Lovely Community Healthcare

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced for a required 1-year annual inspection today at 9:30 a.m. Upon arriving at the facility, the LPA was scanned and greeted at the door by staff. Administrator Cilva Toume arrived shortly thereafter and was explained the reason for the visit. At 10:00 a.m., the LPA, along with the staff and the administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: At 10:00 a.m., the LPA observed the kitchen/dining area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:10 a.m., LPA observed perishable food items in the refrigerator to be expired such as mayonnaise and dressings and observed 5 boxes of expired cereal in the pantry dates of expiration June 6, 2023. The Administrator was advised to monitor food items for expiration and expired food items were disposed of at the time of discovery. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 8 (eight) total bedrooms, 6 (six) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed and were occupied by staff. Administrator will provide updated facility sketch. Continued on LIC 809-C RESTROOMS: Observed beginning at 10:20 a.m., restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:22 a.m. and 10:35 a.m., hot water measured at 114.9 and 118.0 degrees Fahrenheit in the resident restrooms. COMMON AREAS: The LPA observed common area to be clean and properly furnished at the time of the visit. The LPA observed the fire extinguisher to be fully charged and last purchased on 6/13/2023. At 10:43 a.m., fire alarms and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level of 74 degrees F. Cleaning supplies and disinfectants are stored locked cabinet in under the kitchen sink and in the locked garage and laundry room which is only accessible from the outside backyard area. RECORDS: Residents’ records review began at 11:35 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 2:00 p.m.; medications are centrally stored and locked in a cabinet in the kitchen. At 10:00 a.m. the LPA observed medications set aside for the day in an unlocked drawer above the locked medication cabinet. It was discovered that those medications were prepared medications for the day and medications for destruction. LPA reminded staff and administrator that all medications need to always remain locked when not being administered. Medication for Resident #1 (R1) were taken out of original bottle and transferred into non label bottle as they were refused by R1 and planned on being returned to pharmacy and staff explained that was the reason they were no longer in the original bottle. Administrator and staff were reminded that medications must always remain in original prescription bottles per regulation. Administrator and staff corrected the deficiency at the time of the visit. Continued on LIC 809-C INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs obtained the following documents: - LIC500 Personnel Report - Liability Insurance The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Civil penalties were assessed during today’s visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2023

Allegation investigated: Staff slapped resident Staff sexually harassed resident Resident not being fed meals

