Sage Mountain Senior Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Incident visit. LPA met with current Administrator/Executive Director (ED) Sherry Nazari and explained the reason for the visit. On 9/18/2023, the facility submitted a death report for resident 1 (R1). R1 passed away on 9/17/2023. R1 was discovered in their room on the bathroom floor at approximately 8:27 p.m. by staff 1 (S1). At 1:25 p.m. LPA spoke with the ED. At 1:37 p.m. LPA reviewed and obtained pertinent documents. At 2:09 p.m. LPA conducted a tour of the memory care unit and R1's room. At 2:33 p.m. LPA conducted an interview with staff 2 (S2). S2 was also working in the memory care unit when R1 was discovered deceased. S2 stated S1 was assigned to take care of R1. S1 was also the medication technician. S1 had taken R1 into their room at approximately 7:45 p.m. Prior to that R1 had dinner and watched television in the great room with other residents. At 8:27 p.m. S1 had gone into R1's room to give R1 their nighttime medications. S2 heard S1 yelling for help. S2 went to see what was going on and observed R1 was on the bathroom floor, not breathing and appeared deceased. S2 stayed with R1 while S1 called 9-1-1. Law enforcement and paramedics came to the facility and were at the facility for over an hour according to S2. According to the ED, law enforcement released R1's remains to their family and R1 was not examined at the hospital or by the coroner. Document review showed R1 was not feeling well on 9/16/2023. R1 had a slight cough and heavy breathing. The ED stated R1 was tested for COVID-19 but tested negative. Staff faxed a note on 9/16/2023 to R1's primary physician informing them of R1's symptoms and requesting a prescription for a cough suppressant. On 9/18/2023 at 12:17 p.m. the physician's office responded that they would "be in contact for further triage" but never called back. No deficiencies were observed. Exit interview conducted and report issued to ED.the state’s words, verbatim · CDSS document, Sep 25, 2023

Allegation investigated: Facility staff initial training is incomplete Facility staff annual training is not completed

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility regarding the above allegations. The LPA met with Business Office Manager Jennifer Miller and New Administrator Shahrzad "Sherry" Nazari and explained the reason for the inspection. The investigation for the complaint was initiated on 03/22/2022. During the initial visit, the LPA conducted interviews with Administrator at the time, Jill Ford, and Director of Health and Wellness at the time, Nicole Hoznor and conducted record review between 3:10 PM and 4:30 PM. Pertinent copies of records were obtained. At 4:33 PM, the LPA conducted a physical plant tour of the kitchen. On 07/26/2022, a subsequent visit was conducted. The LPA met with Culinary Director Michael Tabada, toured the kitchen, and observed the food storage areas. Between 12:45 PM and 2:30 PM, the LPA conducted interviews with six staff members. Report continued on LIC 9099-C. Substantiated On 02/16/2023, the LPA discussed the allegations with the Administrator at the time Jill Ford and obtained copies of additional facility records. During today's inspection, the LPA reviewed facility records beginning at 11:41 AM and conducted interviews with Business Office Manager Jennifer Miller. Allegations: Facility staff initial training is incomplete and Facility staff annual training is not completed The allegation alleges new staff are working with residents prior to receiving their completed initial training and staff are not up to date on their annual training. The LPA reviewed record for six caregivers and or med-techs. Staff #1 (S1) was hired as a caregiver on 03/15/2022. Record review revealed S1 received 5.5 hours of training through Relias on 03/23/2022 and .50 hours of training on 06/24/2022 and no further record of the required 40 hours of initial training within the first four weeks of employment or the annual training of a total of 20 hours for direct care staff. Records reflect on 07/02/2022, S1 received 24 hours of initial medication training. On 02/08/2023, 03/17/2023, and 05/30/2023, S1 received a medication in-service training but the hours of training received were not documented. Staff #2 (S2) is a medication technician hired on 02/03/2022. Record review revealed S2 received 24 hours of initial medication training on 2/3/22, 2/4/22, 2/5/22, and 2/10/22. S2 received med tech in-service training on 02/08/2023, although there is no record of how long the training was. Staff #3 (S3) was hired on 05/21/2021 as a caregiver. The facility has no record of S3 receiving 40 hours of initial training within the first four weeks of employment or proof of 20 hours of annual training in 2022 or 2023. S3 later became a med-tech and received 24 hours of medication training in June 2021 and August 2021 but there is no record of S3 receiving annual medication training in 2022 and medication training received in 2023 did not reflect how long the training was. Report continued on LIC 9099-C. Staff #4 (S4) was hired on 09/23/2022 as a caregiver. Records reflect S4 received only three hours of training from Relias in October 2022, 14.25 hours of documented training in Relias in 2023, and one hour of in-service training on 07/25/2023. Record review also revealed no proof of current first aid for all six staff files reviewed. Based on the information received, there is sufficient evidence to support the allegations of facility staff initial training is incomplete and facility staff annual training is not completed. Therefore, the allegations are deemed substantiated at this time. The following deficiencies were observed (See LIC 9099-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. Exit interview and report reviewed with Jennifer Miller, Business Office Manager and Sherry Nazari Administrator. A copy of the report and appeal rights were provided. During the inspection on 02/16/2023, the LPA obtained proof the Culinary Director at that time had current Serve Safe/Food Handler certificate and met other requirements. Since the complaint was filed, the facility has a new management company with new job descriptions. Based on the information obtained, there is in sufficient evidence to support the allegation of unqualified staff cooking occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 1, 2023 · control 29-AS-20220321114529

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1)(2) · Plan of correction due date: Aug 22, 2023

§1569.625 (b)(1) The department shall.. require staff members of RCFE's who assist residents with personal ADL's to receive appropriate training. This training shall consist of 40 hours of training. (2) In addition..training requirements shall also include an additional 20 hours annually. This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section above as three out of four caregiver files did not have proof of required initial training and/or annual training which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Business Office Manager and Administrator agrees to submit proof S1, S3, and S4 have proof of all required training to CCL by 08/22/2023.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Aug 22, 2023

1569.69 (b) Each employee who received training and passed.. (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section cited above as three med-techs did not have proof of annual medication training which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Business Office Manager agrees to submit proof S1, S2, and S3, have current annual medication training to CCL by 08/22/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Aug 22, 2023

87411 Personnel Requirements - General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee failed to comply with the section cited above as six out of six files reviewed did not have proof of first aid training which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2023

Plan of correction: The Business Office Manager agrees to submit proof S1, S2, S3, S4, S5, and S6 have proof of current first aid training by 08/22/2023.

Allegation investigated: Resident was sexually harassed while in care.

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility regarding the above allegation. The LPA met with Business Office Manager Jennifer Miller and explained the reason for the inspection. The allegation of 'Resident was sexually harassed while in care' alleges that an unknown person exposed them self to Resident #1 (R1) while on the patio during an unknown date or time. The investigation for this complaint was initiated on 06/30/2023. During the inspection, between 10:01 AM and 12:30 PM, LPA Lopez reviewed facility records and conducted interviews with one staff member and four residents. The LPA attempted to interview R1 but they were not available for interview. Report continued on LIC 9099-C. Unsubstantiated On 07/07/2023, the LPA conducted a subsequent inspection and conducted interviews with two staff members between 11:55 AM and 1:54 PM. The LPA was advised that R1 was not available for interview on this day also. During today's inspection between 12:55 PM and 3:15 PM, the LPA conducted interviews with Director of Nursing Ian Gadea, three residents, and three staff members. The LPA was advised during the inspection that R1 was still not available for interview. At 2:54 PM, the LPA conducted a telephone interview with a family member of R1. Interviews with residents revealed no issues or concerns with any individuals at the facility acting inappropriately with them or exposing them self to the residents. Staff interviews revealed no reports of any individuals being sexually inappropriate with any of the residents. The interview with R1's family member also revealed no reports of any individual at the facility exposing them self or being sexually inappropriate with R1. Based on the information obtained, there is insufficient evidence to support the allegation of resident was sexually harassed while in care. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 25, 2023 · control 29-AS-20230626122339

Allegation investigated: Physical abuse to resident while in care

Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with interim Administrator Julius Osorio and explained the reason for the visit. On 03/22/2022, Community Care Licensing Division (CCLD) received a complaint regarding an allegation of physical abuse. It was reported that on 03/18/2022, Resident #1 (R1) arrived at the hospital with a laceration to their labia. R1 allegedly fell while being assisted in the shower but there was concern due to the injury being in an odd location and the victim is wheelchair bound. On 03/22/2022, LPA Lopez conducted an unannounced initial complaint inspection at the facility and met with Administrator at the time Jill Ford, and Director of Health Wellness at the time Nicolle Hoznor. A review of facility records for R1 revealed an internal Resident Incident report dated 03/18/22 reflects on 03/18/2022 at 7:35 a.m., R1 had a witnessed fall. Staff #1 (S1) was identified as the witness. It was reported that R1 stated they slid down to the floor from the shower bench. Report continued on LIC 9099-C. Unsubstantiated S1 reported when they were transferring R1 to the shower bench, R1 lost their balance and S1 assisted the resident down to the floor. R1 sustained a skin tear and paramedics were called. The internal report was completed by Staff #2 (S2). Ms. Hoznor stated R1 is a two person assist and a fall risk, but they have not had any falls since Hoznor has worked at the facility. The 08/22/2021, service plan for R1 revealed R1 is a two-person assist with transfers. During the visit, the LPA was advised that S1 was an agency staff and not a permanent employee of the facility. Both S1 and S2 were not available for interview during this visit. On 03/22/2022 at 6:46 p.m., CCLD received an Unusual Incident/Injury Report (LIC624) regarding the 03/18/2022 incident with R1. On 07/07/2023, the LPA conducted a subsequent inspection at the facility and conducted an interview with S2, R1, and the family member of R1 between 11:55 a.m. and 1:55 p.m. The LPA attempted to obtain contact information for S1, but it was not available. Interviews with R1 and their family member revealed that R1 did not recall the incident but R1’s family member did recall the incident. The family member stated they met R1 at the hospital when the incident occurred and although, a laceration to the labia was in an odd place for a fall, the family member did not suspect any type of abuse occurred by any staff members at the facility. The family member also stated at the time of the incident, R1 never suggested any type of abuse occurred. Interviews revealed S2 was not present when the fall occurred but arrived afterwards due to the resident being injured. S1 reported to S2 that the injury occurred when the resident slid off the shower bench. S1 was the only staff member present when the injury occurred. It has been determined there is insufficient evidence to support the allegation of physical abuse to resident while in care occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with the interim Administrator. Deficiencies observed during the investigation will be addressed under a separate report.the state’s words, verbatim · CDSS document, Jul 12, 2023 · control 29-AS-20220322104533

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Deficiencies inspection due at the facility today. The LPA met with Interim Administrator Julius Osorio and explained the reason for the inspection. During an investigation under complaint control # 29-AS-20220322104533, interviews and the service plan for Resident #1 (R1) revealed R1 is a two person assist with transfers and is wheelchair bound. During the complaint investigation, it was revealed that S1 reported when they were transferring R1 to the shower bench, R1 lost their balance and S1 assisted the resident down to the floor. R1 sustained a skin tear and paramedics were called. Interviews with S2 revealed they were not present or assisting R1 with showering at the time of the incident and only arrived after there was a call for assistance due to the resident being injured. Interviews with Individual #1 (I1) also revealed they have also observed only one staff responding to assist R1 with transferring. 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. Exit interview and report reviewed with Interim Administrator. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 26, 2023

87468.2 (a) In addition to the rights listed in Section 87468.1,....(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as R1 is a two person assist and only received assistance from one staff member while transferring in the shower resulting in injury which is health and safety risk to R1 in care.the state’s words, verbatim · CDSS document, Jul 12, 2023

