Veterans Home of California-Ventura

Allegation investigated: Resident not being treated with dignity and respect

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced amended report to correct an error in the 10/27/2023 Complaint Investigation Report and to add additional information to the report. Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct an initial 10-day complaint visit. The LPA met with Administrator Selena Garcia Lopez and explained the reason for the visit. Administrator Selena had to leave and instructed Cindy Gambill, Hospital Administrative Resident 2 (HOR2) to sing and review the report. Today, the LPA interviewed two (2) staff and four (4) residents and reviewed documents between 10:50 a.m. and 3:30 p.m. Report will contnue on LIC9099-C Substantiated Regarding the allegation, Resident not being treated with dignity and respect, it was alleged that on 08/20/2023, Staff #1 (S1) told Resident #1 (R1) that they were trying to fall to sue the facility. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted an Unusual Incident Report (UIR) to document the above-mentioned interaction and/or incident. After review of the incident, on 08/28/23 the Administrator informed the LPA that they were in the process of reviewing the event. During the investigation, a written charting note made by S1 regarding the incident was provided to the LPA. S1 wrote that R1 had approached them and requested for R1’s walls to be checked for leaks, and no leakage was found. Later R1 had gone outside as they were “concerned about the downspout flooding outside”. S1 stated that they requested R1 to go back inside, which they did, and R1 later went back outside. S1 wrote they told R1 “maybe you are trying to hurt yourself here, so you can sue the home,” after they had requested for R1 to come inside again. Additionally, Licensing Program Manager KaSandra Lopez conducted a telephone interview with S1 on March 13, 2024. Based on record review, and interviews there is sufficient evidence to support the allegation that Resident not being treated with dignity and respect. The allegation is deemed Substantiated at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report and appeal rights provided to HOR2 Cindy Gambill. Regarding the allegation, Staff threatened resident, it was alleged that on 08/20/2023 S1 threatened R1 to go inside their room or that they would contact the sheriff. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted a Special Incident Report (SIR) to document the above-mentioned interaction and/or incident. To investigate the allegation, the LPA reviewed pertinent documents, and conducted resident and staff interviews. Interviews and record review revealed that S1 told R1 “if you don’t follow my directions, I’m going to call the Sheriffs.” However, interviews with S1 and R1 revealed that S1 had told R1 to step away from blocked off areas due to water leaking multiple times, and R1 had been asked to go inside their room multiple times due to safety concerns due to the hurricane and heavy rain on that day. Interview with one witness (W1) revealed that even though S1 did tell R1 to go inside their room or they would contact the sheriff, it was due to safety concerns. Lastly, all additional residents interviewed revealed that they feel safe and have no concerns regarding S1. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Staff threatened resident”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 29-AS-20231025114008

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 10, 2023

Personal Rights. Each resident shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Administrator stated S1 will be issued a letter of Instruction and received training on residents personal rights. Administrator agrees to submit proof by 11/10/23

Allegation investigated: Staff inappropriately spoke to a resident while in care

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-Day complaint visit to the facility at 12:20 p.m. the LPA was greeted by Cindy Gambill, Hospital Administrative Resident 2 (HOR2), and discussed the reason for the visit. Administrator Selena Garcia Lopez arrived shortly. During today's visit the LPA obained copies of pertinent documents at 12:45 p.m. and interviewed three (3) residents, two (2) staff and the administrator between 01:00 p.m. and 3:15 p.m. Report will continue on LIC9099-C Substantiated Regarding the allegation, Staff spoke inappropriately to resident in care, it was alleged that on 09/16/2023, Staff #1 (S1) began yelling at Resident #1 (R1) as R1 walked towards the nursing station and yelled “They don’t give a shit about you!” It was further alleged that R1 reported the incident to S2, and S2 intervened and told S1 to stop yelling. During the investigation, R1 informed the LPA that S1 had yelled at them from the hallway and woken them up and confirmed that S1 yelled “They don’t give a shit about you.” A written statement made by S1 regarding the incident was provided to the LPA. S1 wrote that he spoke to the resident, “we don’t care about your shitty attitude. I am passing out meal orders and ensuring that you are safe and getting your meals.” Based on record review, since S1 admitted to speaking inappropriately to R1, there is sufficient evidence to support the allegation that staff spoke inappropriately to resident in care. The allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC9099-D). Exit interview was conducted with the Administrator. A copy of the report and Appeal Rights were issued. Regarding the allegation, Staff yelled at residents while in care, it was alleged that on 9/16/2023 Staff #1 (S1) began yelling at Resident #1 (R1) as R1 walked towards the nursing station and yelled “They don’t give a shit about you!” It was further alleged that R1 reported the incident to S2, and S2 intervened and told S1 to stop yelling. During the investigation, R1 informed the LPA that S1 had yelled at them from the hallway and woken them up and confirmed that S1 yelled “They don’t give a shit about you.” The LPA was unable to interview S2, however was able to interview two additional residents. When asked if they have ever heard staff yelling at residents or to them, they stated that they had not heard staff yelling, nor had they been yelled at while in care. They stated, “staff is real great” and that staff are “pretty mellow”. In addition, Administrator Selena stated that even though S1 had admitted to speaking inappropriately to R1, S1 denied yelling at S1. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Resident was yelled at while in care”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of the report was provided to Administrator Selena.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 29-AS-20230920135710

