleged that the staff that worked in the memory care unit were not adequately trained to manage residents with a diagnosis of dementia. As defined by Health and Safety Code 1569.626(a)(1) direct care staff must have eight (8) hours of in-service training per year on the subject of serving residents with dementia. For newer staff, staff must receive twelve (12) hours of initial dementia care training. During today’s visit, the LPA audited staff training records for five (5) staff from 2022. Out of the five files reviewed, four out of five staff failed to have the required hours of dementia training as required per Health and Safety Code. Based on the information obtained in the file audit, there is sufficient evidence to support the claim that all staff were not fully trained as it related to residents with a diagnosis of dementia. This allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were issued. Page 2 1. Regarding the allegations: Staff failed to assess the resident in care and 2. Staff failed to meet resident's medical needs It was alleged that the facility failed to assess R1’s medical needs, such as completing a UTI test, assessing whether R1’s medication regimen was working, medication crush orders, or assessments into R1’s causes of behavior. In addition, it was alleged that the facility failed to assess the resident in care. As the facility is a non-medical facility, the majority of the requests would have been fulfilled by R1’s primary care physician (PCP). In addition, per regulation, a facility is not required to have nursing staff, as the facility is not capable or required to provide medical care. The facility does not have the capacity to run a ‘UTI test’ or other medical or pain assessments. As R1 had an assigned PCP, requests had to go through the PCP. If residents at this community required a doctor’s appointment, they would have to travel outside of the community to attend a doctor’s appointment. Records review revealed that the facility regularly communicated with R1’s primary care physician (PCP) regarding R1’s increased agitation and aggressive behavior. Requests dated 2/3/2022 documented that R1 exhibited agitation and exit-seeking behavior. R1’s PCP responded with ordering an increase to R1’s Seroquel as an attempt to manage the behavior. Notes on 5/31/2022 documented that R1 was having trouble taking their medication, which was increasing R1’s agitation. As such, staff requested a time change as to when R1 took the medication to increase R1’s likelihood of taking the medication. R1’s PCP agreed and wrote an order for R1’s medication to be taken at a different time. On 6/9/2022, after the facility communicated that R1 continued to display aggression and biting behavior towards staff, R1’s PCP again recommended a medication increase. A follow up note to R1’s PCP on 6/22/2022 again resulted in R1’s PCP recommending a medication adjustment. Throughout this time, interviews indicated a 1:1 companion was needed for R1 for additional oversight and safety monitoring, as R1’s behaviors had not improved. As such, the facility attempted multiple strategies towards decreasing R1’s agitation. There were multiple requests written to R1’s PCP in June due to R1’s increased agitation and physical aggression towards staff. Records indicated that on 6/6/2022, R1’s PCP recommended a psychiatric evaluation, and indicated that it needed to be scheduled by R1’s responsible party, not the facility. On 6/22/2022, R1’s PCP again documented that a psychiatric evaluation was needed once staff informed the PCP that R1 continued to bite staff. Page 3 The note stated Psych consult ASAP! Tell [family member]. On 9/27/2022, after communicating to R1’s PCP that R1 was exhibiting aggressive behavior, R1’s PCP documented that they had asked for a psychiatric evaluation and wrote that the family needed to request it ASAP. R1’s PCP noted the same direction on 10/13/2022, re-iterating that the family needed to schedule a psychiatric evaluation. Staff continued to inquire with R1’s PCP about the best course of action to manage R1’s behaviors. Staff interviews indicated that they attempted to provide contact information for different psychiatrists, and staff communicated that they too attempted to call locations. However, staff indicated that when it comes to referrals, families are typically responsible for schedule the requested evaluations. Records titled ‘Gables of Ojai Routine Check Report’ represented charting notes specifically of R1. Records demonstrated that staff documented R1’s mood, behavior, specific outbursts, incontinence, and willingness to take medications on a daily basis. Staff also documented times that R1 refused care, such as being changed and taking showers. Staff interviews stated that when R1 would refuse care, staff would try multiple intervention methods to ensure that resident needs are tended to in a timely manner. Staff claimed that if they are unsuccessful with assisting R1, they will elevate the concern to management to mitigate the challenge or will enlist the assistance of another caregiver. Lastly, although there was a claim that R1 had lost a tooth and it was provided to R1’s family, there was insufficient evidence obtained in staff interviews or records to corroborate this claim. Staff were unaware of this occurrence. Records reviewed indicated that on 9/4/2020, staff informed R1’s PCP that R1 had a broken tooth on the upper left side of R1’s mouth, and notes reflected that R1 had a 2 p.m. appointment that day. Otherwise, no other mention of R1 having any missing or broken teeth. Based on the investigation, there is insufficient evidence to support the claims that the facility failed to meet R1’s medical needs, nor that the facility failed to assess R1. Records and interviews indicated that facility was in regular communication with R1’s PCP and took direction from R1’s PCP to best manage R1’s care as instructed. The facility implemented multiple medication changed in an attempt to manage R1’s behaviors. Staff attempted to be involved with the researching and scheduling of a psychiatric evaluation, but the responsibility ultimately was on R1’s responsible party. The allegations Staff failed to meet resident's medical needs and Staff failed to assess the resident in care are Unsubstantiated at this time. Page 4 3. Regarding the allegation: Due to lack of supervision, resident escaped from facility It was alleged that R1 eloped