Plan of correction: The Administrator agrees to have an in-service training regarding R1's care plan and specifically the need for a two person assist and submit proof to CCL by 07/26/2023.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Incident visit at the facility today. The LPA met with interim Administrator Julius Osorio and explained the reason for the inspection. On 07/11/2023, The Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) completed 07/07/2023 from interim Administrator Julius Osorio. The SOC 341 report pertained to Resident #1 (R1) and Staff #1 (S1) for an alleged incident that occurred on 07/06/2023. On 07/11/2023, the LPA spoke with Mr. Osorio on telephone regarding the alleged incident and he stated S1 is currently on leave pending an investigation. During today's inspection, the LPA reviewed facility records and obtained pertinent copies. When the LPA arrived there was a Ventura County Sheriff's vehicle outside the building. The LPA was advised that law enforcement was speaking with R1 at the time. A copy of the report number was obtained. Further investigation is needed. Community Care Licensing Division's (CCLD) Investigation Branch (IB) Investigator Juan Lozano has been assigned to the investigation. Exit interview conducted and report reviewed. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2023

Allegation investigated: Residents are not receiving appropriate care Resident records are not accurate

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint investigation regarding the above allegations. The LPA met with Business Office Manager Jennifer Miller and explained the reason for the inspection. During a previous inspection on 09/01/2021, the LPA reviewed resident records beginning at 2:16 PM and obtained pertinent copies. At 3:54 PM, an interview was conducted with Resident #1 (R1). During today's inspection between 10:30 AM and 2:30 PM, the LPA reviewed additional facility records and conducted interviews with three staff members. Report continued on LIC 9099-C. Unsubstantiated Allegation: Resident records are not accurate The allegation alleges Resident #1 (R1) had diagnosis of early onset dementia for two years and recently had their diagnosis changed by the physician and the resident's care plan does not include provision to keep the resident safe given their previous dementia diagnosis. Interviews and record review revealed R1 moved into assisted living on 09/30/2020 and remained in assisted living until they passed away on 03/10/2022. On 09/30/2020, R1 had a medical assessment conducted by their physician and the box for dementia was checked and the confused/disorientated box was checked. On the report, the doctor notes the patient was previously very smart and an attorney who has had increasing confusion since surgery for metastatic colon cancer in January 2020 with chemotherapy ending in July 2020. On 08/05/2021, R1 had an updated medical assessment with a new physician. On this report, the MCI box was checked instead of dementia and the confused/disorientated was not checked this time. On the 08/05/2021 report it is noted the resident refused to sign the medical report as they disagreed with the doctor's assessment. On 09/15/2021, R1 had another updated medical assessment by the same doctor from 08/05/2021 and the assessment remained the same from the 08/05/2021 report date, although it was added that R1 may have a glass of wine daily. The 09/30/2020 assessment conducted by the facility nurse for R1 indicated R1 needed assistance with dressing, grooming, and mobility but had no cognition/orientation impairment and was alert and orientated to person, place, and time, with no behavior issues or an elopement risk. An undated mini-mental state examination for R1 had a score of 27 out of 30 which was within the normal range. On 05/19/2021, R1 had an updated assessment which indicated R1 was independent for dressing grooming, bathing, and mobility, and had no cognition/orientation impairment and was alert and orientated to person, place, and time with no behavior issues or an elopement risk. During the interview with R1 on 09/01/2021, they stated they did not agree with the doctor's diagnosis of MCI or the previous' doctor's assessment of dementia and stated they managed their own medical treatment and finances. Interviews with staff today revealed no issues or concerns pertaining to R1 residing in assisted living until their passing. Based on the information obtained, there is insufficient evidence to support the allegation of Resident records are not accurate occurred, Therefore, the allegation is deemed unsubstantiated at this time. Report continued on LIC 9099-C. Allegation: Residents are not receiving appropriate care The allegation alleges Resident #2 (R2) and Resident #3 (R3) who both lived in assisted living, wander and are confused and should be in memory care or receiving 1:1 support. Record review revealed R2 had a diagnosis of dementia and noted confusion at times. R2 was given the mini-mental state examination on 08/25/2021 and scored a 24 which fell under the category of mild degree of impairment (20-25). Record review did not reveal any wandering behaviors. Record review for R3 revealed R3 had no diagnosis of dementia or MCI and no indication of any confusion. Interviews with staff revealed although R2 was confused at times, they still felt assisted living was an appropriate placement for R2 and R2 remained in assisted living until they moved out of the facility on 07/15/2022. Staff interviewed did not recall R3 and could not provide any additional information pertaining to R3. R3 passed away on 02/11/2022. Based on the information obtained, there is insufficient evidence to support the allegation of 'Residents are not receiving appropriate care'. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with Ms. Miller and Regional Nurse Leticia Higares. A copy of the report and appeal rightsthe state’s words, verbatim · CDSS document, Jul 7, 2023 · control 29-AS-20210826104708

Allegation investigated: Facility staff financially abused resident(s)

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced complaint inspection to deliver the findings regarding the above allegation. The LPA met with Regional Nurse Leticia Higares at 9:55 AM and explained the reason for the inspection. The visit was concluded with Director of Nursing Ian Gadea. Allegation: Facility staff financially abused resident(s) The allegation alleges while Resident #1 (R1) resided at the facility a credit card was taken from R1’s wallet and used unauthorized at retail establishments. Information received also revealed there was a pending theft investigation with law enforcement pertaining to another resident in the facility later identified as Resident # 2 (R2). Report continued on LIC9099-C. Unsubstantiated During a previous inspection on 07/22/2021, LPA Lopez met with interim Administrator Jacob Primeau, reviewed records and conducted interviews with R2 and one staff member. Mr. Primeau was the Administrator until former Administrator Martha Berard was replaced. Mr. Primeau stated they began working at the facility at the end of May 2021. He stated the former Administrator advised him of the alleged theft concerning R1 that had been brought to her attention by a family member of R1, but he had no knowledge of any other alleged thefts in the building. During the course of the investigation, the LPA obtained and reviewed Ventura County Sheriff’s reports for two alleged credit card thefts pertaining to R1 in April 2021 and for R2 in approximately October 2020. R1 no longer resides at the facility as of May 2021. Information received alleged R1 had two fraudulent charges in person on 04/16/21 in Reseda and on 04/17/21 in Woodland Hills. Although information received revealed R1 was mostly non-verbal and wheelchair bound, there is insufficient evidence to support a staff member made these charges or participated in this theft. Information received during the investigation also revealed R2 had some fraudulent charges on their credit card and law enforcement identified Individual #1 (I1) as a person of interest. The LPA reviewed the criminal record clearance data base and this individual is not currently finger print cleared or associated to any licensed facilities in our data base. The LPA also checked with facility personnel and this individual was never a permanent employee or temporary agency staff member who worked at their facility. The interview with R2 revealed they recalled a theft occurred when they first moved in with their credit card but it had been resolved. R2 also reported cash missing from the their room but facility records and staff interviews revealed the reported missing cash was located in the resident’s room. Based on the information received there is insufficient evidence to support the allegation of 'Facility staff financially abused residents'. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview and report reviewed with Ian Gadea. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 29-AS-20210721151329

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management Deficiencies inspection due to a deficiency observed during a complaint investigation. The LPA initially met with Leticia Higares at 9:55 AM. The visit was concluded with Director of Health and Wellness Ian Gadea. During record review during a complaint inspection, the LPA observed Resident #1 (R1) to have a diagnosis of Dementia and their medical assessment on file is older than one year (dated 07/28/2020). The following deficiency was 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. Exit interview and report reviewed with Ian Gadea. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jul 14, 2023

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidence by: Based on record review, the licensee failed to comply with the section cited above as one resident with dementia had a medical assessment older than one year which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 30, 2023

Plan of correction: The Director of Nursing agrees to get an updated medical assessment for R1 and submit to CCL by 07/14/2023.

Allegation investigated: Medications not given to resident timely Staff mismanaged resident's medication Staff does not respond to pendent calls timely

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regarding the above allegations. The LPA met with Business Officer Manager Jennifer Miller at 10:27 AM and explained the reason for the visit. During a previous visit on 06/14/2021, between 10:58 AM and 12:45 PM, LPA Lopez conducted interviews with Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). Beginning at 12:54 PM, the LPA reviewed medications and records for R1. At 1:00 PM the LPA conducted an interview with Staff #1 (S1). At 2:21 PM the LPA conducted an interview with Staff #2 (S2). On a subsequent visit, on 07/22/2021 the LPA conducted interviews with one resident (Resident #6) and one staff (Staff #3). Report continued on LIC 9099-C. Substantiated Allegation: Medications not given to resident timely The allegation alleges on 06/05/2021, staff only brought Resident #1 (R1) three of R1’s AM medications when R1 receives more than three AM medications. When R1 questioned where the other medications where, staff stated they would return with them. It was alleged after lunch, R1 still had not received the missed AM medications. Medication record review revealed, R1 received ten (10) AM medication to be dispensed at 9:00 AM. Medication Passing Detail records for R1 on 06/05/2021, revealed R1 received six (6) of their AM medications at 9:00 AM and four (4) of their AM medications at 12:24 PM. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Medications not given to resident timely' is deemed Substantiated at this time. Allegation: Staff mismanaged resident's medication The allegation alleges R1 did not receive all their medications and facility staff acknowledged they failed to order R1's medications timely. Medication Passing Detail records for R1 revealed R1 did not receive two (2) AM medications on 06/06/2021 (Asprin and Losartan Pot 50 MG) due to the medication being on route for delivery. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff mismanaged resident's medication' is deemed Substantiated at this time. Allegation: Staff does not respond to pendent calls timely The allegation alleges residents have to wait 20 minutes or longer for staff to respond to pendent calls. During the investigation, the LPA interviewed six residents. Five out of the six residents interviewed used their pendent when they need assistance and reported they sometimes have to wait 20 minutes to over an hour for staff to respond to their call. Pendent call records were reviewed for 05/14/2021 through 06/14/2021 revealed the following. Report continued on LIC 9099-C. On 05/23/2021 and 05/14/2021 R2 had to wait 20 minutes for staff response; R4 had the following wait times, on 05/15/2021 24 minutes, 05/18/2021 30 minutes, 05/21/2021 36 minutes, 05/31/2021 32 minutes, 06/08/2021 28 minutes, 06/11/2023, 20 minutes, and 06/14/2021 22 minutes, R6 had the following wait time, on 06/01/2021 45 minutes, 06/02/2021 22 minutes, 06/02/2021 58 minutes, 06/03/2021 29 minutes, 06/03/2021 35 minutes, 06/04/2021 1 hour and 16 minutes, 06/05/2021 53 minutes, 06/07/2021 1 hour 2 minutes, 06/08/2021 1 hour 4 minutes, 06/10/2021 1 hour 19 minutes, 06/10/2021 32 minutes, 06/11/2021 1 hr 12 minutes, 06/14/2021 40 minutes. During the 06/14/2021 visit, the LPA met with Business Office Manager at the time Annabel Amaya, who reported they did have issues with staff at the time and were in the process of hiring additional staff but were using agency staff to help supplement. Ms. Amaya said staff should be responding within 10 minutes to pendent calls. During the interview with S1 they stated recently due to there being only one staff (S1) and one agency staff on shift, they did not respond timely to R6 and it took over 30 minutes for S1 to respond. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore the allegation of 'Staff does not respond to pendent calls timely' 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 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jennifer Miller. A copy of the report and appeal rights were provided. Allegation: Staff falsified facility records The allegation alleges Staff #4 (S4) on 06/05/2021, S4 documented on R1's records that all their medication had been given that day when it had not. Record review revealed on 06/05/2021, Staff #5 (S5) dispensed the AM medications and not S4. On 06/06/2021, S4 documented R1 did not receive two medications because they were on order from the pharmacy. Both S4 and S5 no longer work for the company. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff falsified facility records' is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, May 24, 2023 · control 29-AS-20210610131205

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 7, 2023

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above R1 received their medication late and R1 did not receive their medication due it not being ordered timely which poses an immediate health risk to R1 in care.the state’s words, verbatim · CDSS document, May 24, 2023

Plan of correction: The Administrator shall submit proof of an in-service training with current medication techs to ensure the deficiency does not occur again. Proof of training shall be submitted by 06/07/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 7, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... 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 three residents (R2, R4, R6) had pendent call wait times in excess of 20 minutes which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 24, 2023

Plan of correction: The Administrator shall submit a plan by 06/07/2023 indicating how they will ensure timely pendent response times for all residents in the community.