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit to deliver the findings for the above allegations. The LPA met with Staff at 10:45 a.m., Administrator Cilva Toume was unable toarrice at the facility and gave permission for staff to sign the report. The LPA explained the reason for the visit. During the visit on 4/6/2023, the LPA toured the facility at 10:30 a.m., collected pertinent documents at 10:40 a.m., interviewed staff at 10:50 a.m.,10:57 a.m., and 11:21 a.m., interviewed residents at 11:04 a.m., 11:08 a.m., 11:10 a.m., 11:16 a.m., and 11:17 a.m. Attempted interviews with witnesses at 12:58 p.m. and 1:38 p.m. During today’s visit, the LPA toured the facility at 10:55 a.m. to ensure that there were no immediate health and safety concerns and delivered the findings. ***Continued on LIC9099-C*** Unsubstantiated Regarding the allegation: Staff slapped resident It was alleged that staff slapped resident #1 (R1). An interview with R1 denied claims that staff at Lovely Community Healthcare ever physically abused them or slapped them. Staff denied all claims that they had slapped R1 while providing care. Staff said that although R1 would present behavioral difficulties such as resistance to cleaning their room or keeping it organized, they never slapped R1. Staff further claimed that if R1 needed anything or asked for something they would comply. R1’s physician stated that they did not know if the concern addressed was in regard to this facility or a previous facility at which R1 resided for a number of years. R1’s physician stated that due to past experiences and trauma they believed that R1’s claims have the potential to lack validity in relation to the claims being brought against this facility. R1 claimed that they had not had negative interactions with the facility staff other than a personal disagreement with the Administrator related to insurance. Residents claimed that staff had appropriate relationships with the residents and denied claims that staff had ever been physically abusive. Residents did not have any negative things to say about the staff. Based on the information obtained, there is insufficient evidence to support the claim that staff slaps residents. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff sexually harassed resident It was alleged that staff sexually harassed resident #1(R1). An interview with R1 denied claims that staff at Lovely Community Healthcare have ever made any sexual advances, made sexual remarks, or ever touched them in appropriately. Staff denied all claims that they have sexually harassed any resident. Staff said that although R1 would present behavioral difficulties such as resistance to cleaning their room or keeping it organized, they were never talked to inappropriately or sexually harassed. R1’s physician stated that they did not know if the concern addressed was in regard to this facility or a previous facility at which R1 resided for a number of years. R1’s physician stated that due to past experiences and trauma they believed that R1’s claims have the potential to lack validity in relation to the claims being brought against this facility. R1 claimed that they had not had negative interactions with the facility staff other than a personal disagreement with the Administrator related to insurance and that staff had never harassed them in any way. Residents claimed that staff had appropriate relationships with the residents and denied claims that staff had ever been inappropriate with them. Residents did not have any negative things to say about the staff. Based on the information obtained, there is insufficient evidence to support the claim that staff sexually harassed resident. This allegation is deemed Unsubstantiated at this time. ***Continued on LIC 9099-C*** Regarding the allegation: Resident not being fed meals It was alleged that staff was not feeding meals to resident #1(R1). An interview with R1 denied claims that staff at Lovely Community Healthcare have left them without a meal. Staff denied all claims that they have ever not fed a resident in care. Staff said that when residents are resistant to eat at meal times that they ensure that there is a meal available to them at any time. Additionally, LPA observed on multiple occasions that staff were preparing meals at various times of the day and observed resident’s eating either in their room or at the dining room table. R1’s physician stated that they did not know if the concern addressed was in regard to this facility or a previous facility at which R1 resided for a number of years. R1’s physician stated that due to past experiences and trauma they believed that R1’s claims have the potential to lack validity in relation to the claims being brought against this facility. R1 claimed that they had not had negative interactions with the facility staff other than a personal disagreement with the Administrator related to insurance and that they loved how staff cooked meals. Residents claimed that staff cooked wonderfully and denied claims that staff had ever left them without food. Residents did not have any negative things to say about the staff. Based on the information obtained, there is insufficient evidence to support the claim that resident is not being fed meals. This allegation is deemed Unsubstantiated at this time. No immediate health and safety concerns observed during today's visit. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 29-AS-20230329111941

Allegation investigated: Staff refuse to issue resident a refund

Licensing Program Analyst (LPA), Elsie Campos conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, the LPA met with staff Raymund Escoto and explained the reason for the visit. Administrator, Cilva Toume arrived shortly thereafter. During today's inspection, the LPA interviewed staff at 11:20 a.m., interviewd the Adminsitrator at 12:02 p.m., conducted a facility tour to ensure there are no health and safety concerns at 11:30 a.m., at 11:45 a.m. the LPA conducted a resident file review and obtained copies of resident records and other pertinent documents relevant to the investigation. **Continued on LIC 9099-C** Unsubstantiated On the allegation: Staff refuse to issue resident a refund It was alleged that staff refused to issue the resident a refund after they moved out for the remaining (13) thirteen days left in the month that they were no longer living here, 1/19/23-1/31/23. The LPA spoke to the Administrator who confirmed that resident #1 (R1) was under an eviction notice that was in effect September 21st with an eviction date of October 21st. The administrator compromised with R1 and the responsible party (RP) that the resident would be able to remain at the facility until they were able to find a new residence. The LPA reviewed R1’s admission agreement page 6 which states under Refund Policy: “in the event that the resident decides to leave the facility with no medical reason, a thirty (30) day written notice to vacate shall be issued to the administrator. Refund shall be issued based on the number of days not used in the month paid”. However, the administrator was not issued a written notice of the intended date to vacate the facility and moved out without written notice on 1/18/23. The facility administrator informed the LPA that the refund dispute was resolved with RP and that the RP for R1 was issued a refund on 3/14/2023 for the remaining days in January that R1 was no longer residing at the facility in the amount of $1500.00. Staff interviews confirmed that the Refund check was picked up and given to R1’s RP on 3/14/23 in the amount of $1500.00. Copies of the check receipt were given to LPA during the visit. Based on information received and documents received, this allegation is deemed to be 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, Mar 15, 2023 · control 29-AS-20230310145441