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 6, 2023

87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff...This requirment was not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above when staff (S1) spoke to R1 inappropiately which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Administrator has agreed to review with staff (S1)the regulation 87468.1 (a)(1)-and send proof orself-verification via a letter to the CCLD department by 10/06/2023.

Allegation investigated: Facility did not notify resident's responsible party of an incident. Facility did not seek medical treatment for resident in a timely manner.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the above facility at 2:40 p.m. LPA met with Hospital Administrative Resident 2 (HOR2) Cindy Gambill and the reason for the visit was explained. Administrator Julian Bond was notified of the visit and directed LPA to HOR 2 Cindy Gambill to issue the findings of today's report.. On 4/20/2023, LPA toured the facility with Hospital Administrative Resident 2 (HOR2) Cindy Gambill between 10:28 a.m. – 10:40 a.m., observed the parking lot during the tour, and requested copies of pertinent documents. Between 11:00 a.m. – 4:25 p.m. LPA interviewed nine (9) staff and five (5) residents. On 5/12/2023 LPA conducted a file review and obtained pertinent documentation between 01:20 p.m. and 04:15 p.m. During today's visit LPA conducted a file review between 2:50 p.m. and 4:15 p.m. Report will continue on LIC 9099-C. Unsubstantiated It was alleged facility did not notify resident’s Responsible Party (RP) of an incident. It was further reported that R1’s emergency contact was not notified of a fall. Administrator indicated that resident’s emergency contacts are not notified of resident’s incidents if, they are not the residents’ responsible party, unless it is a critical medical situation where the resident is unable to make that decision. In addition, the administrator stated that in case of a serious incident, staff will assess the resident and if they are oriented and able, staff will ask the resident if they want their emergency contacts to be notified. A review of Unusual/Serious Injury Reports (SIRs) submitted to the department reflected that Resident #1s (R1) incident was reported to the licensing agency, however R1 is their own responsible party and therefore the facility did not have to notify R1’s emergency contacts. Additionally, interviews conducted with random facility residents reflected that their RPs are notified in case of emergency however, if the resident choose the RP to not be notified the facility would respect the residents wishes. LPA also conducted interview with random RPs of facility residents which reflected that they are notified of any incidents pertaining to the residents. Based on information gathered, the Department does not have sufficient evidence to determine that facility did not notify resident’s responsible party of an incident. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time. It was alleged facility did not seek medical treatment for resident in a timely manner. It was further reported R1 was denied medication when they requested it and not taken to the hospital in a timely manner. Interviews conducted revealed that when residents are ill, residents are assessed by facility’s nurses and resident’s Primary Care Physician (PCP) to determine the medical treatment needed. If it is an urgent medical concern, the facility will immediately contact 9-1-1 emergency services to transport residents to the hospital. Moreover, interviews conducted reflected that R1 was diagnosed with COVID-19 and R1’s PCP was notified. Based on recommendation of the PCP, R1 was not given the medication for COVID due to possible medication contradictions with the current medication R1 was taking. Moreover, a review of R1’s medication records reflected that R1 did not have a prescription for Ibuprofen and therefore, the facility could not assist R1 with self-administration of medication. However, upon discharge from the hospital R1 received a new prescription order for the medication and therefore, was provided the medication. Based on information gathered, the Department does not have sufficient evidence to determine that Facility did not seek medical treatment for resident in a timely manner Therefore, the above allegation is deemed UNSUBSTANTIATED at this time. No citations were issued. Exit interview conducted with HOR2 Cindy Gambill. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 25, 2023 · control 29-AS-20230412151519