Allegation investigated: Resident made to wait an excessive amount of time for assistance.

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regarding the above allegations. The LPA met with Business Officer Manager Jennifer Miller at 10:27 AM and explained the reason for the visit. The investigation was initiated on 06/21/2021 by LPAs Martha Guzman Chavez and Brian Balisi. During their inspection, the LPAs conducted a physical plant with Adminstrator Martha Berard, interviewed staff, residents and reviewed and obtained copies of documents relevant to the investigation On 07/22/2021, LPA Lopez conducted a subsequent visit, and conducted a physical plant tour at 12:53 PM and conducted a interviews with six residents between 1:24 PM and 3:00 PM and with one staff beginning at 3:33 PM. Report continued on LIC 9099-C. Substantiated Allegation: Resident made to wait an excessive amount of time for assistance The allegation alleges staff do not respond timely to resident requests to use the restroom and response times can be one (1) to two (2) hours long. Pendent call records for all residents for the time period of 06/14/2021 through 06/21/2021 were reviewed. Records reflect on 06/20/2021, seven residents received pendent response times of 22 minutes, 24 minutes, 23 minutes, 37 minutes, 2 hours and 2 minutes, 1 hour and 14 minutes, 34 minutes, 1 hour and 38 minutes and 22 minutes (one resident had three late response times in the same day); on 06/19/2021, one resident had a response time of 34 minutes; on 06/18/2021 two residents had response times of 27 minutes and 29 minutes; on 06/17/2021 five residents had response times of 29 minutes, 30 minutes, 30 minutes, 49 minutes, and 39 minutes; on 06/16/2021 two residents had response times of 22 minutes and 57 minutes; and on 06/14/2021, two residents had response times of 41 minutes and 26 minutes. Resident interviews conducted on 06/21/2021 and on 07/22/2021 revealed five complaints from residents regarding pendent response times. Today on 05/24/2023, the LPA also substantiated a similar complaint received on 06/10/2021 (complaint control # 29-AS-20210610131205) of staff not responding to pendent calls timely. The allegation was substantiated due to record review revealing multiple pendent call wait times observed to be more than 20 minutes during the time period from 05/14/2021 through 06/14/2021 and resident and staff interviews. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Resident made to wait an excessive amount of time for assistance' 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 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jennifer Miller. A copy of the report and appeal rights were provided. Allegations: Residents are unable to access facility after hours and Residents' medication and supply deliveries are delayed. The allegation alleges the concierge desk is only staffed until 7:30 PM which results in residents being unable to enter the facility after hours and delaying medication deliveries after hours. At the time the complaint was filed, in an effort to mitigate the spread of COVID-19, the facility locked their perimeter doors from the outside which resulted in staff having to manually open the door for residents, visitors, vendors, etc. Currently, the facility is no longer locking their perimeter doors. Interviews conducted today with Ms. Miller and during previous visits revealed the concierge desk is staffed until 8:00 PM. The facility phone number is also posted on the front door for after hours visitors which the LPA observed today. During after hours, staff carry a portable phone and receive after hour calls directly. Interviews conducted with residents on 06/21/2021 and 07/22/2021 also revealed no issues or concerns regarding gaining access inside the building after hours. One resident stated about six months prior they had a hard time accessing the building when they returned back at 11:00 PM but has had no issues since. Interviews with staff revealed they normally don't get medication deliveries after 8:00 PM but if they did, the delivery person could call the facility directly to get a hold of staff. Based on the information obtained there is insufficient evidence to support the allegations occurred. Therefore, the allegations of 'Residents are unable to access facility after hours and 'Residents' medication and supply deliveries are delayed' are deemed Unsubstantiated at this time. Allegation: Staff doesn't provide care and assistance to residents after hours. The allegation alleges there is only one or two staff on duty after hours and residents are not receiving assistance. A review of the staff schedule for the month of June 2021 revealed two caregivers scheduled during the PM shift and two caregivers scheduled during the NOC shift along with mostly two medication technicians during the PM shift and 1-2 medication technicians during the NOC shift. Interviews with residents revealed although there were complaints of excessive wait times for pendent calls, there was no indication that the wait times were specific to a certain time of day or shift. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Staff doesn't provide care and assistance to residents after hours' is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 24, 2023 · control 29-AS-20210618140653

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: May 24, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... 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 three residents (R2, R4, R6) had pendent call wait times in excess of 20 minutes which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 24, 2023

Plan of correction: The Administrator shall submit a plan by 06/07/2023 indicating how they will ensure timely pendent response times for all residents in the community.

Allegation investigated: Insufficient staffing

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility to deliver the findings for the above allegation. The LPA met with Business Office Manager Jennifer Miller and informed her of the reason for today's inspection. During a previous inspection on 07/22/2021, the LPA met with interim Administrator Jacob Primeau and reviewed facility records beginning at 11:42 AM and conducted interviews with six residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) during the time period of 1:24 PM and 3:00 PM and interviewed Staff #1 at 3:33 PM. Allegation: Insufficient staffing The allegation alleges the complainant did not receive information timely due staff on duty not have access to the resident roster and staffing shortage due to the facility having an interim Administrator. Report continued on LIC 9099-C. Unsubstantiated Interviews during this investigation with Jacob Primeau and during a previous investigation under complaint control # 29-AS-20210610131205 with Business Office Manager Anabel Amaya on 06/14/2021 revealed, the Administrator at the time Martha Berard was on leave but the facility had interim Administrators and multiple staff from their Regional Office to provide administrative support for the facility. Also at the time the complaint was filed, reception did not have access to the resident roster and it had to be printed by the Business Office Manager, which it was done during the complainant's visit. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of 'Insufficient staffing' is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 24, 2023 · control 29-AS-20210720151601

Allegation investigated: Facility staff does not respond to resident's requests for assistance in a timely manner.

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent inspection at the facility today regarding the above allegations. LPA Lopez met with Business Office Manager, Jennifer Miller at 10:07 AM and explained the reason for the inspection. Administrator Jill Ford arrived during the inspection. During the initial inspection on 04/07/2023, the LPA conducted a brief physical plant tour with the Administrator and observed nine resident apartments between 11:13 AM and 12:20 PM. The LPA conducted interviews with three residents between 11:35 AM and 12:30 PM and with five staff members between 12:35 PM and 2:24 PM. At 2:24 PM, the LPA took of tour of the kitchen area with the Dining Room Manager. At 2:45 PM, LPA reviewed pendent call records. During today's inspection, the LPA conducted an interview with the Maintenance Director Jace Evans at 10:20 AM, reviewed facility records beginning at 10:38 AM, conducted interviews with five residents between 1:25 PM and 1:30 PM, and interviewed one staff at 2:13 PM. Report continued on LIC 9099-C. Substantiated The allegation of ‘Facility staff does not respond to resident's requests for assistance in a timely manner’ alleges staff do not respond timely to Resident #1 (R1) when they use their pendent for assistance. On 04/07/2023, the LPA conducted an interview with R1 who stated pendent call wait times varies and can sometimes be thirty minutes to an hour before staff respond. During the 04/07/2023, the LPA also conducted interviews with three caregivers which revealed response times vary depending on how busy they are, but they were not aware of response time being longer than 30 minutes. The LPA reviewed the pendent call records for R1 between March 7th, 2023 and April 7th, 2023. Record revealed the following response times over 20 minutes; March 9th 38 minutes (m) 36 seconds,(s) (6:27 AM, March 10th 34m 23s (10;48 AM), March 11th 1 hour (h) 1m 12s (6:30 AM), March 11th 28m 29s (8:23 AM), March 11th 30m 46s (12:08 PM), March 11th 34m 29s (12:57 PM), March 12th 31m 17s (7:23 PM) March 13th 50m 55s (7:52 AM), March 13th 51m 2s (9:18 AM), March 14th 51m 42s (7:36 AM), March 14th 42m 49s (3:36 PM), March 14th 1 hr 4s (6:04PM), March 15th 37m 4 s (7:04 AM), March 15th 31m 41s (6:39 PM), March 1th 29m 23s 7(6:52 AM) March 17th 25m 53s (8:13 AM) March 18th 30m 6s (2:31 PM), March 18th 26m 54s (6:02 PM), March 21st 38m 30s (11:15 AM), March 22nd 2h 21s (6:34 PM), March 23rd 31m 3s (6:37 AM), March 23, 34m 57s (5:58 PM), March 23rd 29m 49 s (9:30 PM) , March 24th 1 hr 2m 23s (2:40 PM), March 25th 58m 20s (7:14 AM), March 25 49m 53s (9:27 AM) March 26thth 25m, (12:05PM), March 27th 36m 14 s (12:54 PM), March 27th 35m 14s (7:23 PM), March 28th 26m 45s (2:37PM), March 29th 50m 14 s (7:43 PM) March 30th 51m 38s (6:29 AM) March 30th 45m 41s (5:20 PM), March 31st 38m 41s (6:23 PM), April 1st 1hr 12m 24 s (7:27 AM), April 1st 34m 56 s (12:56 PM), April 2nd 49m 43s (8:40 AM) April 2nd 30m 11s (2:26 PM) April 3rd 34m 27s (7:25 AM), April 3rd 1h 12m 5s (6:17 PM), April 6th 34m 8s (6:53 PM) April 6th, 41m 15s , (8:44 PM), and April 7th 46m 18s (9:34 AM). Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of 'Facility staff does not respond to resident's requests for assistance in a timely manner’ 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 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jill Ford. A copy of the report and appeal rights were provided. The allegation of ‘Facility staff did not ensure that resident's apartment was free of carpet stains’ alleges that R1’s carpet was supposed to be brand new upon move in, but the carpet has stains and has not been cleaned as requested. During the initial inspection on 04/07/2023, the LPA observed R1’s apartment and observed a dime size stain in the living and some smaller spots on the carpet near the bathroom. Facility record review and interviews revealed the following. R1 moved into the apartment on 01/12/2023. An invoice from Interior Logic Group reflects carpet was installed on 12/06/2022. Interviews with Maintenance Director Jace Evans revealed the apartment remained vacant after the carpet was installed until R1 moved in. Facility work orders reveals a carpet cleaning request was submitted on 01/23/2023 and it was completed on 01/26/2023. On 02/01/2023 another request for the carpet spots to be cleaned was submitted and it was cleaned the same day. On 02/03/2023, R1 requested the carpet to be cleaned again which was cleaned the same day. On 03/25/2023 a request to clean the carpet outside the bathroom was requested and it was completed on 04/03/2023. During the interview with Mr. Evans he stated they have not received any requests to clean the carpet since 03/25/2023. Based on the information obtained, there is insufficient evidence to support the allegation ‘Facility staff did not ensure that resident's apartment was free of carpet stains’ occurred. Therefore, the allegation is deemed unsubstantiated at this time. The allegation of 'Facility staff does ensure that resident is able to maneuver their wheelchair in a safe manner at the facility' alleges R1’s request for a flooring solution to aid in wheelchair maneuvering has been denied. Interviews today with Maintenance Director Jace Evans revealed the facility is currently working on a solution for the transition piece between the carpet in the living room and the flooring in the kitchen and stated R1’s request has not been denied. Mr. Evans showed the LPA several text messages between himself and the sales Representative from Interior Logic Group Property between March 3rd, 2023 and April 11th 2023 regarding the new transition piece for R1’s apartment. Mr. Evans said several transition pieces have been brought to the facility by the carpet company during this time, but they did not correct the issue. Mr. Evans said on Monday the carpet company is scheduled to come out and fix the issue. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of ‘Facility staff does ensure that resident is able to maneuver their wheelchair in a safe manner’ is deemed unsubstantiated at this time. Report continued on LIC 9099-C. The allegation of ‘Facility staff does not provide resident an adequate amount of food’ alleges portion sizes of food are sometimes small and second helpings are denied. During the interview with R1, they stated sometimes proteins are small in quantity and when they have requested two servings of a meal on their room service meal slip request, they do not always receive it. The interview with the Dining Room Manager on 04/07/2023 revealed they were not aware of requests for seconds being denied. The LPA also toured the kitchen with Dining Room Manager and was shown multiple signs posted in multiple locations in the kitchen to help kitchen staff be aware of special diets, requests, etc. for residents. During the tour, the LPA observed signs for R1 reminding staff to follow what's written on the meal slip request and to make sure the order is complete before delivering tray. Interviews with two residents on 04/07/2023 and five residents during today’s inspection revealed no issues or concerns regarding portion size and revealed seconds are provided upon request. Based on the information obtained, there is insufficient evidence to support the allegation of ‘Facility staff does not provide resident an adequate amount of food’ occurred. Therefore, the allegation is deemed Unsubstantiated at this time. The allegation of ‘Facility staff does not ensure that resident's apartment is cleaned according to schedule’ alleges house keeping does not always come weekly as scheduled. Interviews with seven residents on 04/07/2023 and during today’s visit revealed house keeping 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 house keeping services weekly. Based on the information obtained there is insufficient evidence to support the allegation of Facility staff does not ensure that resident's apartment is cleaned according to schedule. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted with Jill Ford. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2023 · control 29-AS-20230405082631