from the facility. A specific incident referenced took place on 8/4/2022, when R1 allegedly was in front of the memory care building and staff were unable to get R1 to return to the building. A physical plant tour of the memory care unit and staff interviews supported claims that although the door is equipped with delayed egress, should residents egress out the front door, staff must follow the resident and use non-physical intervention methods to guide the resident back into the communities. Interviews and a review of the facility ‘Incident Report’ revealed that staff attempted to coerce R1 back into the community, to which R1 refused. R1 successfully egressed to the front patio/lawn of the memory care unit. Staff called management over to assist with guiding R1 back into the memory care unit, but R1 refused to go. Staff ultimately called R1’s responsible party to help with assisting R1 back into the community. Staff indicated that R1 did not leave the building due to lack of supervision, as staff were aware that R1 was at the front entrance, but in attempts to guide R1 away from the door, R1 refused. Staff felt that they employed multiple intervention methods and supports in an attempt to assist R1 back into the community. Based on the information obtained in interviews and records review, there is insufficient evidence to support the claim that due to lack of supervision, R1 eloped from the facility. This allegation is Unsubstantiated at this time. 4. Regarding the allegation: Staff failed to administer resident's medication as prescribed It was alleged that staff were unsure as to whether R1 was taking their medication or not. In addition, it was alleged that the staff failed to put a crush order in place, nor did the staff request a medication review by the pharmacy. Staff interviews confirmed that R1 would regularly refuse to take their medications, and that staff would communicate this concern to R1’s primary care physician. Staff also alleged that they were documenting the times and dates in which R1 would refuse to take medication. The LPA reviewed R1's electronic Medication Administration Record (eMAR) and noted that staff indicated all the times in which R1 would refuse medication assistance. Staff also alleged that they were informing R1's responsible party of these instances, as it was a frequent occurrence. Page 5 Records titled ‘Gables of Ojai Routine Check Report’ represented charting notes specifically of R1. Records demonstrated that staff documented R1’s mood, behavior, specific outbursts, incontinence, and willingness to take medications on a daily basis. Records review revealed that the facility regularly communicated with R1’s primary care physician (PCP) regarding R1’s challenges with adhering to a medication regimen. Requests dated 2/3/2022 documented that R1 exhibited agitation and exit-seeking behavior. R1’s PCP responded with ordering an increase to R1’s Seroquel as an attempt to manage the behavior. Notes on 5/31/2022 documented that R1 was having trouble taking their medication, which was increasing R1’s agitation. As such, staff requested a time change as to when R1 took the medication to increase R1’s likelihood of taking the medication. R1’s PCP agreed and wrote an order for R1’s medication to be taken at a different time. On 6/9/2022, after the facility communicated that R1 continued to display aggression and biting behavior towards staff, R1’s PCP again recommended a medication increase. A follow up note to R1’s PCP on 6/22/2022 again resulted in R1’s PCP recommending a medication adjustment. Throughout this time, the staff kept in regular communication with R1’s PCP, who was overseeing R1’s medication regimen. Today, the LPA conducted a medication audit of five (5) residents in the memory care unit. No medication errors were observed during the medication audit. Staff documented the times residents would refuse medication in the electronic Medication Administration Record (eMAR). Based on the information obtained in the medication audit, interviews, and record review, there is insufficient evidence to support the claim that staff failed to administer R1’s medication as prescribed. This allegation is Unsubstantiated at this time. 5. Regarding the allegation: Facility failed to provide resident's records to authorized representative It was alleged that R1’s responsible party had requested R1’s full records, which were allegedly heavily redacted and/or edited. It was stated that R1’s responsible party had received minimal information. Staff interviews supported claims that the facility had provided R1’s family with R1’s complete file. Staff denied claims that information was redacted, edited, or removed. Staff claimed that R1’s responsible party was provided with documents during the in-person care conference, and indicated that all documents were provided as requested. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to provide resident's records to authorized representative. This allegation is deemed Unsubstantiated at this time. 6. Regarding the allegation: Facility doesn't return phone calls It was alleged that the facility failed to return the phone calls from R1’s responsible party as it related to R1’s care. Various statements were obtained related to this allegation; staff indicated that they oftentimes had to call R1’s responsible party to provide updates and indicated that R1’s family did not return the phone calls from the staff. However, R1’s responsible party indicated that they only received phone calls to obtain payment, and that the facility did not return their calls related to R1’s care and behavior. In general, staff interviews indicated that families either called the front desk and calls were then transferred over to the appropriate parties or to the memory care unit, or families could directly call the memory care unit if need be. It was further communicated that the receptionist would ensure that calls were sent to the requested parties and not only taking messages, as they understood the importance of the call and did not want the messages to get lost. In addition, residents raised no concerns as it related to receiving calls from loved ones if they called the facility. Based on the information obtained, there is insufficient evidence to support the claim that the facility failed to return phone calls. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 31, 2023 · control 29-AS-20230313110145