Allegation investigated: Staff did not notify resident's physician of resident's change of condition

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue the findings for the above allegation. The LPA met with staff and explained the reason for the visit. It was alleged that Resident #1 (R1) experienced a change of condition and staff allegedly failed to notify R1’s psychiatrist. There was an overall concern for R1’s well-being due to the change of behavior. On 3/15/2022, Licensing Program Analyst (LPA) JoAnn Rosales made a visit to this facility from 10:26 a.m. – 1:45 p.m., to which the LPA interviewed staff, reviewed records, and obtained documents. The investigation revealed that an incident report submitted to the Department dated 3/13/2022, indicated that on 3/13/2022, staff found a note written by R1, where R1 expressed that something ‘bad’ had happened and that it ‘had to be fixed’. R1 was not in the facility at the time the note was found. The incident report also indicated that R1’s attending physician (ie. Facility house doctor) was also notified of R1’s status. Unsubstantiated Staff contacted R1 over the phone on 3/13/2022, in which R1 was making suicidal ideations. In response, staff contacted the local police department and informed them of the incident. R1 ultimately returned to the facility on 3/14/2022. Staff met with R1, and although R1 appeared to be in a better mood, staff contacted the county suicide prevention hotline on 3/15/2022 for additional feedback. Staff encouraged R1 to contact emergency services if they continued to experience suicidal ideations. On 3/16/2022, R1 began to experience suicidal ideations, in which staff responded by contacting the local police department. Staff contacted emergency services, and R1 was ultimately transferred to a psychiatric unit and did not return to the facility. Interviews and records review revealed that upon admission to the facility on 1/25/2018, R1 had a diagnosis of anxiety and depression. As a result, R1 had regularly consulted with a psychiatrist with regards to managing their diagnosis. Records documented that R1 was an ‘independent and active’ resident, owned their own vehicle, and participated in their own ‘self-directed activities’. A review of internal care notes confirmed that staff were aware of R1’s diagnosis and had regularly checked in with R1 regarding their increased depression and anxiety. Reviewed notes documented that R1 had recently seen the facility social worker, who documented that R1 continued to struggle with symptoms of depression and highlighted that R1 received psychiatric services from the local clinic. Notes also indicated that R1 had seen their psychiatrist on 3/4/2022 at 3/8/2022, who assessed R1 and adjusted R1’s medications accordingly. Given the events that took place on 3/13/2022, the LPA observed a care note created on 3/15/2022 at 2:22 p.m. indicated that R1 was scheduled to speak to their psychiatrist on 3/16/2022 at 11:00 a.m. “if [R1] is willing to speak to [them]”. Per the note, it appears that staff had informed R1’s physician about the change of condition and scheduled an appointment, despite the claim that R1 may not speak to them at the time. The date and timing of the note was entered prior to the submission of this complaint to our department. Based on the information obtained in interviews and records review, there is insufficient evidence to support the claim that staff failed to inform R1’s physician of R1’s change of condition. Per the investigation, staff contacted both R1’s physician and psychiatrist about R1’s change of condition. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued to the Administrator.the state’s words, verbatim · CDSS document, May 22, 2023 · control 29-AS-20220315144546

Allegation investigated: Facility parking lot is unsafe resulting in resident suffering a fall.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the above facility at 1:00 p.m. LPA met with Administrator Julian Bond and the reason for the visit was explained. Findings were delivered to Administrator Julian Bond. On 4/20/2023, LPA toured the facility with Hospital Administrative Resident 2 (HOR2) Cindy Gambill between 10:28 a.m. – 10:40 a.m., observed the parking lot during the tour, and requested copies of pertinent documents. Between 11:00 a.m. – 4:25 p.m. LPA interviewed nine (9) staff and five (5) residents. During today’s visit LPA conducted a file review and obtained pertinent documentation between 01:20 p.m. and 04:15 p.m. Report will continue on LIC 9099-C. Unsubstantiated It was alleged facility parking lot is unsafe resulting in resident suffering a fall. It was further reported that multiple residents have tripped over the parking lot wheel stops and injured themselves. Interviews conducted and observations made during the facility tour during the investigation reflected that the facility’s parking lot has no visible hazards or obstructions making the parking lot unsafe. Interviews also revealed that the wheel stops placed in all handicap parking spaces is to assist drivers with parking their vehicles and prevent vehicle overhangs from blocking the sidewalks. Furthermore, five (5) of five (5) residents stated they consider the parking lot to be safe. As an added precaution, during today’s visit, a discussion was held between LPA and the facility administrator regarding the possibility of ensuring that all wheel stops contrast with the surrounding pavement, similar to the black and yellow in comparison to the rest gray cinder block wheel stops. Based on information gathered, the Department does not have sufficient evidence to determine that facility parking lot is unsafe resulting in resident suffering a fall. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time. No citations were issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 12, 2023 · control 29-AS-20230412151519