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

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4)To care, supervision, and services that meet their..needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidenced by: Based on interview and record review, the licensee failed to comply with the section cited above as R1 had approximately 46 pendent response time in excess of 20 minutes during a one month time period which is an immediate personal rights and health and safety risk to R1 in care.the state’s words, verbatim · CDSS document, Apr 12, 2023

Plan of correction: The Administrator shall submit a plan by 04/20/2023 indicating how they will ensure timely pendent response times for R1 and all residents in the community.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case-Management Incident inspection regarding a death report pertaining to Resident #1 (R1). The LPA met with Business Manager Jennifer Miller and explained the reason for the visit. On 04/07/2023, The Department received a Death Report (624A) pertaining to Resident #1 (R1) who was hospitalized on 03/31/2023 and expired at the hospital on 04/01/2023. The cause of death is unknown at this time. During today's visit the LPA met with Director of Health and Wellness Ian Gadea. Mr. Gadea contacted the mortuary during today's inspection but was advised the death report would not ready for one week. Mr. Gadea will forward a copy to the LPA as soon as it is received. During the inspection the LPA reviewed records for R1. No deficiencies are being cited at this time. Upon receipt of the death certificate, the LPA will return if further investigation is needed. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2023

Allegation investigated: Licensee is allowing resident's personal rights to be violated

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection regarding the above allegation. The LPA met with Jill Ford at 10:11 AM and explained the reason for the visit. The allegation of 'Licensee is allowing resident's personal rights to be violated' alleges Resident #1 (R1) is blocking and/or restricting the Certified Ombudsman from attending Resident Council meetings and the facility is allowing it. On 08/24/2021, the LPA conducted interviews with seven residents, including R1, between 1:50 PM and 2:59 PM. The interview with R1 revealed they have invited the ombudsman to council meetings in the past when they have had problems but they are not always needed at every meeting. Interviews with the other six residents revealed no one has ever told them not to invite the ombudsman to their council meeting and they had no issues or concerns if the ombudsman was invited. Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted and report reviewed. A copy of the report and appeal rights were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 16, 2023 · control 29-AS-20210824100751

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.

Allegation investigated: Facility does not provide a comfortable environment for residents.

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection at the facility today regarding the above allegation. The LPA met with Administrator Jill Ford at 10:11 AM and explained the reason for the visit. The allegation of 'Facility does not provide a comfortable environment for residents' alleges residents are fearful to speak with the long term care ombudsman. During the course of the investigation, on 07/21/2021, the LPA interviewed with six residents between 1:24 PM and 3:00 PM. Interviews revealed residents interviewed had no fear of speaking with the long term care ombudsman or fear of retaliation by anyone if they spoke with the ombudsman. Based on this information, there is insufficient evidence to support the allegation occurred. Therefore, the allegation is deemed unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 16, 2023 · control 29-AS-20210720151601

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.

Allegation investigated: Staff drinks alcohol while on duty

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent complaint inspection to deliver the findings for the above allegation. The LPA met with Business Office Manager Jennifer Miller and Director of Health and Wellness Ian Gadea at 10:08 AM and explained the reason for the inspection. Administrator Jill Ford was unavailable today. On 01/17/2023, Community Care Licensing Division (CCLD) received a complaint alleging 'Staff drank alcohol while on duty'. On 01/18/2023, LPA Lopez conducted an inspection at the facility initiating the investigation and conducted interviews with eight staff members in person and one staff member on the telephone, including Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) between approximately 10:50 AM and 1:15 PM. The LPA also conducted a physical plant tour with Ms. Miller and Mr. Gadea, including but not limited to the memory care, memory care kitchen, and memory care kitchen storage area. Records were also reviewed during the visit. Report continued on LIC 9099-C. Substantiated On 01/18/2023, two additional staff members were also interviewed after the issuing of the report at the facility between approximately 3:56 PM and 4:19 PM. On 01/19/2023 and on 01/23/2023, the LPA conducted telephone interviews with three staff, including Staff #4 (S4). On 01/26/2023, the LPA conducted a subsequent inspection, and conducted additional interviews with S1 and S2 between 11:29 AM and 12:03 PM. During the course of the investigation, LPA Lopez received photos that were posted on social media allegedly by S1. In the photos, four staff members identified as S1, S2, S3, and S4 and who were working in the memory care at the time. The staff members were all wearing blue tops and the photos were identified as being taken at the facility. On the social media post the words “WHEN ITS MY BDAY EVERYONES DRINKING LOL” were written. In the photos, one staff member is holding what appears to be a clear, wide glass bottle, although the label on the photo was unclear in the photo. In another photo, a staff member is seen drinking from this bottle. The LPA also obtained a photo of the alleged bottle staff were drinking while at work. The bottle brand was "Gran Malo" and "Spicy Tamarindo" was written on the label. The rest of the wording was in Spanish. However, on the bottle it states "LICOR CON TEQUILA SABOR TAMARINDO. HECHE CON TEQUILA BLANCO. The alcohol content listed is 30% Alc. 750 ml. The bottle is a clear wide bottle with a white label and red writing and a silver screw on top. The person holding the bottle is wearing a blue top, has long dark nails and is holding the bottle over what looks to be a plastic container with food in it on a tan counter top with a tile floor. During the initial telephone interview with S1, S1 confirmed on 01/13/2023 they made the post on their Instagram story of S1, S2, S3, and S4 while having a potluck birthday party for S1 while at work. S1 stated the potluck was during their lunch break at 11:30 AM during the AM shift in the memory care. S1 stated they made food for the potluck. When asked about the social media post, S1 stated they were only joking when they posted the quote “WHEN ITS MY BDAY EVERYONES DRINKING LOL”. S1 denied there being alcohol in the bottle being drank from in the photos and stated it was “Tamarind”, which was a “Mexican candy water”. S1 described the bottle as a white "Voss" like looking water bottle. Report continued on LIC 9099-C. During the subsequent interview with S1 on 01/26/2023, the LPA showed S1 the picture of the Gran Malo alcoholic beverage taken in the memory care. S1 stated although they had long nails at the time of the party, they denied they were holding the bottle in the photo, stating the person in the photo had a different color polish than what they had at the time. S1 also denied this was the bottle S4 brought to the pot luck and in their social media post. During the interviews with S2, they confirmed they were in the social media photos posted by S1. S2 was observed to have long nails but denied being the person holding the bottle of alcohol in the photo. S2 stated they could not recall what staff were drinking during the potluck and denied drinking any alcohol. During the interview with S3, they confirmed they were the person who was drinking from the bottle in the photo on social media. Although, S3 denied they were drinking alcohol and stated they were drinking water. During the interview with S4 they also denied drinking alcohol at work and stated what staff were drinking was “Tamarindo water”, which was described as a “Mexican sparkling water”. During the interview with S4, they confirmed they were the individual who brought the bottle to work for the potluck. S4 stated they also brought food to the party. S4 stated they had the bottle in their car. S4 stated the bottle was gift from their sister who purchased it in Mexico and stated it was Tamarindo sparkling water. S4 said it was clear like sparkling water and did not contain alcohol. LPA inquired if S4 knew the name of brand of the water they brought to the party but S4 said they were not sure and it was a Mexican brand During the investigation, the LPA observed the memory care kitchen and storage area and was able to confirm the photos posted on social media with the four staff members and the photo of the Gran Malo Spicy Tamarindo was taken in the memory care kitchen due to the background in the photos. The Administrator Jill Ford and Business Office Manager Jennifer Miller also confirmed during the investigation that the social media photos and the photo of the alcohol bottle were taken at the facility. Three staff members interviewed, Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7), also confirmed they observed on two different social media sites, that S1, S2, S3, and S4 were drinking alcohol while at work. Report continued on LIC 9099-C. Based on the information obtained, there is sufficient evidence to support the allegation of ‘Staff drank alcohol while on duty’ occurred as S1 made the statement of “WHEN ITS MY BDAY EVERYONES DRINKING LOL” on social media with photos taken at the facility; a photo of an alcoholic beverage, Gran Malo Spicy Tamarindo was taken on facility grounds in the memory care kitchen; the bottle S4 was pictured drinking from on social media looks similar to the photo of Gran Malo Spicy Tamarindo taken at the facility, and three staff members observed the staff drinking alcohol while at work on social media. Therefore, the 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 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Ms. Miller. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 10, 2023 · control 29-AS-20230117111024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Feb 17, 2023

87468.1 Personal Rights of Residents in All Facilities (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 and observation, the licensee did not comply with the section cited, as a photo of an alcoholic beverage was taken in the memory care and staff posted on social media they were drinking while at work which poses an immediate H&S risk to residents in care.the state’s words, verbatim · CDSS document, Feb 10, 2023

Plan of correction: The Administrator shall submit a plan of correction by 02/17/2023, indicating how they will prevent this violation from occurring again.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection at the facility today due to a deficiency observed during a complaint investigation. Record review and interview with Business Office Manager Jennifer Miller, revealed Staff #1's (S1) criminal record clearance was not transferred and associated to the facility. File review and an interview with S1 revealed S1 has worked at the facility since August 2022. During the inspection, Ms. Miller associated S1 to the facility. This deficiency warrants an immediate civil penalty. This is also a repeat violation of the same citation that was issued on 03/22/2022 which is within a twelve (12) month period. Therefore, civil penalties are being assessed in the amount of one hundred ($100) per day for the maximum amount of thirty (30) days. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview and report reviewed with Jennifer Miller, Business Office Manager. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jan 18, 2023

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to...1569.17(b) shall prior to working.... in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidence by: Based on interview and record review the licensee failed to comply with the section cited above as Staff #1 (S1) has worked at the facility since August 2022 and their criminal record clearance has not been transferred to the facility which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Jan 18, 2023

Plan of correction: This is a repeat violation of a citation issued on 03/22/2022. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days. See LIC 421BG. Plan of correction is cleared as S1 was associated to the facility during today's inspection.