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.626(a)(1) · Plan of correction due date: Aug 4, 2023

1569.626(a)(1) Training requirements for direct care staff. Twelve hours of dementia care training ... All 12 hours shall be devoted to the care of persons with dementia. This requirement is not met as evidenced by: Based on file audit, the licensee did not comply with the section cited above in 4 out of 5 staff (S1, S2, S3, S4), which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 31, 2023

Plan of correction: The Administrator agreed to do the following: 1. Audit staff files in the memory care unit. Identify who needs to complete/finish training for 2023. Submit a letter, indicating the schedule in which training hours will be completed for staff no later than 8/4/2023

Allegation investigated: . Staff failed to meet resident's incontinent needs 2. Staff failed to meet resident's hygiene and grooming needs 3. Staff isolated resident in care 4. Facility has insufficient staffing to meet residents' needs 5. Resident rooms are malodorous 6. Staff failed to keep the resident's room clean 7. Facility is unclean and unkempt

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Executive Director (ED), Matteo Digrigoli, and explained the reason for the visit. On 03/20/2023, LPAs Kasandra Lopez, Esther Cortez, and Ashley Smith conducted an initial visit. The LPAs toured the memory care campus from 10:14 a.m.-10:50 a.m., conducted five (5) staff interviews from 11:00 a.m. – 2:10 p.m., and conducted a file review and collected documents from 2:45 p.m. – 3:30 p.m. On 07/17/2023, LPA Smith conducted a subsequent visit where the LPA conducted three (3) staff interviews from 10:00 a.m. - 11:30 a.m., and reviewed resident files from 11:30 a.m. - 1:00 p.m. Today, the LPA conducted a physical plant tour, and interviewed ten (10) residents from 10:20 a.m. – 11:45 a.m. Unsubstantiated Page 2 Regarding the allegation: Staff failed to meet resident's incontinent needs and staff failed to meet resident's hygiene and grooming needs. It was alleged that staff would leave Resident #1 (R1) soiled. A review of R1’s charting notes indicated that at times, R1 would not allow staff to assist with care. However, staff indicated that they would either ask another care staff for assistance, return at a later time to assist R1 when R1 was ready, and would ensure that they informed management and R1’s responsible party. Staff indicated that residents that required assistance with toileting were checked and changed at least every two (2) hours. Staff who provided care to R1 indicated that R1 would oftentimes refuse care and would act aggressively towards staff, but staff denied claims that R1 was ever left soiled. Staff also claimed that oftentimes, they had to use two (2) staff to provide care to R1, as R1 would oftentimes become aggressive when receiving care. Staff would also document the times in which R1 would refuse care. During the physical plant tour on 3/20/2023 and 7/26/2023, residents appeared well groomed. The LPA’s did not smell any odors nor did residents indicate that staff failed to meet their incontinent needs. Residents also denied claims that they had ever been left soiled for an extended period of time. The LPA attempted to reach out to R1’s family for additional information, but the LPA did not receive a response. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to meet resident's incontinent needs or the claim that staff failed to meet resident's hygiene and grooming needs. These allegations are deemed Unsubstantiated at this time. Regarding the allegation: Staff isolated resident in care It was alleged that R1 had not left their room in ‘a long time’. During the physical plant tour on 3/20/2023 and 7/26/2023, the LPAs observed that many residents in the memory care unit were congregating in the common living room. Staff supported claims that they encouraged residents to leave their room for activities, but also respected if residents wanted to stay in their room for personal reasons. Staff stated that R1 would oftentimes opt to stay in the room, but also indicated that R1 was found to participate in certain communal activities. Residents did not indicate that they ever felt isolated in the community and stated that there were many activities to participate in. The LPA interviewed five (5) residents in the memory care unit, whom communicated no concerns and did not indicate that they were ever forced to