Allegation investigated: Facility did not provide adequate meal service to residents in care

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint visit to this facility for the above complaint allegation. LPA arrived at 09:37AM, met with Administrator Julian Bond, and discussed the reason for today's visit. During today's visit LPA interviewed staff from 09:55AM to 10:12AM and at 10:56AM, toured the dining room and kitchen areas with the Food Service Director and Facility Designee at 10:13AM, interviewed random residents from 10:19AM to 10:55AM, observed lunch service at 11:28AM and obtained copies of pertinent documents. The following was then determined: It was alleged that one morning food service was inadequate, as residents were only served cold cereal for breakfast. Interviews revealed that on the morning of 03/27/2023, the kitchen vents were noted as inoperable. For safety reasons, the menu items listed, bacon and blueberry pancakes, were unable to be Continued on LIC 9099-C Unsubstantiated prepared at that time. Staff interviews revealed that all items listed on the always available menu were available on that date. Instead of the regular menu items listed for 03/27/2023, kitchen staff prepared cold cereals, hot cereals such as grits, oatmeal, and cream of wheat, as well as toast, bagels, hard boiled eggs, both fresh fruit and canned fruit. Residents also had the option for various yogurts, juices, snacks and regular beverage items. Staff indicated the only 2 items not available on that date were bacon and blueberry pancakes. Interview revealed that when residents arrived at the dining room, staff communicated to the residents that menu items were unavailable. Resident interviews revealed that for the most part, residents are happy with the food service, there are many options available, and there hasn't been any day that residents can recall that there were not sufficient available options for meal service. Residents did comment that diabetic menu choices are limited, but there are still some choices to meet resident needs. LPA observed adequate food supply available during today's visit and food service observed during today's visit followed the printed menu and appeared adequate. Therefore, based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation "facility did not provide adequate meal service to residents in care" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted with Facility Designee Cindy Gambill. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 5, 2023 · control 29-AS-20230330133309

Allegation investigated: Resident sustained pressure injury while care Staff failed to meet residents incontinent care needs Staff forced resident to sign documents without residents authorized representative authorization

Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to deliver findings for the above allegations that were investigated by LPA JoAnn Rosales. LPA met with Administrator Julian Bond and explained the reason for the inspection. Concerns were that resident #1 (R1) sustained a pressure injury while in care as staff would not let R1 get up from bed and would have to sit in a wheelchair all day. On 9/8/21 starting at 12:55 pm interviews were conducted with staff and R1. R1 when interviewed denied that staff was not letting them get out of bed. R1 stated that when they moved into the facility they could move themselves. R1 stated that staff would check on them every hour and would reposition them every 2 to 4 hours. Staff when interviewed denied telling R1 that they could not get out of bed and R1 was able to reposition themselves. Report continued on LIC 9099-C. Unsubstantiated A review of R1’s records on 12/22/22 starting at 4:13 pm revealed that R1’s pressure injury was being treated by a Hospice agency. Based on the information obtained during the investigation, the allegation that resident #1 (R1) sustained a pressure injury while in care is unsubstantiated at this time. Concerns were that staff failed to meet resident #1 (R1)’s incontinent care needs as staff were putting 3 diapers on R1 so they would not have to change R1. On 9/8/21 starting at 12:55 pm interviews were conducted with staff and R1. R1 when interviewed denied that staff were putting 3 diapers on them at one time. R1 stated that staff are really good about helping them. R1 stated that the staff are very attentive. Staff when interviewed denied ever putting 3 diapers on R1. Based on the information obtained during the investigation, the allegation that staff failed to meet resident #1 (R1)’s incontinent care needs is unsubstantiated at this time. Concerns were that staff forced resident #1 (R1) to sign documents without residents authorized representative authorization. On 9/8/21 starting at 12:55 pm interviews were conducted with staff and R1. R1 when interviewed denied that staff forced them to sign documents without their authorized representative authorization. Staff when interviewed denied forcing R1 to sign documents without their authorized representative authorization. Based on the information obtained during the investigation, the allegation that staff forced resident #1 (R1) to sign documents without residents authorized representative authorization is unsubstantiated at this time. Exit interview conducted. Today's report and appeals rights were reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Jan 27, 2023 · control 29-AS-20210830085056