Allegation investigated: Services not being provided in a timely manner Residents are being left soiled for extended amount of time

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Jill Ford and discussed the reason for today’s visit. Entrance interview conducted. Previously, LPA Dulek conducted a virtual initial complaint inspection on 01/21/2021. During that visit, LPA conducted a telephone interview with the administrator Martha Berard at 12:05PM, a FaceTime virtual tour of the facility at 12:14PM, and LPA requested copies of pertinent documents. LPA then conducted a subsequent complaint inspection in person on 10/06/2022 where LPA toured the facility with Business Office Manager Jennifer Miller at 01:29PM, and conducted resident and staff interviews from 01:51PM to 03:00PM. LPA conducted additional telephone interviews with residents, residents’ family members, as well as staff and resident interviews intermittently throughout the investigation. LPA also Report Continued on LIC 9099-C Unsubstantiated reviewed pertinent documents. The following was then determined: Regarding the allegation “Services not being provided in a timely manner:” Throughout the course of the investigation, LPA Dulek conducted interviews with staff and residents. Resident interview revealed that staff are doing a good job, are responsive to the residents’ needs, and occasionally medications are late, but none were reported to be greater than 30 minutes late. Medication review revealed medications were administered at regular intervals throughout the day, as prescribed. Residents did indicate that food was delivered later than ideal during the COVID outbreak at the facility, which coincides with the time frame of the complaint allegation. However, when the food was served, residents indicated facility staff would warm the food up for the residents and ensure each resident still received a warm meal of their choosing. Additionally, interview with Administrator revealed that the facility instituted a snack and hydration program to ensure all residents were provided snacks and water throughout the day. Interview revealed that the facility call light system was functional throughout the COVID lockdown and all staff, including agency staff carried their radios and ipods regularly. The facility’s policy outlines a 10-minute response time for all calls, however the facility staff acknowledges that this timeline can be difficult when multiple residents call at same time or when staff are busy meeting the needs of other residents. During the time the allegation was made, the facility was experiencing a significant COVID outbreak, which was initially reported on 12/28/2020 and resulted in continued daily communication and support from CCLD through 02/02/2021. Ventura County Public Health advised the facility to create COVID cohorts for COVID positive and COVID negative residents. Residents were asked to stay in their individual rooms, and care staff delivered all meals to resident rooms. Facility staff were required to wear full PPE to enter resident rooms and to change PPE prior to entering the next resident’s room, for the health and safety of all residents and staff. As a result, a care staff providing care to their regular 8 residents assigned also had to don and doff full PPE 8 times during each care run, adding an additional challenge to meet the facility’s 10-minute response time. Resident interview revealed that “they come on time” and with the exception of a few outliers, residents interviewed were happy with the timeline in which services are provided. Therefore, based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation “services not being provided in a timely manner” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C Regarding the allegation “Residents are being left soiled for an extended period of time:” LPA interviewed residents during the course of the investigation. All residents the LPA spoke with felt their incontinence needs were met, even during the time of the COVID outbreak. Staff interview revealed that incontinent residents are checked every 2 hours and as needed. Interview revealed agency staff who were employed at the time of the complaint were trained and were capable of changing residents regularly and as needed. Although the facility acknowledged that they were experiencing staffing shortages due to the COVID-19 outbreak at the facility, they utilized staffing agencies, instituted a 12-hour shift rather than regular 8-hour shifts, and all staff were trained and utilized on the floor for direct care, including management staff. Another strategy the facility employed was utilizing as many staff as possible as care staff and asking the staff to complete all ADL tasks at a time when entering a resident’s room, due to the need for full PPE. For example, staff would deliver the resident’s food, assist with dressing, grooming, and incontinent needs all during one trip to the resident’s room, rather than making multiple trips for each individual task. Residents interviewed felt their incontinence needs were met and staff interviewed indicated they did not hear any complaints from residents regarding incontinence care. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore, the allegation “residents are being left soiled for an extended period of time” is deemed UNSUBSTANTIATED at this time. No citations related to this complaint were issued. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Dec 13, 2022 · control 29-AS-20210112140705

Allegation investigated: Inadequate staffing to meet the needs of the residents Facility is not safeguarding residents’ belongings Residents’ authorized representatives are not notified of changes in residents’ conditions Residents are not being offered activities Appropriate variety of foods not provided to residents Staff did not ensure resident received meal

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Jill Ford and discussed the reason for today’s visit. Entrance interview conducted. Previously, LPA Dulek conducted a virtual initial complaint inspection on 02/05/2021. During that visit, LPA conducted a telephone interview with Administrator Martha Berard at 9:07AM. A video visit via FaceTime was initiated at 11:56AM to conduct a virtual tour and ensure the health and safety of residents in care. LPA also requested copies of pertinent documents. LPA then conducted a subsequent complaint inspection in person on 10/06/2022 where LPA toured the facility with Business Office Manager Jennifer Miller at 01:29PM, and conducted resident and staff interviews from 01:51PM to 03:00PM. LPA conducted additional telephone interviews with residents, residents’ family members, as well as staff and resident interviews Report Continued on LIC 9099-C Unsubstantiated intermittently throughout the investigation and LPA reviewed pertinent documents. The following was then determined: Regarding the allegation “Inadequate staffing to meet the needs of the residents:” During the time period the complaint was received, the facility was experiencing a significant COVID outbreak, which was initially reported on 12/28/2020 and resulted in continued daily communication and support from CCLD through 02/02/2021. During the time period of the complaint allegation, locating qualified staffing was challenging for not only the facility, but the caregiving industry as a whole. Interview revealed that the facility had many regular staff who had tested positive for COVID and were therefore not cleared by Public Health to work. The facility had signed contracts with two different staffing agencies and were able to schedule staff to work with the COVID positive cohort. However, many agencies just did not have available staff. Interview with Administrator revealed Martha had called “so many staffing agencies and no one has staff available.” Care logs reviewed revealed the facility employed 788.25 hours of agency care staff for the time period of 12/07/2020 – 01/31/2021. Administrator contacted CCLD for additional staffing resources and still struggled to obtain adequate replacement staffing. Administrator tried alternate strategies such as scheduling staff for 12-hour shifts rather than the regular 8-hour shifts and had employed an “all hands on deck” strategy where even salaried management staff stepped in to complete daily caregiving tasks and serving residents’ meals. Administrator had spoken with Ventura County Public Health about alternate staffing resources and worked within their company’s corporate entity to create alternate staffing solutions. Interview with staff and residents revealed that residents’ needs were met. Residents reported that they did have to wait at times, particularly for meals, but that the staff that were there remained helpful and positive throughout the pandemic. Interview revealed that as COVID positive staff were cleared to work, they were brought back into the facility and staffing concerns subsided. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “inadequate staffing to meet the needs of the residents” is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Facility is not safeguarding residents’ belongings:” The complaint alleges that during the time of the COVID outbreak, that residents were moved to alternate rooms and some of their personal belongings were not brought with the residents. At the time of the Report Continued on LIC 9099-C complaint allegation, the facility was experiencing a significant COVID-19 outbreak. At the direction of Ventura County Public Health, the facility management staff made the decision to create a cohort of COVID positive residents to limit COVID exposure to the remaining residents and staff. The facility set up a cohort on the second floor of the facility, so staff caring for COVID positive residents could enter and exit the building separate from staff caring for residents who had tested negative for COVID and had no known COVID exposure. Interviews revealed that Assisted Living residents were instructed to pack up their personal belongings in anticipation of their temporary relocation. Interview revealed that the facility maintenance staff as well as hired movers were brought in to assist in moving the residents’ beds, chairs, necessary items, and all packed personal belongings to their new rooms. Interview also revealed that residents’ family members were allowed on premises to assist their loved ones in moving personal belongings to their temporary cohort location. The facility was instructed by Public Health officials to create cohorts in the interest of safety for all the residents. Interview revealed that no items were reported missing during the transition into the cohorts and back into their regular apartments. Based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility is not safeguarding residents’ belongings” is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents’ authorized representatives are not notified of changes in residents’ conditions:” It was alleged that facility staff did not notify families of their loved ones’ COVID status in a timely manner. Throughout the course of the investigation, LPA Dulek spoke with residents’ family members regarding the facility communication. Interviews revealed that there were a few days of transition between Administrators where communication wasn’t ideal. However, shortly thereafter, the families began receiving messages and recordings from the facility as well as email communication. There had been a power outage at the facility while the facility staff were working on relocating residents to their COVID-positive and COVID-negative cohort locations, but that was resolved within the day during normal business hours. The facility organized a family Zoom meeting, as in-person meetings were limited by Ventura County Public Health due to the COVID outbreak. Staff interviews revealed that caregiving staff continued utilizing their communication logs regarding the residents’ care status throughout the pandemic. While Administrative interview revealed that communication could have been better, due to the size of the outbreak at the facility and the large number of residents and staff affected, they had to utilize creative communication methods to Report Continued on LIC 9099-C accommodate the facility’s needs within the constraints of the COVID lockdown. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore, the allegation “residents’ authorized representatives are not notified of changes in residents’ conditions” is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents are not being offered activities:” At the time of the complaint, the facility was in contact with Ventura County Public Health and had been given guidance in order to mitigate the spread of COVID-19 within the facility. Many staff and residents had tested positive for COVID, so some staff were unable to work and residents were directed to remain in their own individual apartments, for their health and safety. Visitation was limited to essential visitors only, by direction of state public health guidelines, therefore outside vendors were not permitted inside the facility at that time. All communal dining and congregate activities were restricted at the direction of public health in order to limit transmission of COVID-19. Interview revealed that activity staff were reallocated to alternate jobs to help with the facility’s staffing shortage. During the time the complaint allegation was made, the facility was focused on COVID mitigation and ensuring the safety of all residents. The complaint alleges that residents were moved to alternate rooms to cohort and left without entertainment or amenities the facility regularly offers. Interviews revealed that the facility currently provides basic cable in all apartments and that residents were instructed to gather their personal belongings they wished to move to the temporary rooms. Interview further revealed that residents’ families were permitted to assist in temporarily relocating their loved one and moving anything the resident desired to their temporary location. Staff interview did reveal that at that time there were no activities staff, but that residents had the ability to request individual in-room puzzles or newspapers. Therefore, based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation “residents are not being offered activities” is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Appropriate variety of foods not provided to residents:” During the complaint inspection, LPA Dulek reviewed the facility menu provided to residents. At the time of the allegation, the facility was experiencing a COVID outbreak, and therefore had closed all common areas, including the dining room. Residents were asked to order their meals in advance using the menu paper provided. Interview revealed that residents were asked to choose as many or as few choices as they preferred for each meal. For breakfast, residents had a choice of 5 entrée options, 5 sides, and 6 drink Report Continued on LIC 9099-C options, as well as condiment choices. For lunch, residents had a choice of 5 entrées, 5 sides, and 5 drink choices, as well as a fill-in-the-blank line for dessert. For dinner, residents had 8 entrée options, 7 side dish choices, and 5 drink choices, as well as a fill-in-the-blank line for dessert. The weekly menu was also provided to residents and listed the daily specials. Foods listed on both the weekly menu and the ordering menu provided options from all food groups and contained varied choices within each food group. Additionally, during the course of the investigation, LPA interviewed residents. Residents indicated the facility food is sufficient and varied. Therefore, based on record review and interview, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation “Appropriate variety of foods not provided to residents is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff did not ensure resident received meal:” During the investigation, LPA Dulek interviewed multiple residents and staff. At the time of the complaint allegation, the facility was experiencing a COVID outbreak within the facility. At Public Health’s direction, to ensure the health and safety of all residents, the residents were asked to remain in their own individual rooms. Meals were then cooked in the facility kitchen, delivered in carts to each floor of the facility, then delivered to individual rooms by care staff during their care rounds. Staff interviews revealed that the process of food delivery was very lengthy in time and food would cool before the staff could make all their deliveries. As such, care staff would heat the food for the resident in their apartment when delivering food. Some residents preferred staff to leave the meal on their table in their apartment, some wished to eat right away and some were resting when food was delivered. Resident interviews revealed that lunch was delivered late, around 1:00-1:30PM by the time they got to the 3rd floor. One resident stated they had not been delivered food at all one weekend and another resident indicated they “went without a lot of meals.” It is unclear whether the residents were served food and did not eat it or whether the residents were aware food was delivered to them. Staff interview revealed that they would leave the food on the resident’s table then were instructed to go back later and discard any uneaten food. Staff interviewed stated on several occasions it was difficult to tell if the plate had been touched or not, if the resident chose not to eat, or the resident did not know the food had been delivered. Staff indicated they did deliver food to all their assigned residents daily and did not hear feedback that food was not delivered in other areas. As thus, based on interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a Report Continued on LIC 9099-C violation occurred, therefore the allegation that “staff did not ensure resident received meal” is deemed UNSUBSTANTIATED at this time. No citations related to this complaint were issued. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Dec 13, 2022 · control 29-AS-20210128140336