stay in their room or were isolated from activities. Based on the information obtained, there is insufficient evidence to support the claim that staff isolated R1.This allegation is deemed Unsubstantiated at this time. Page 3 Regarding the allegation: Facility has insufficient staffing to meet residents' needs It was alleged that there were not enough staff in the memory care unit. Interviews and records indicated that fully staffed meant there were at least three caregivers for the AM shift and PM shift, not including a medication technician. Staffing is also based on the needs of the current residents within the facility. Staff admitted that at times, if someone calls off, staff will need to supplement with agency staff, assign a medication technician to also conduct caregiving duties, or management staff will step in. Although some staff indicated that additional staff members were needed, the majority of staff felt that there was sufficient coverage to manage resident care needs. Similarly, most residents interviewed indicated that care needs have not suffered or gone un-met due to staffing concerns. Based on the information obtained in interviews and record review, there is insufficient evidence to support the claim that facility has insufficient staff for residents while in care. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Resident rooms are malodorous It was alleged that rooms smelled of excrement. During the physical plant tour conducted on 03/20/2023, the LPA’s toured all thirteen (13) rooms in the memory care unit. Rooms appeared clean, well kempt, and did not smell of any odor. The LPAs did not observe any soiled furniture, and resident furniture appeared clean and in good condition. During the physical plant tour conducted today, the LPA again found rooms to be clean and did not observe any unpleasant odors in either the memory care unit or assisted living rooms. Residents indicated that rooms were cleaned on a weekly basis, and both staff and residents indicated that if rooms required extra cleaning, housekeeping would be alerted. Based on the information obtained, there is insufficient evidence to support the claim that resident rooms are malodorous. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to keep the resident's room clean It was alleged that staff allowed R1’s trash can to overflow, and that R1’s room overall appeared unclean. Staff whom provided care to R1 claimed that R1 and all residents received weekly housekeeping services. Staff said that if R1 ever asked them to leave the room, they would do so, but staff would also ensure that R1’s room was cleaned regularly. Page 4 During the physical plant tour conducted on 03/20/2023, the LPA’s toured all thirteen (13) rooms in the memory care unit. Rooms appeared clean, and well kempt. During the physical plant tour conducted today, the LPA again found rooms to be clean in both the memory care unit and assisted living rooms. Residents indicated that rooms were cleaned on a weekly basis, and both staff and residents indicated that if rooms required extra cleaning, housekeeping would be alerted. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to keep R1's room clean. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Facility is unclean and unkempt It was alleged that the facility was unclean. Staff claimed that common spaces were cleaned on a daily basis, and that resident rooms received housekeeping services at least once a week. During the physical plant tour conducted on 03/20/2023, the LPA’s toured all thirteen (13) rooms in the memory care unit, including the common spaces. Rooms appeared clean, and well kempt. During the physical plant tour conducted today, the LPA again found rooms to be clean in both the memory care unit and assisted living rooms. Residents indicated that rooms were cleaned on a weekly basis, and both staff and residents indicated that if rooms required extra cleaning, housekeeping would be alerted. Interviews with ten (10) residents during today’s visit revealed housekeeping services are provided once a week and there are no issues or concerns regarding services not being provided as scheduled. Interviews with staff revealed residents are provided housekeeping services weekly. Based on the information obtained, there is insufficient evidence to support the claim that the facility is unclean and unkempt. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 26, 2023 · control 29-AS-20230313110145