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit at the above facility at 9:30 a.m. The LPA met with Administrator, Cilva Toume and explained the reason for the visit. The purpose of this visit is to investigate an incident report submitted to the Department by the facility regarding Resident #1 (R1) refusing all his medication for two (2) days. Entrance interview. During today’s visit, the LPA conducted a plant tour to ensure there are no immediate health and safety concerns. At 9:35 a.m., LPA attempted to speak with R1; however, R1 refused to open the door and speak with anyone. An interview was conducted with one staff at 9:20 a.m., and with the Administrator at 10:20 a.m. At 9:50 am., the LPA conducted a resident file review and obtained copies of pertinent documents. At 10:03 a.m., LPA called R1’s Pain Management Physician (PMP) and spoke with the Office Manager. PMP will call LPA at a later time. Exit interview conducted. A copy of the report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 16, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit at 9:00am. The LPA met with Administrator, Cilva Toume and explained the reason for the visit. The purpose of this visit is to investigate an incident submitted to the Department by the facility regarding Resident #1 (R1) self-neglecting and not allowing staff into their room. Entrance interview. During today’s visit, the LPA conducted a plant tour to ensure there are no immediate health and safety concerns and interviewed the Administrator, one staff, and resident between 9:15am and 10:15 am. At 10:20 am., the LPA conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. Further investigation is required prior to issuing findings. Exit interview conducted. A copy of the report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Sep 9, 2022

Allegation investigated: Facility food caused resident to become ill.

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. On 8/18/2022, LPA Arroyo conducted an initial 10-day complaint inspection. On today’s visit, LPA Arroyo met with Administrator Cilva Toume. Entrance interview conducted. During the initial visit on 08/18/2022, LPA Arroyo conducted a physical plant tour, interviewed the administrator, one staff, and four residents at 1:16pm. At 2:35pm, the LPA conducted a resident file review and obtained copies of resident records and other pertinent documents. On 08/24/2022, LPA Arroyo conducted a telephonic interview with resident’s family member at 11:57am. (...Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) It was alleged that facility food caused resident to become ill. It was reported that Resident #1 (R1) was given a yogurt to eat and after consuming, R1 began vomiting violently for approximately 45 minutes before calling 9-1-1 and being transported to the hospital. Information gathered revealed that R1 was transported and admitted to the hospital on 7/29/2022 due to nausea, vomiting, and hypokalemia. Additionally, R1 was advised to eat high potassium food as documents obtained and reviewed revealed R1 had low potassium levels. Interviews conducted revealed R1 has been ordering outside food to be delivered to the facility. Also, R1 has been refusing to eat the facility’s food for at least two months. Additionally, R1 has mainly been consuming protein bars and water as their daily meals. Furthermore, R1 reported taking Zofran daily to not get nauseas and has not been taking that medication for a few months. Centrally stored medication log for R1confirmed R1 has not been taking medication Zofran since April 2022. Interviews with residents revealed the facility provides three meals a day plus snacks in between. Correspondingly, residents displayed no concerns and stated they felt safe living at the facility. Based on the information gathered and interviews conducted, there is insufficient evidence to support the allegation, “facility food caused resident to become ill”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of the report will be emailed to Administrator. (Report Continued from LIC 9099...) It was alleged that facility is not providing care to resident. It was reported that staff are not responsive to R1’s care needs and R1’s family has come to the facility to provide care in the absence of a caregiver. Information gathered revealed R1 was admitted to the facility on 8/17/2017. Additionally, R1’s Admissions Agreement dated 8/17/2017, states on page 2, “assistance with personal activities of daily living as follows: dressing, eating, bathing, grooming, other personal care needs: ice packs PRN, stack toilet paper, occasional help with electronics, and set up weights for physical therapy exercises”. These are all basic services the facility had agreed to provide to R1 upon admission. Interviews conducted revealed R1 has become agitated and aggressive towards facility staff. Furthermore, there have been two staff that were working with R1 and both have quit in the last 30 days. However, due to the lack of staff, R1’s family has been coming to the facility from 7pm to 10pm to assist R1 with their personal activities of daily living as the facility does not have a caregiver to care for R1. Therefore, based on interviews and records obtained and reviewed, the allegation of “facility is not providing care to resident.” is deemed Substantiated at this time. It was further alleged that facility illegally evicted resident. It was reported that resident received a 30-day “notice to vacate the room” from the Administrator. Additionally, eviction letter notes R1’s family member is listed as the responsible party; however, R1 claims to be self-responsible. Review of documents revealed R1 was given an eviction letter dated 8/03/2022. In the eviction notice, the Administrator stated that R1’s health condition requires immediate transfer to protect the health and safety of all residents and staff in the facility. However, the Administrator did not identify such specific behaviors in the eviction notice, and no incident reports were provided to the department. As required by Title 22 Regulations, Section 87224 and §1569.683 the facility failed to provide the following: Specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons noted. Information about resources available to assist the resident in identifying alternative housing and care options, including public and private referral services and case management organizations. Information about the resident’s right to file a complaint with the CDSS regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) A statement that if a licensee pursues an unlawful detainer action, the resident must be served with a summons and complaint. A statement that the resident has the right to contest the eviction in writing and through a hearing. Based on the 30-day notice lacking the required information as stated above, the 30-day eviction letter is not valid. Therefore, the allegation of “facility illegally evicted resident” is deemed as Substantiated. Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 9099-D). Exit interview conducted. Citation issued. Appeal Rights discussed. A copy of report provided via email.the state’s words, verbatim · CDSS document, Sep 6, 2022 · control 29-AS-20220816111702