Allegation investigated: Staff did not report a change in condition to resident's authorized representative. Staff did not seek medical attention for resident in a timely manner. Staff mismanaged resident's medication. Staff did not ensure that resident's needs were met. Resident fell multiple times while in care.

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Jill Ford and discussed the reason for today’s visit. Entrance interview conducted. Previously, LPA Dulek conducted an initial complaint inspection on 07/03/2020 telephonically with facility Designee Jade Alma-Harris. During that visit, LPA Dulek conducted a telephone interview with the facility Designee at 02:47PM and LPA requested documents pertinent to the investigation. LPA Dulek also conducted a subsequent complaint inspection on 07/13/2020 with facility Designee Jade Alma-Harris, where LPA interviewed Designee at 10:35AM and the LPA requested additional documents related to Resident #1 (R1). Throughout the course of the investigation, LPA Dulek interviewed R1’s family members and conducted interviews with facility staff. Additionally, Community Care Licensing (CCL) Program Report Continued on LIC 9099-C Substantiated Continued from LIC 9099 Clinical Consultant (PCC) conducted a medical record review for R1, which was completed on 09/22/2022. The following was then determined: Regarding the allegation “Staff did not report a change in condition to resident’s authorized representative:” Record review revealed that R1 moved into the facility on 02/28/2020. R1’s physician’s report dated 02/21/2020 indicated R1’s diagnoses included hyperlipidemia, diabetes type 2, major depressive disorder, and atherosclerotic heart disease. R1’s weight as indicated on the physician’s report was 189 pounds and height was 72”. R1’s care plan dated 02/16/2020 indicates diabetic alerts, fall risk, vitals/weights monthly – every 1st Wednesday. Interview and record review revealed that there was no weight check conducted on the 1st Wednesday in March 2020 or April 2020. R1’s weight record indicates on 5/1/2020 R1 weighed 165 pounds, indicating a 24 pound weight loss in 2 ½ months. Interview revealed that the facility’s computerized weight management system will automatically alert staff of significant weight loss. However, since no weights were recorded in March or April, facility Designee stated that the computer system did not alert staff of the weight loss. R1’s weight was measured on 06/25/2020 the hospital and recorded at 153 pounds, indicating an additional 12 pound weight loss since 05/01/2020. Interview with R1’s family members revealed that they were not made aware of R1’s weight loss, nor that R1 was not eating. Additionally, care notes reviewed did indicate “all parties were notified” of the falls R1 sustained on 06/15/2020, 06/18/2020, 06/21/2020, and 06/22/2020. However, record review revealed that R1’s Primary Care Physician (PCP) was only notified of the last two of the four fall incidents. Facility staff did not complete a new care plan for R1 due to the increased number of falls or significant weight loss. Based on interview and record review, the allegation that “staff did not report a change in condition to resident’s authorized representative” is deemed SUBSTANTIATED at this time. Regarding the allegation “Staff did not seek medical attention for resident in a timely manner:” Medication Administration Record (MAR) review revealed R1’s physician had ordered a daily blood glucose check. There is no evidence to indicate the facility faxed the monthly blood glucose check, per the PCP’s orders nor is there evidence to prove the facility informed the PCP about the resident’s low blood sugar levels on 03/25/2020 or on the 7 dates in June 2020 in which R1 was experiencing low blood sugar (06/07/2020, 06/10/2020, 06/12/2020, 06/14/2020, 06/20/2020, 06/21/2020, and 06/22/2020.) Documents Report Continued on LIC 9099-C Continued from LIC 9099-C reviewed revealed the only time the blood glucose check was faxed was on 06/23/2020, once R1 had already been transported to the hospital. Records reviewed revealed that R1’s PCP responded promptly with a change in medication based on the reports received on 06/23/2020. Additionally, as previously identified above, R1’s physician was not made aware of 2 of 4 occurrences in which R1 fell in June 2020. R1 also lost a total of 36 pounds (or 19% of R1’s total body mass), during the time R1 resided at the facility, between 02/21/2020 and 06/25/2020. Interview revealed facility staff were unaware of R1’s weight loss, and therefore had not reported to the resident’s physician. Care notes revealed R1 had informed staff they were not eating, but this was also not reported to a medical professional until R1 reported to hospital staff during the 06/23/2020 hospital intake. Therefore, based on interview and record review, the allegation “staff did not seek medical attention for resident in a timely manner” is deemed SUBSTANTIATED at this time. Regarding the allegation “staff mismanaged Resident’s medication:” Medication Administration Record (MAR) review revealed R1’s physician had ordered a daily blood glucose check. MAR indicates “please fax monthly report to Dr.” A review of PCP records revealed there was no evidence to indicate the facility followed the doctor’s orders to fax the monthly report of the daily blood sugar level for the resident. There was also no evidence to indicate the facility informed the PCP about the resident’s low blood sugar levels on 03/25/2020 or on the 7 dates in June 2020 in which R1 was experiencing low blood sugar. Documents reviewed revealed the only time the blood glucose check was faxed was on 06/23/2020, once R1 had already been transported to the hospital. Additionally, although R1’s prescription medication Glimerpiride was ordered “take with breakfast” and Metformin was to be taken “twice a day *take with food” although facility staff documented in care notes R1 was not eating, medications were still administered daily without food. Progress notes indicate R1 did not have breakfast, lunch or dinner on 06/22/2020 and was hypoglycemic on this date. However, both medications ordered to be given with food were still administered. Blood glucose check performed by the facility Licensed Vocational Nurse (LVN) on 06/23/2020 at 07:00AM, indicated his blood glucose level was 23. Progress note indicated R1 was then given ½ cup of orange juice at 07:36AM. Another blood glucose check was performed at 08:16AM and measured even lower at 21. An additional ½ cup of orange juice was given to R1. As per niddk.nih.gov, orange juice is not to be given when one is having hypoglycemia for people with kidney disease, due to its high potassium content. Medication Administration Record (MAR) reviewed indicated both glimepiride and Report Continued on LIC 9099-C Continued from LIC 9099-C metformin (both medications are listed on www.ncbi.nlm.nih.gov as used to lower blood glucose levels) scheduled at 09:00AM were given to R1 during a period of hypoglycemia prior to Emergency Medical intervention. Therefore, based on interview and record review, the allegation “staff mismanaged Resident’s medication” is deemed SUBSTANTIATED at this time. Regarding the allegation “staff did not ensure resident needs were met:” The allegation refers to R1 allegedly not eating or drinking while residing at the facility. R1 moved into the facility on 02/28/2020. R1 chose a vegan diet and interview revealed staff were aware of the resident’s chosen dietary needs. Progress notes indicate “late entry for 02/28/2020 5:00PM…(R1) is diabetic and vegan.” Interview with R1’s family members revealed prior to move in, facility staff assured R1 that the facility was able to accommodate R1’s dietary preferences. LPA Dulek reviewed 5 (five) weekly menus for June-July 2020 as well as the daily order choices. No items listed on the menu were noted as vegan, therefore, without viewing recipes, it is difficult to discern whether the printed menu contains any vegan options. As far as listed entrees, 0 (zero) of 35 (thirty five) lunch menu entrée choices and 0 (zero) out of 70 (seventy) dinner menu entrée choices appeared to be vegan. Approximately 2 (two) times a week, the soup offered at lunch was likely vegan as well as many salads, side dishes, and desserts would likely fit within R1’s vegan diet. However, R1 was also diabetic, and according to www.niddk.nih.gov, “the key to eating with diabetes is to eat a variety of healthy foods from all food groups.” No protein options listed on the facility menu were vegan. Additionally, the time period R1 resided in the facility was during COVID “safer at home orders” and residents were isolated in their rooms. Meals were delivered to resident rooms, and residents were asked to order according to the menu choices. Interview revealed that R1 was only ordering side dishes and desserts. Care notes revealed that R1 did not eat at all on 06/22/2020. R1 had a total weight loss of 36 pounds within a 4-month time frame while residing at the facility, which could also indicate R1 was not receiving proper nutrition. Review of medical documentation revealed R1’s weight loss nor decreased oral consumption was reported to R1’s PCP and interview revealed it was not reported to R1’s family members either. Therefore, based on interview and record review, the allegation “staff did not ensure resident needs were met” is deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C Continued from LIC 9099-C Regarding the allegation “Resident fell multiple times in care:” Upon admission to the facility, R1’s physician’s report indicated good physical health status for R1. R1 was listed as non-ambulatory, but able to independently transfer to and from bed. Service Agreement dated 02/16/2020 indicates service type: Alerts: Fall Risk, Mobility: 1 person wheelchair, Transfers: Assist, Night Care: once each shift. Progress notes indicate R1 fell on 06/15/2020 around 02:00PM. Interview revealed that R1’s responsible party was notified that R1 would be on increased status checks to monitor R1’s safety post-fall. Subsequently, R1 fell again on 06/18/2020, which was noted in the progress notes at 03:23PM. Facility staff indicated they would extend the 3-day monitoring an additional 3 days to ensure resident safety. Again, on the 3rd day (06/21/2020,) R1 fell a third time over a 6-day period. Interview revealed R1’s family member called R1 just after R1 had fallen on 06/21/2020, so R1 informed them of the fall, but the facility did not. R1 fell a 4th time on 06/22/2020, which was documented in Progress Notes at 08:26PM. Documentation reviewed revealed R1’s physician was only informed of the last 2 of the 4 total falls. Facility staff was aware that R1 was a fall risk upon admission to the facility. Then the facility did not modify R1’s care plan although R1 was noted falling frequently. The facility was unable to provide any documentation reflecting increased status checks or increased monitoring following the first three falls. It wasn’t until 06/21/2020 that Progress Notes indicate “requested orders for PT/OT for right arm and gait,” but still no change in condition or change in level of care was indicated at that time. Therefore, based on interview and record review, the allegation that “resident fell multiple times in care” is deemed SUBSTANTIATED at this time. Pursuant to the California Code of Regulations, Title 22, the following deficiencies are cited (please see LIC 9099-D), and an immediate $500 civil penalty was assessed during today’s visit on 10/26/2022. The Executive Director was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f). Exit interview conducted with Executive Director Jill Ford. Today’s reports and appeal rights were reviewed and provided via email.the state’s words, verbatim · CDSS document, Oct 26, 2022 · control 29-AS-20200624145514