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident phone does not funtion the same as other residents

Licensing Program Analyst (LPA) Olson conducted a 10-Day complaint visit to the facility above. LPA met with Matteo Digrigoli, Administrator and explained the purpose of the visit. LPA requested documents and interviewed Administrator at 2:50 PM, Resident 1 (R1) at 3:20 PM, Resident 2 at 3:14 PM and Resident 3 at 3:50 PM and Recptionist at 4:50 PM. It was alleged that Resident 1 (R1)’s phone did not have the same features as other phones in the facility. During the investigation, LPA verified residents have access to phones at the facility. LPA confirmed R1 has a phone in their room; however it is not connected to the main phone system at the facility and could not be easily added to the system. The phone in R1’s room was added on a separate phone line. In order to provide a workaround, the facility preprogramed numbers on “speed dial” to assist the resident. Contined on 9099-C Unsubstantiated R1 stated when they call other residents in the facility, they are not able to dial an extension like the other residents can, but rather they have to call the front desk and be transferred. The facility also offered to move R1 to a different room, but R1 declined. LPA asked if the administrator can program internal resident phone numbers onto the “speed dial” function, so the R1 can call other residents directly. Interview with Receptionist revealed that that is not possible due to the system not being automated. Receptionist stated some residents can call other rooms using their extension and others cant. Some residents have to call the front office and asked to be transferred to different apartments. Based on the information obtained, a regulation was not violated and the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report emailed to Administrator/Licensee.the state’s words, verbatim · CDSS document, Oct 19, 2022 · control 29-AS-20221011100818

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Olson conducted an unannounced infection control annual inspection. LPA met with Matt Digrigoli, Administrator and explained the purpose of the visit. LPA took a physical plant tour of the facility with Administrator. The facility has an entry point at the front door where everyone entering completes sign-in, symptom questionnaire and temperature screening on all staff and visitors wanting to come into the facility. The entry station has hand sanitizer along with a thermometer. 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 is noted or any residents are showing any signs, symptoms, or a temperature. Signs are posted on the front door, entry area regarding Covid-19. 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 has 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. The Administrator and Assisted Living Director are in charge of infection control and provides training and education to staff, residents and visitors. Continued on 809-C Staff will use full PPE with N95 masks and face shields when around with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for residents so isolation can be arranged when and if needed. The facility has single rooms with restrooms, that are disinfected and wiped down daily. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30-day supply of PPE on hand. 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. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission, and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Residents’ medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in locked cabinets. 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. Administrator Certificate is valid. Facility has hard wired smoke detectors throughout the facility. All infection control protocols are implemented and are being followed. At approximately 12:00 pm, LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined there is one staff member currently working in the facility and have not been associated to the facility. 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, Oct 19, 2022

Allegation investigated: Facility staff did not assist resident with medication as prescribed