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(c) · Plan of correction due date: Sep 16, 2022

87464(c)The admission agreement shall specify which of the basic services are desired and/or needed by, and will be provided for, each resident. The requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the facility is not providing the basic needs care outlined per the Admissions Agreement signed and dated on 8/17/2017, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 6, 2022

Plan of correction: The Licensee has agreed to review and submit a statement of understanding on Regulation 87464 Basic Needs to CCL no later than 9/16/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(B)(1)(2) · Plan of correction due date: Sep 16, 2022

87224(d)(B)(1)(2) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts...ferral services that will aid in finding alternative housing. Case management organizations which help manage individual care and service needs. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the eviction notice did not include referral services and a notice of case management organization which help manage individual care and service needs, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 6, 2022

Plan of correction: The Administrator has agreed to read, review, and submit a statement of understanding on Regulation 87224 Eviction Procedures to CCL no later than 9/16/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 12:10 p.m. The last Annual conducted at this facility was on 6/20/2019. Upon arrival, the LPA was scanned and greeted at the door by Staff, Raymund. The Administrator, Cilva Toume arrived shortly after and was explained the reason for the visit. Entrance interview. At 12:35 p.m., the LPA along with the Administrator began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The LPA observed one (1) refrigerator and one (1) freezer with a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps in a drawer next to the sink locked and inaccessible to residents at the time of visit. BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms. Bathrooms were measure for hot water, at 12:42 p.m., the first bathroom measured at 125.8 degrees Fahrenheit, and at 12:44 p.m., the second bathroom measured at 124 degrees Fahrenheit. The Administrator had the water adjusted at the time of visit. …Report Continued on LIC 809C… ...Report Continued from LIC 809... BACKYARD: There is a patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. LPA observed a secured pool in the backyard at the time of visit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings at the time of visit. If needed, the facility has the capacity to self-isolate residents if the facility has a confirmed case of COVID-19. The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate. 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. Appeal Rights Discussed. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Jul 29, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to the above facility. The LPA met with Administrator, Cilva Toume to discuss the necessary documents in resident files as per regulation. Entrance interview conducted. Per record review, it was revealed that Resident #1 (R1) was admitted to the facility on 4/11/2022, and the Administrator had not acquired a signed copy of R1’s Admissions Agreement by 4/18/2022. On 4/15/2022, LPA contacted Administrator regarding incident report pertaining to R1 contacting law enforcement because they felt facility was not assisting them to move in and settle down. Administrator stated they had yet to receive a signed copy of Admissions Agreement for R1. Interviews revealed facility gave paperwork to R1 to fill out and sign to turn in within seven (7) days. However, per interviews conducted, it was revealed that R1 had lost the Admissions Agreement and the Administrator had printed a new copy to give to R1. During the visit, R1 stated they would submit completed Admissions Agreement and submit to the facility before the end of the day. 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. Appeal Rights discussed. A copy of the report will be provided via email.the state’s words, verbatim · CDSS document, Apr 29, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(c) · Plan of correction due date: May 2, 2022