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 26, 2022

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes....that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as Resident #1 (R1) had a change of contition, and the facility did not intervene nor report, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2022

Plan of correction: Executive Director has already trained all staff on the change of condition criteria and have been following newer protocols regarding resident observation and care notes. Training has been conducted and documented. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b) · Plan of correction due date: Oct 26, 2022

87463 Reappraisals (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above section, as R1 had significant weight loss, decreased oral intake, and increased falls and no reappraisal was completed, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2022

Plan of correction: Executive Director has changed the assessment criteria. Staff have been trained and are doing reassessments on residents who have a need monthly. Families are notified and sign the reassessments. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 26, 2022

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interview, observation, and record review the licensee did not comply with the above cited section, as facility staff were aware R1 was a fall risk, R1 fell multiple times, and the falls weren't reported, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2022

Plan of correction: Executive Director is conducting training monthly on basic services and meeting the residents needs. LPA observed inservice documentation during today's visit. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 26, 2022

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as the facility administered R1's medications without food, as it was ordered, which posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2022

Plan of correction: Executive Director and Health & Wellness Director have modified the facility's medication plans, medication audits are conducted quarterly and residents' physicians are communicated with regularly & documented as thus. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(5) · Plan of correction due date: Oct 26, 2022

87555 General Food Service Requirements (b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for...food habits of residents. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as food provided at the facility was not aligned with R1's medical needs and personal food choices, so R1 did not eat, which posed an immediate health & personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2022

Plan of correction: Executive Director has modified the initial assessment process and the 30 day post-move in assessment to ensure resident needs were met. Physician's reports are reviewed with the Kitchen staff and Dietician. Additional vegan protein options are now available. POC cleared.

Allegation investigated: Resident passed away due to lack of care and supervision

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint investigation with the purpose of delivering findings for the allegation listed above. LPA met with Executive Director Jill Ford and discussed the reason for today’s visit. Entrance interview conducted. Previously, LPA Dulek conducted an initial complaint inspection on 07/13/2020 telephonically with facility Designee Jade Alma-Harris. During that visit, LPA Dulek conducted a telephone interview with the facility Designee at 02:47PM and the LPA requested documents pertinent to the investigation. Throughout the course of the investigation, LPA Dulek interviewed Resident #1 (R1)’s family members and conducted interviews with facility staff. Additionally, Community Care Licensing (CCL) Program Clinical Consultant (PCC) conducted a medical record review for R1, which was completed on 09/22/2022. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099-C Record review revealed that R1 moved into the facility on 02/28/2020. R1’s physician’s report dated 02/21/2020 indicated R1’s diagnoses included hyperlipidemia, diabetes type 2, major depressive disorder, and atherosclerotic heart disease. Interview with family members revealed that prior to admittance to the facility, R1 had been diagnosed with stage 1 kidney failure. R1’s care plan dated 02/16/2020 indicates diabetic alerts, fall risk, vitals/weights monthly – every 1st Wednesday. While residing at the facility, R1 had fallen on at least 4 dates in June 2020. Record review revealed R1’s physician was only notified of 2 out of the 4 total falls. And although R1’s physician’s orders state to “check fasting glucose levels daily. Please fax monthly report to (Primary Care Physician - PCP),” the facility did not fax record of blood glucose levels to R1’s PCP until after R1 was hospitalized on 06/23/2020. R1’s physician’s report dated 02/21/2020 indicated R1 weighed 189 pounds. Weight check conducted on 05/01/2020 revealed a weight loss of 24 pounds, as R1 weighed 165 pounds at that time. Record review revealed R1’s physician was not notified of this unplanned weight loss. Review of R1’s daily blood sugar document revealed that R1 had episodes of hypoglycemia on 03/25/2020, 06/07/2020, 06/10/2020, 06/12/2020, 06/14/2020, 06/20/2020, 06/21/2020, and 06/22/2020. Progress notes indicate R1 did not have breakfast, lunch or dinner on 06/22/2020 and was hypoglycemic on this date. However, 2 medications ordered to be given with food were still administered. Blood glucose check performed by the facility Licensed Vocational Nurse (LVN) on 06/23/2020 at 07:00AM, indicated his blood glucose level was 23. Progress note indicated R1 was then given ½ cup of orange juice at 07:36AM. Another blood glucose check was performed at 08:16AM and measured even lower at 21. An additional ½ cup of orange juice was given to R1. As per niddk.nih.gov, orange juice is not to be given when one is having hypoglycemia for people with kidney disease, due to its high potassium content. Medication Administration Record (MAR) reviewed indicated both glimepiride and metformin scheduled at 09:00AM were given as well. At 10:51AM, R1 was transported via ambulance to the emergency department due to hypoglycemia. Emergency Department physician notes indicated R1 reported decreased consumption over the last several days. Additional hospital records reviewed indicated on 06/23/2020, R1’s labs were drawn and that R1 had both elevated potassium and creatine levels. That day, R1 was admitted to the hospital with diagnoses including “persistent hypoglycemia likely secondary to AKI (acute kidney injury) with oral antiDM (anti-diabetes mellitus) meds,” hyperkalemia (high potassium level in the blood), and dehydration. Report Continued on LIC 9099-C Continued from LIC 9099-C R1 remained hospitalized until R1 passed away on 07/03/2020. Death certificate review indicated R1’s immediate cause of death was listed as cardiopulmonary arrest, with additional conditions leading to the cause of death that initiated the events resulting in death are listed as acute respiratory failure, non st elevation myocardial infarction, and coronary artery disease. Other significant conditions contributing to death were listed as chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus type II. Medical attention/intervention should have been extended by notifying R1’s physician for the occurrences as outlined above: unplanned weight loss, decrease in oral consumption, and incidents of hypoglycemia. The facility’s failure to notify or seek guidance from a qualified health professional for R1’s change in condition and failure to follow physician’s orders, contributed to R1’s hypoglycemia, dehydration, and acute kidney injury that necessitated R1’s hospitalization. However, there is no concrete medical evidence that can directly connect the delay of medical intervention as the cause or contributory factor to the resident’s death. Therefore, based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred; as thus, the allegation "resident passed away due to lack of care and supervision" is deemed UNSUBSTANTIATED at this time. No citations were issued. Exit interview was conducted with Executive Director Jill Ford. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Oct 26, 2022 · control 29-AS-20200710125947

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) KaSandra Lopez initiated a Case Management - Incident visit. The purpose of this visit is to conclude an investigation initiated by LPA Lopez during a Case Management – Incident visit conducted on 06/10/2022. During today’s visit LPA Lopez met with Director of Health And Wellness Nicolle Hozner. Administrator Jill Ford was not available for today's visit. Entrance interview conducted. On 05/28/2022, Community Care Licensing Division (CCLD) received a faxed death report pertaining to Resident#1 (R1) who passed away on 05/28/2022. R1 was receiving hospice care services at the time of death and was admitted under hospice with a diagnosis of Intracranial Hemorrhage. At the time the death report was received, the last reported fall to CCLD R1 had was on 03/11/2022 when another resident pushed R1 and no injuries were sustained. On 06/10/2022, LPA Lopez conducted an unannounced Case Management inspection at the facility. During the inspection, the LPA reviewed facility records, obtained copies of pertinent records, and discussed R1's history with the Administrator Jill Ford and Director of Health and Wellness Nicolle Hozner, between 11:10 AM and approximately 2:00 PM. Record review revealed, internal Resident Incident Reports dated 04/18/2022 and 04/20/2022 state the resident had unwitnessed falls resulting in a bump on their head with fresh blood requiring emergency medical treatment at the hospital for the fall and head injury. R1 was then admitted under hospice care on 04/29/2022 with a diagnosis of Intracranial Hemorrhage. R1 also had an unwitnessed fall on 05/06/2022 and complained of leg pain. R1’s family took R1 to the hospital for this fall. During the interview with the Administrator, she stated hospice gave the diagnosis of Intracranial hemorrhage due to a history of falls and was not related to a particular fall. Interviews with the Administrator and Ms. Hozner also revealed, the fall incidents were not reported to CCLD, as Ms. Hozner was mistakenly under the impression from her prior employer, that CCLD did not need to be notified if a resident returned to the facility from the hospital within 24 hours. Report continued on LIC 809-C. The LPA determined further investigation was needed and CCLD’s Investigation’s Branch (IB) Investigator Peter Zertuche was assigned to complete the investigation. Investigator Zertuche reviewed facility records, and reviewed subpoenaed records from Los Robles Medical Center, Livingston Memorial Hospice, and the Ventura County Recorder’s office. Investigator Zertuche also conducted telephone interviews with Witness #1, (W1) on 08/16/2022, Family member of R1, Staff #1 (S1) and Resident #2 (R2) on 08/18/2022, Staff #2 (S2) on 08/22/2022, and Witness #2 (W2) on 08/29/2022. Interviews and record review revealed R1 had a history of falls and a diagnosis of Intracranial Hemorrhage. However, according to W2, the cause of the Intracranial Hemorrhage was unknown and could have been caused by a stroke. W2 also reported no neglect or anything suspicious of R1’s death. The interviews with the family member and W1 also revealed no issues or concerns of neglect related to R1’s death. Additionally, interviews conducted revealed R1 did not need one to one care. A review of the Certificate of Death lists the cause of death as End Stage Ischemic Cerebrovascular Disease. Based on the information obtained, there were no deficiencies related to R1’s death at this time. However, a deficiency will be cited for the facility failing to report R1’s multiple falls to CCLD. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview and report reviewed with the Ms. Hozner. A copy of the report and appeal rights will be emailed.the state’s words, verbatim · CDSS document, Oct 14, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 21, 2022

87211 Reporting Requirements a) Each licensee shall furnish to the licensing agency such reports as the Department may require, ... D)Any incident which threatens the welfare, safety or health of any resident, such as.... This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above, as the facility did not submit written incident reports to CCLD pertaining to Resident #1 (R1) which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2022

Plan of correction: The Administrator shall submit proof staff who are responsible for submitting written incident reports to CCL have had training in regards to regulation 87211. Proof shall be submitted to CCL by 10/21/2022.