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year Inspection at the facility today. The LPA met with Administrator Julian Bond and informed him of the reason for today's visit. Beginning at 10:52 AM, the LPA along with the Administrator began the tour of the physical plant areas, inside and outside to ensure there are no health or safety hazards and facility is in compliance with Title 22 Regulations. Infection control practices were discussed with the Administrator and they are adequate. LPA inspected common areas including, but not limited to, the dining room, library, computer room, and activity rooms. LPA observed that the common areas were clean and fully functioning. Hand sanitizer stations were observed on the walls through out the facility. Fire extinguishers observed were fully charged and last serviced 03/22/2022. The carbon monoxide detector in the laundry room was tested an operational. Smoke detectors are serviced annually and quarterly. The last quarterly service was in December 2022 and the last annual service was in March 2022. Facility had a sufficient supply of Personal Protective Equipment and cleaning supplies. Medications and resident records are stored in the secured medication rooms. The kitchen was observed which had a sufficient supply of perishable and non-perishable food and food was stored at the appropriate temperature. The facility has a sufficient supply of emergency water. Cleaning supplies and chemicals were stored separate from food storage areas. Resident bedrooms have single or double occupancy with a shared restroom. Resident bedrooms observed were furnish appropriately. The call button located in one resident's bedroom was tested and was operational. Restrooms were clean and sanitary and in working condition. The hot water temperature measured in three resident rooms measured at 115.2 degrees F., 115 degrees F., and 114.1 degrees F. No deficiencies were observed during the inspection. Exit interview conducted with the Administrator. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2023