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 11:02AM and met with Executive Director Matteo DiGrigoli and Assisted Living Director Deedee Quolas. Entrance interview conducted. During today's visit, LPA toured the facility with Mr. DiGrigoli at 11:15AM, conducted interviews with staff at 11:05AM, 1:07PM, and 1:48PM, LPA reviewed pertinent records at 11:32AM, and LPA gathered copies of pertinent documents. The following was then determined: Resident #1 (R1) was admitted to hospice on 05/18/2022. Following hospice admittance, R1 had regular hospice visits by the nurse and others on the hospice care team. R1 sustained 2 falls on or around 05/26 and 05/27/2022. After the falls, R1's physician changed R1's medication orders. Facility staff documented medications administered by the facility, as well as when R1's family member administered medications. REPORT CONTINUED ON LIC 9099-C Unsubstantiated Between 05/27/2022 and 05/31/2022, R1's family members were at R1's bedside both during the day and at night. R1's family member requested and administered PRN medications to R1. Review of hospice admit paperwork indicates R1's family member was "explained medications, dosage, routes, side effects, and schedule of administration" for R1's medications. Hospice paperwork further states "provided and discussed written policy and procedures on the management and disposal of controlled medications," indicating R1's family member, who is also designated as R1's Power of Attorney (POA) has been trained on proper administration of R1's medications. Staff interviews revealed R1's family member requested medications for R1 often, but they were prescribed every hour as needed for pain or shortness of breath and documentation review revealed the medication was not given to R1's family member to administer more often than prescribed. Therefore, based on interview and record review, the allegation that "Facility staff did not assist resident with medication as prescribed" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted with Executive Director Matteo DiGrigoli. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Jun 9, 2022 · control 29-AS-20220601105540

Allegation investigated: Staff did not notify resident #1 (R1) authorized representative of medical appointments

Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint visit to this facility for the above complaint allegation to deliver final investigation findings. LPA met with staff Ashley Phelps who is authorized to review and sign reports. Concerns were that staff did not notify R1's authorized representative of medical appointments. Interviews on 3/3/22 starting at 2:07 pm and 3/8/22 at 4:38 pm and a review of R1’s records on 3/10/22 starting at 9:21 am revealed that R1’s authorized representative was not notified of all R1’s medical appointments. Based on the information obtained during the course of the investigation the allegation is deemed 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. Today's reports and appeal rights were reviewed and emailed to the Administrator. Substantiatedthe state’s words, verbatim · CDSS document, Mar 10, 2022 · control 29-AS-20211011144616

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(9) · Plan of correction due date: Mar 18, 2022

1569.269 Enumerated rights; severability (9) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding the care and services to be provided in accordance with... and to involve persons of their choice in the planning process... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee did not notify R1’s authorized representative of all R1’s medical appointments which posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2022

Plan of correction: Staff stated that they will provide documentation of staff training regarding regulation 1569.269(9) to CCL by 3/18/22.

Allegation investigated: Staff leave residents unattended while in care

Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent unannounced complaint visit to this facility for the above complaint allegation to deliver final investigation findings. LPA met with Administrator Eric Terrill. Concerns were that staff left residents alone in the Gardens (memory care unit) during the night for about 10 minutes. Interviews conducted with random staff and residents on 1/25/21 starting at 2:34 pm, 9/9/21 starting at 11:11 am, 10/19/21 starting at 1:52 pm and 3/3/22 at 8:24 am revealed that no one is aware of residents being left alone in the Gardens at any time. A review of staff records on 9/9/21 starting at 2:44 pm revealed that staff were scheduled to work the Gardens throughout the night. Based on the information obtained during the course of the investigation the allegation is deemed unsubstantiated at this time. Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 3, 2022 · control 29-AS-20210104113506

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 1/23/22. LPA met with Eric Terrill - Administrator. On 1/24/22 LPA spoke with the Administrator regarding an incident of Elopement for resident #1 (R1) on 1/23/22. R1 was missing for approximately 3 hours. Facility staff searched the immediate and surrounding areas and called the Sheriff's department. Administrator stated that they called in additional staff to help with the search. R1 was found at a home located next door to the facility sitting in an unlocked car. R1 was taken back to the facility by the Administrator. R1 did not sustain any injuries. R1's physician and family member were notified of the incident. Administrator stated that based on R1's physicians report R1 is not able to leave the facility unassisted. During today’s visit LPA toured the facility with staff Naomi Hernandez and the Administrator. LPA conducted interviews with random staff and R1. A review of R1's records starting at 12:35 pm revealed that R1 is not able to leave the facility unassisted. Administrator stated that they conducted interviews with staff working at the time of the incident who indicated that they are not aware of how R1 left the facility. Administrator stated that the door alarms were functioning properly. Based on information obtained during the investigation staff failed to supervise R1 on 1/23/22 as R1 eloped from the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted, todays reports were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Jan 27, 2022

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2022

Plan of correction: Administrator stated that R1 was placed on frequent checks and they have started staff retraining regarding elopement protocols. Administrator stated that they will conduct a reappraisal for R1 and will provide a copy of reappraisal and staff training to CCL by 2/7/22.