87507(c) Admissions Agreement. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident… and the licensee no later than seven days following admission… This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as R1 does not have a signed admission agreement on file which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2022

Plan of correction: The Administrator will submit a copy of R1’s signed admission agreement as proof to CCL by 5/02/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced Case Management-Deficiencies visit today to issue a citation that was inadvertently recorded under a complaint visit. The purpose of the case management visit is to issue a citation for a deficiency observed during the course of the investigation of Complaint Control# 29-AS-20210824114220 observed on 08-26-2021. On 08-26-2021 at 5:21pm, while conducting a plant tour with the Administrator, the LPA observed cleaning supplies which included ‘Krud Kutter Heavy Duty Cleaner’ unlocked under the sink in the common bathroom accessible to residents in care. During the visit, staff immediately locked and secured the cleaning supplies in a drawer making them inaccessible to residents in care. This deficiency was previously cleared by the licensee on 08-27-2021. Plan of Correction has been submitted and will be cleared. 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. A copy of the report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Nov 12, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Aug 26, 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 toxic items were observed in an accessible location to residents which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 12, 2021

Plan of correction: Staff placed toxic items in an inaccessible location during the facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 8/27/21.

Allegation investigated: Facility violated residents’ personal rights – Unsubstantiated

Licensing Program Analyst (LPA) Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. On 08/26/2021, LPA Guzman Chavez conducted an initial 10-day complaint inspection. On today’s visit, LPA Guzman Chavez met with Administrator Cilva Toume. Entrance interview conducted. During the initial visit on 08/26/2021, LPA Guzman Chavez conducted a physical plant tour with Administrator Cilva at 4:58pm. Between 5:10pm - 7:38pm, the LPA interviewed residents, Administrator, and staff. On 08/27/2021, LPA Guzman Chavez conducted telephonic interviews with family members of residents between 3:22pm and 4:24pm. Regarding the allegation, ‘Facility violated residents personal rights,’ the complainant’s concern is residents do not have a choice of bedtime hours. It was further alleged that the Reporting Party (RP) visited the facility on different occasions, and all lights were out in the residence and residents were in bed. (...Continued on LIC 9099C...) Unsubstantiated (...Continued from LIC 9099...) During the investigation, LPA Guzman Chavez conducted interviews with residents, resident family members, Administrator, and staff. Interviews with residents revealed that they do not know what time they go to sleep, but they know it is close to their bedtime because they are tired. Additionally, residents interviewed were asked about their daily routine and they mentioned that residents start early every day as they all wake up early. According to residents, breakfast is usually ready before 7:00am, lunch is around 11:00am, and dinner is before 5:00pm. Also, there is no set bedtime for residents. Interviews with residents also revealed, that some residents have dinner around 3:30pm, and shortly afterwards go to bed. Interviews with resident family members revealed, the families are aware of residents going to sleep early. Resident family member mentioned that previously, resident was restless, but feels they are getting better rest now, as they are more responsive when they visit. Another family member mentioned that they are aware of resident going to sleep early, and they appreciate that they allow them to rest. In the past few weeks, they have noticed an improvement in resident’s health, and they are more alert during visitation. Family member also said they are not sure what time resident goes to bed, but every time they come visit resident, they are clean and well kept. Resident family member stated, If the resident does not complain about their bedtime, they have no problem with it either. Interviews with facility staff revealed, residents wake up early in the morning every day. When asked about resident’s daily routine, staff said residents are usually awake while they do their morning routine checks. During the morning routine check, staff take residents out to the living room to have breakfast and start their day. When asked about bedtimes, staff interviews revealed, there is no bedtime, residents ask to go to their rooms shortly after having dinner stating they are tired and would like to go to bed. Furthermore, interview with the Administrator revealed, staff accommodate residents by taking them to their rooms early in the day per resident’s request. Based on the evidence gathered through interviews with residents, resident family members, staff, and Administrator, there is insufficient evidence to support the allegation, ‘Facility violated residents’ personal rights.’ Therefore, this allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of the report will be emailed to Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2021 · control 29-AS-20210824114220