Allegation investigated: Staff engaged in verbal altercations with residents in care Staff speaks inappropriately to residents in care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the finding to the above facility. The LPA met with Administraor Julian Bond at 9:20 a.m. and discussed the reason for visit. On 11/17/2021, the Department received a complaint alleging that staff engaged in verbal altercation with residents in care and staff speaks inappropriately to residents. An interview with the Administrator Julien Bond on 11/19/2021, starting at around 1:05 p.m., revealed that they have yet to receive any written statement from Staff #1 (S1) and Resident #1 (R1) regarding the alleged altercation. Administrator Bond stated that the supposed incident happened due to a high-profile trial; and, that in addition to the alleged verbal altercation, R1 had allegedly choked S1 near the office early in the morning on 11/15/2021. Administrator Bond also added that the surveillance tapes have been checked and nothing could be seen from the alleged incident. During the investigation, R1 was interviewed and confirmed that R1 did not put hands on S1. S1 stated that R1 attempted to choke S1, but S1 was able to evade R1. Continued on LIC 9099- C Substantiated Lastly, since the day of the alleged incident, Administrator Bond conducted an all staff training on the Code of Conduct for all employees. LPA Ascencio received a copy of the Code of Conduct handout. On 12/01/2021, LPA Ascencio conducted S1’s interview starting at 2:50 p.m. The interview with S1 revealed that on 11/15/2021 at approximately 2:50 p.m., S1 was called over to a table that R1 and other residents were sitting. S1 was questioned by R1 what their stance was on a political view. S1 responded. R1 was visibly upset by the response. A further interview with S1 revealed that on 11/16/2021, starting at approximately 7:00 a.m., S1 walked into the building to find R1 yelling and calling S1 racist names. S1 stated they jokingly went along with the name calling. R1 stated that S1 is a “white supremist” and eventually lifted up their hood as if they were a ”KKK” member. S1 stated they know they should not have engaged with R1 and should have changed their approach about the situation. An interview with R1, on 11/17/2022, starting at 9:30 a.m. revealed that on 11/15/2021 at approximately 3:00 p.m., R1 called S1 to the table where R1 was sitting to discuss a high-profile trial. R1 informed the LPA of the comments that S1 allegedly made. R1 added that S1 was also talking about former President, Donald Trump and S1’s views on him. R1 continued, the next day, on 11/17/2021 at around 6:45 a.m., R1 was in the gym and noticed S1 walk in the door. S1 noticed R1 and started talking about their political views to R1, continuing the conversation from the previous day. R1 stated R1 took offense to what S1 was saying and began recording a video engaging S1 and calling S1 a “white supremist” and member of the “KKK.” R1 added that S1 admitted to being a “white supremist” and put their hood up. The LPA was not able to observe the alleged recording; however, interviews on 11/19/2021 and 12/01/2021 with S1, S2, S3, and S4, all confirmed that they watched the video and witnessed S1 having a verbal altercation with R1 and observed S1 stating that S1 was a “white supremist, KKK member” and putting their hood up. Based on evidence gathered throughout the investigation, although S1 stated that they were joking when they the verbal altercation, which resulted in S1 speaking inappropriately to R1, the allegations are deemed substantiated at this time. S1 further revealed that on 11/16/2021, starting at approximately 7:00 a.m., S1 walked into the building to find R1 yelling and calling S1 names like a “white supremist” and a “member of the KKK.” S1 stated they jokingly went along with the name calling stating that S1 was a “white supremist” and eventually lifting up their hood as if they were a ”KKK” member. S1 stated they know they should not have engaged with R1 and should have changed their approach about the situation. An interview with R1, on 11/17/2022, starting at 9:30 a.m. revealed that on 11/15/2021, at approximately 3:00 p.m., R1 called S1 to the table where they were sitting to discuss a high-profile trial. R1 said that S1 made an inappropriate comment. R1 stated R1 did not feel threatened by S1’s statements. R1 continued, the next day, 11/17/2021, at around 6:45 a.m., R1 was in the gym and noticed S1 walk in the door. S1 noticed R1 and started talking about their political views to R1, continuing the conversation from the previous day. R1 stated R1 took offense to what S1 was saying and began recording a video engaging S1 and calling S1 a “white supremist” and member of the “KKK.” R1 added that S1 admitted to being a “white supremist” and put their hood up. R1 again added that they did not feel threatened or was threatened by S1. Regarding whether R1 was threatening to residents in care, staff did not bring up the issue to LPA Ascencio, though they did mention that R1 can be intimidating to staff at times. Residents were also interviewed, and they mentioned that they haven’t heard or witnessed R1 being intimidating or threatening, but more observed R1 as being a spokesperson to those who don’t have a voice or are unable to say anything. Based on evidence gathered, the allegation that staff threatens residents in care, is deemed unsubstantiated at this time. Exit interview conducted and copy of the report provided to the administrator via email.the state’s words, verbatim · CDSS document, Jan 3, 2023 · control 29-AS-20211117090131

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 4, 2023

87468 Personal Rights of Residents in all Facilities (a)(1) Each resident shall be accorded dignity in his/her personal relationships with staff, residents and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as S1 engaged with R1 inappropriately which poses an immidiate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 3, 2023

Plan of correction: Admin will have Ombudsman provide conduct training on 87468 (a)(1) to all staff. Admin will provide training materials and attendees of the training to CCL 01/27/2023.

Allegation investigated: Facility staff interacted with resident inappropriately

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10-day complaint. The LPA met with Executive Director Julian Bond and explained the reason for the visit. Today, the LPA interviewed staff at 10:17 a.m., 10:38 a.m., 10:59 a.m., 11:22 a.m., 12:35 p.m., and 12:42 p.m.; interviewed residents at 12:03 p.m., and 12:25 p.m., and reviewed documents. Regarding the allegation: Facility staff interacted with a resident inappropriately It was alleged that there was a verbal altercation between Staff #1 (S1) and Resident #1 (R1), in which S1 was observed speaking to R1 inappropriately. Interviews and records review confirmed that during a meeting that took place on approximately 7/21/2022, R1 allegedly became upset. Substantiated Witnesses claimed that during the meeting R1 became visibly upset. R1 then came within several feet of S1 and yelled obscenities at S1. However, interviews conducted with S1, R1, and other parties supported claims that S1 engaged with R1 inappropriately during the meeting. Whereas S1’s statements were in response to the fact that R1 was yelling obscenities towards S1, the response to R1 was deemed unprofessional. It was communicated that it was out of character for S1 to speak out of turn. R1 has since apologized to S1 and other parties that were present during the meeting. Based on the information obtained, there is sufficient evidence to support the claim that facility staff interacted with a resident inappropriately. This allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report, along with appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 8, 2022 · control 29-AS-20220805125623