Allegation investigated: Staff lied to residents authorized representative regarding services provided by the facility

Licensing Program Analyst (LPA) JoAnn Rosales made an unannounced complaint visit to this facility for the above complaint allegation. LPA met with Administrator Eric Terrill. During today's complaint investigation LPA toured the facility with the Administrator, interviewed random residents and staff, and obtained pertinent documents. Concerns were that the Administrator lied to resident #1 (R1's) authorized representative regarding (CCL) Community Care Licensing mandating 1:1 caregiving services for R1. Interview with Administrator starting at 3:16 pm revealed that CCL did not mandate 1:1 caregiving services for R1. Administrator stated that based on R1 physicians report indicating R1 is not able to leave the facility unassisted and R1 authorized representative refusing memory care after R1 left the facility unassisted 1:1 caregiving was the only option. Administrator stated that telling R1's authorized representative that CCL mandated 1:1 caregiving services was the wrong choice of words. Based on the information Continued on 9099C Substantiated obtained during the course of the investigation the allegation is deemed substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 29-AS-20211011144616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 29, 2021

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on interviews, the Administrator made a false claim to R1’s authorized representative which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2021

Plan of correction: Administrator stated that they will provide documentation of training regarding false claims to CCL by 10/29/21.

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: Required - 1 Year

Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 11:17 a.m. The LPA met with Administrator Eric Terrill and discussed the reason for the visit. Entrance interview conducted. The LPA interviewed facility Administrator during tour. Admin revealed their current census is 73. LPA and Admin toured the physical plant areas inside and outside starting at 11:45 a.m. to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 89 total bedrooms; 76 (seventy-six) are assisted living resident rooms and 13 (thirteen) are in memory care resident rooms. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Continued on LIC 809-C The courtyard area has a covered outdoor patio equipped with furniture for resident use. There was a swimming pool observed to have a cover and a locked gate. The LPA observed a locked roomed containing the emergency food supply and Personal Protective Equipment (PPE). KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 12:20 p.m. There are 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility is allowing visitors, however LPA noted that the facility is allowing visitors for both indoor and outdoor. The LPA observed an adequate supply of Personal Protective 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 a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Oct 7, 2021

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 8/26/21. LPA met with Eric Terrill - Administrator. On 9/2/21 LPA spoke with staff Ashley Phelps regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 8/26/21. R1 was observed approximately 2 blocks from the facility and was redirected by staff back to the facility. R1 did not sustain any injuries. R1's primary care provider and family member were notified of the incident. Staff stated that based on R1's physicians report R1 is not able to leave the facility unassisted. LPA reviewed R1's records on 9/7/21 which revealed that R1 is not able to leave the facility unassisted. During today’s visit LPA toured the facility with staff Ashley Phelps. During facility tour starting at 10:41 am with staff Phelps LPA observed lysol disinfecting wipes, bleach, disinfectant cleaner, laundry detergent, fabric softener, oxi clean stain remover, lime-a-away cleaner, toilet bowl cleaner, and furniture polish in an unlocked housekeeping room accessible to residents. Interview with Administrator at 3:28 pm revealed that R1 will be provided with 1:1 caregiving services until they are able to move R1 to the Gardens (Memory Care). Administrator stated that R1 is scheduled to move to the Gardens on 9/13/21. Based on information obtained during the investigation staff failed to supervise R1 on 8/26/21 as R1 eloped from the facility. 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, todays reports were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 9, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Sep 10, 2021

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

Plan of correction: Administrator stated that R1 will be placed with a 1:1 caregiver starting immediately. Administrator stated that they will provide documentation of staff training regarding safety and elopement protocols to CCL by 9/20/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Sep 10, 2021

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as cleaning supplies and disinfectants were accessible to residents which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 9, 2021

Plan of correction: Staff locked cabinet containing the lysol wipes, bleach, disinfectant cleaner, laundry detergent, fabric softener, oxi clean stain remover, lime-a-away cleaner, toilet bowl cleaner, and furniture polish. Administrator stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) by 9/10/21.