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Aug 10, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as S1 engaged with R1 inappropriately and unprofessionally, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2022

Plan of correction: The Administrator agreed to do the following: 1. Administrator claimed that staff have reviewed the Employee Code of Conduct as a result of the 7/21 incident. Additional training will take place for S1. Proof of completion to be submitted to CCL before 8/10/2022.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced Case Management visit to the facility. The case management visit is being conducted to discuss alleged incidents that were reported to Community Care Licensing on 3/17/22 regarding resident #1 (R1) and staff #1 (S1). During today's visit LPA toured the facility with the Administrator, conducted interviews with random staff and residents, reviewed R1's records, and obtained copies of pertinent documents. LPA will need to return at a later to continue the investigation. No citations were issued during today's visit. Exit interview conducted. Today's report was reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Mar 25, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) JoAnn Rosales conducted a Required 1 - Year visit to this facility. LPA met with Administrator Julian Bond. LPA conducted a facility tour to inspect for infection control practices. Infection control practices were discussed with the Administrator. An inspection of the common areas, resident rooms and restrooms were conducted. LPA observed hot water temperature at 113.5, 114, 114.3 and 115.6 degrees F. in resident rooms. LPA observed signal system which operates from each resident room. There is an adequate amount of perishable and non-perishable food. Outdoor area toured. PPE supplies were observed. LPA observed the fire extinguishers fully charged. The carbon monoxide detectors were tested and operable. Administrator stated that the Fire Marshall conducted a test on the smoke alarms on 7/15/21 and they passed inspection. Administrator provided LPA a copy of the Priority Inspection Report from the Department of Forestry and Fire Protection dated 7/15/21 which indicates that the facility passed inspection. During facility tour at 1:28 pm with the Administrator LPA observed Shuffleboard Cleaner and Shuffleboard Silicone in a cabinet in the lounge accessible to residents. During facility tour at 1:32 pm with the Administrator LPA observed Sani-Cloth germicidal disposable wipes on a cart outside of the lounge accessible to residents. 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, today's reports and appeal rights were reviewed and issued.the state’s words, verbatim · CDSS document, Feb 10, 2022

Allegation investigated: Staff sleeping during shift.

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint visit at the facility today regarding the above allegation. The complaint was initiated by LPA Lopez on 03/05/2021. Today the LPA met with at Administrator Julian Bond and Cindy Gambill, Hospital Administrative Representative II and explained the reason for today’s inspection. During the initial 10-day virtual inspection on 03/05/2021, the LPA conducted a FaceTime interview with Administrator Julian Bond at 11:37 AM and conducted a virtual physical plant tour of the two (2) medication rooms and the workstations rooms in hallways C & D beginning at 11:49 AM. Pertinent documents were also emailed to the LPA. The allegation of ‘Staff sleeping during shift’ alleged staff were sleeping while on duty during the night shift. On 11/08/2021 and 11/29/2021, the LPA conducted telephone interviews with facility staff who work the overnight shift. Report continued on LIC 9099-C. Unsubstantiated On 11/08/2021, 11/29/2021, and 12/01/2021, the LPA attempted to conduct telephone interviews with other relevant facility staff; however, was not successful. Moreover, during today’s inspection, the LPA conducted an interview with Staff #1 at 11:20 AM, and conducted a physical plant tour at 11:35 AM. The LPA also conducted interviews with five residents during the time period of 11:58 AM through 1:15 PM. Interviews with the Administrator and the six staff revealed no reports of staff sleeping while on duty during the overnight shift. Interviews with residents revealed no issues or concerns regarding the overnight staff. Record review revealed four (4) LVNs, three (3) CNAs and two (2) Security Guards were scheduled to work overnight during February 2021 and March 2021. Based on the information obtained, the department does not have sufficient evidence to support the allegation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted and report reviewed with the Administrator. A copy of the report and appeal rights will be emailed.the state’s words, verbatim · CDSS document, Dec 2, 2021 · control 29-AS-20210225161741