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 Jennifer Miller, Business Office Manager, at 10:41 AM and explained the reason for today's visit. Administrator Jill Ford was not available. Today's annual will also have an emphasis on infection control practices and procedures. The LPA, along with Jennifer Miller, and Maintenance Director Jace Evans conducted a physical plant tour of the inside and outside of the facility to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations and the Health and Safety Code. Common areas - Upon entry into the facility, there is central screening station at the front desk for signs and symptoms of COVID-19. Furnishings in common areas were found to be in good repair. Signs regarding infection control are posted in the common areas and common bathrooms. The Community Care Licensing complaint filing information poster along with other required postings were observed by the resident mail boxes on the first floor. The smoke detectors and fire alarm system was last serviced on 09/26/2022 and passed inspection. Fire extinguishers observed were fully charged and last serviced on 07/08/2022. Medications are centrally stored in the medication rooms in the memory care unit and on the third floor in Assisted Living. An Evac-Chair was observed in the stairwell between the third and forth floor. Personal Protective Equipment supplies were observed in a storage room. Kitchen/Dining area: The LPA toured the kitchen, and kitchen storage areas with Anthony Aquino, Director of Culinary Services. The menu was posted. The freezers and refrigerators stored food at the appropriate temperatures. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies and chemicals are stored separately from the food. Report continued on LIC 809-C. Resident Apartments: A random selection of six resident apartments in assisted living and four resident apartments in the memory care were observed between 11:04 AM and 1:00 PM. There are currently 64 assisted living residents and 23 memory care residents. The smoke detectors/carbon monoxide detectors and the hot water temperature was tested in apartments 109, 212, 257, 238, 244, 230, 222, 322, 343, and 403. The smoke/carbon monoxide detectors tested were operational. The hot water measured between 111.2 and 116.6 degrees F. Resident bathroom showers were observed to have grab bars and non-skid strips. Resident apartments were observed to be furnished appropriately. The signal system in Assisted Living was tested and is operational. The delayed egress doors in the outside patio of the memory care were tested and found to be operational. Although the alarm to alert staff audibly inside the memory care front desk/medication room area was not operational when the alarm was activated by Maintenance Director Jace Evans. The LPA observed the ipod which caregivers carrying to be alerted that the delay egress door alarm was activated. File Review: LPA reviewed files for six memory care residents. Files had signed admission agreements and current medical assessments. INFECTION CONTROL: During today’s visit, the LPA spoke with the Business Office Manager Jennifer Miller and Maintenance Director Jace Evans regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility has at least a 30 day supply of Personal Protective Equipment (PPE) and the ability to obtain more if necessary. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room. The following deficiency(ies) 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. Exit interview and report reviewed with Ms. Miller. A copy of the report and appeal rights was emailed.the state’s words, verbatim · CDSS document, Oct 14, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 18, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by: Based on observation, the licensee failed to comply with the section cited above, as the delayed egress auditory alarm located in the memory care front desk/medication room was not operational which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2022

Plan of correction: The business manager and maintenance director agreed to have an in-service today to advise staff that the auditory alarm is not operational. Proof all staff have been notified shall be submitted to CCL by 10/18/2022.

Allegation investigated: Resident was physically abused while in care

Licensing Program Analyst (LPA) Kelly Dulek initiated a subsequent complaint investigation for the allegation listed above. LPA arrived at 10:45AM and met with Executive Director Jill Ford. Entrance interview conducted. During today’s visit, LPA interviewed Executive Director Jill Ford throughout the visit, reviewed pertinent records at 11:00AM, toured the facility with Health and Wellness Director at 02:15PM, and conducted interviews between 02:22PM and 03:55PM. Previously, during an initial complaint inspection on 12/28/2020, LPA Dulek conducted a telephone interview with the Associate Executive Director Jade Alma at 4:25PM and LPA requested copies of pertinent documents. LPA conducted a subsequent complaint inspection on 09/09/2021 where LPA conducted a facility tour at 12:02PM with Sales and Marketing Director Melissa Saldibar and gathered copies of pertinent documents. Throughout the investigation, LPA reviewed REPORT CONTINUED ON LIC 9099-C Unsubstantiated Report Continued from LIC 9099: documents. The following was then determined: It was alleged that Resident (Resident #1 – R1) was physically abused while in care. Record review revealed that on 12/10/2020, during weekly skin monitoring, there was an open area noted on right hip with discoloration. Affected area was cleansed, dried and treated by the facility nurse. An incident report was sent to the Regional Office which was dated 12/11/2020 indicating R1 was noted with discoloration to lower abdominal area during toileting. Resident denied pain or discomfort to affected area. R1’s family member requested R1 be transferred to the hospital for evaluation. Care notes reveal that medical evaluation and rape test conducted at the hospital indicated “no evidence of injury was found.” R1 moved out of the facility upon discharge from the hospital, so R1’s hospital records were not provided to the facility. Record review revealed that R1 had diagnoses which included dementia, gait instability, and R1 is at risk for falls. R1 required transfer assistance, escorts, and assistance with all hygiene needs. Additionally, physician’s report did indicate R1 is able to independently transfer to and from bed and R1 used a wheelchair to ambulate. Interview revealed that any abnormalities in a resident’s appearance would be reported to the medication technician and the floor nurse or med tech would assess the resident. After initial assessment, care notes would be written, and any incident would be reported to the resident’s family and primary care physician. In the case of R1, care notes did reveal observed discoloration, but no known cause was noted. According to the report, R1 denied pain or discomfort at the time of the observation and R1’s physician’s report indicated R1 is able to communicate needs. Around the time of the allegation, there is no report indicating R1 told staff that they were injured or in pain. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to prove a violation occurred, therefore the allegation that “Resident was physically abused while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies were cited. Exit interview conducted with Jennifer Miller, Business Office Manager. A copy of the report was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 29-AS-20201215114039

Allegation investigated: Facility staff are not assisting resident with hygiene needs

Licensing Program Analyst (LPA) Kelly Dulek initiated a subsequent complaint investigation for the allegation listed above. LPA arrived at 10:45AM and met with Executive Director Jill Ford. Entrance interview conducted. During today’s visit, LPA interviewed Executive Director Jill Ford throughout the visit, reviewed pertinent records at 11:00AM, toured the facility with Health and Wellness Director at 02:15PM, and conducted interviews between 02:22PM and 03:55PM. Previously, during an initial complaint inspection on 02/05/2021, LPA Dulek conducted a telephone interview with the administrator at 9:07AM, a video tour at 11:56AM, and LPA requested copies of pertinent documents. The following was then determined: It was alleged that facility staff are not assisting resident (Resident #1 – R1) with showering. Record CONTINUED ON LIC 9099-C Unsubstantiated Continued from LIC 9099 review revealed that R1 initially planned to move into the Memory Care unit and was not receiving any additional care services. However, when R1 moved in, they moved into an Assisted Living unit, rather than Memory Care. Care plan was completed on 07/03/2020 and indicated “staff to assist with a shower daily. Wash hard to reach areas and encourage (R1) to participate as much as (they) are able to.” Physician’s Report dated 06/19/2020 indicated R1 had a diagnosis of Dementia and R1’s capacity for self-care indicated R1 was unable to bathe self, unable to dress/groom self, and unable to care for own toileting needs and that R1 was receiving hospice care at the time. Review of additional care notes revealed that R1 was on hospice during the time of the complaint allegation, however it is unclear whether hospice care plan included showering the resident or if the responsibility for assisting the resident was solely that of the facility staff. Care notes revealed that R1 also had a private caregiver when R1 moved into the facility, and R1 refused assistance with dressing and refused to be checked by the private caregiver. It is unclear whether R1 always had a private caregiver assisting with R1’s care needs, or just at the time of admit into the facility. Interview revealed that staff assist residents at least twice per week up to daily with showers, based on their agreed upon care plan as determined by the resident and their family. Staff will stay with the resident and shower them to ensure they are clean, dry and changed following their shower. If a resident just needs a standby assist, staff will stay with the resident the entirety of their shower. Interview revealed that many families prefer the hospice agency to assist with showers, but hospice typically only visits up to 4 times a week, so if a resident on hospice required daily showers, some would be provided by the facility staff and some by hospice staff. If a resident refuses a shower for any reason, staff would note this in the care notes. Care notes for R1 did not indicate any shower refusal. Based on record review and interview, although the allegation may be valid, at this time there is insufficient evidence to prove a violation occurred, therefore the allegation that “facility staff are not assisting resident with hygiene needs” is deemed UNSUBSTANTIATED at this time. No deficiencies were cited. Exit interview conducted with Jennifer Miller, Business Office Manager. A copy of the report was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 29-AS-20210126140443

Allegation investigated: Licensee failed to meet resident's hygiene needs

Licensing Program Analyst (LPA) Kelly Dulek initiated a subsequent complaint investigation for the allegation listed above. LPA arrived at 10:45AM and met with Executive Director Jill Ford. Entrance interview conducted. During today’s visit, LPA interviewed Executive Director Jill Ford throughout the visit, reviewed pertinent records at 11:00AM, toured the facility with Health and Wellness Director at 02:15PM, and conducted interviews between 02:22PM and 03:55PM. Previously, during an initial complaint inspection on 02/26/2021 conducted virtually, LPA Dulek conducted a telephone interview with the administrator at 04:20PM, a virtual tour at 04:33PM. During a subsequent complaint inspection conducted on 09/09/2021, LPA Dulek conducted a facility tour at 12:02PM with Sales and Marketing Director Melissa Saldibar and gathered copies of pertinent documents. The following was then determined: REPORT CONTINUED ON LIC 9099-C Unsubstantiated It was alleged that Resident #1 (R1) developed a severe infection while in care. R1’s records were reviewed throughout the investigation. Record review revealed that R1’s care plan dated 12/01/2020 indicated R1 “does not require assistance with daily grooming, but staff will need to confirm (R1) is washing (R1’s) hands, face, and brushing (their) teeth. (R1) wears partial dentures that (they) need to soak at night and put on in AMs.” Care notes indicate that R1 was checked daily and had no concerns noted regarding hygiene. R1 was diagnosed with a tooth abscess while R1 was hospitalized for an unrelated event. R1 was then prescribed antibiotics for the infection and scheduled for a follow up appointment with the dentist a week later. R1’s antibiotics were administered daily at the facility, as prescribed. Interview revealed that R1 was very independent and was compliant with meeting hygiene needs. Although it is not necessary, interview revealed that most staff will stay with a resident to ensure they complete tasks, even if they are only on reminders to ensure resident needs are met. If a resident does not require assistance with brushing teeth, the staff would not have been observing that resident's teeth on a daily basis, especially during this time period, as residents were required to wear masks and socially distance. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to prove a violation did occur, therefore the allegation that “resident developed a severe infection while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies were cited. Exit interview conducted with Jennifer Miller, Business Office Manager. A copy of the report was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Sep 15, 2022 · control 29-AS-20210219171530

Allegation investigated: Food served is not of good quality

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint inspection at the facility today. The LPA arrived at 11:39 AM and met with the concierge. At 11:58 AM, the LPA met with Nicolle Hozner, Director of Health and Wellness as the Administrator Jill Ford was not available. The allegation of 'Food served is not of good quality' alleges the food the facility serves make the resident sick and the resident was served spoiled cole slaw and a spoiled sandwich. During today's inspection between 11:58 AM and 4:00 PM, the LPA conducted interviews with Ms. Hozner, met with Culinary Director Michael Tabada, toured the kitchen, observed the food storage areas, interviewed Mr. Tabada, interviewed six staff, and interviewed two residents. Report continued on LIC 9099-C. Substantiated During the inspection of the kitchen and food storage areas, the LPA observed food to be stored at the appropriate temperature. During the inspection, the LPA observed the following. Beginning at 12:54 PM in the refrigerator, the LPA observed Glenview Farms low fat cottage cheese with a best by date of 07/16/2022, Glenview Farms low fat cottage cheese with a best by date of 07/23/2022, and three Abbottford Farms single serve hard boiled egg packages with a use by date of 06/13/2022. In the dry storage area beginning at 1:07 PM, the LPA observed 2 boxes of Cream of Rice with best by dates of 10/17/2021, approximately six boxes of Cream of Rice with best buy dates of 03/30/2022, and approximately 10 boxes of Near East Couscous mix with best by dates of 07/11/2022. At 1:36 PM, the LPA observed the refrigerator again, and observed the only three packages of pre-washed green cabbage coleslaw mix with use by dates of 07/24/2022, and two packages of cauliflower with a use by date of 07/14/2022 and 07/23/2022. The LPA also observed two containers of opened Kraft coleslaw dressing and three or four unopened containers. None of the dressings had expiration dates on the packaging but Mr. Tabada was able to tell one of the open containers was older than the other due to different numbers on the packaging. Mr. Tabada looked though shipping receipts but was only able to find the invoice for the newer cole slaw dressing ordered on 06/30/2022 during the LPA's inspection. The LPA obtained photos of the food observed. The food in question, including the cole slaw dressing was disposed of during the inspection. Based on the LPA's observation, there is sufficient evidence to support the allegation of Food served is not of good quality. Therefore, the allegation is deemed Substantiated at this time. The following deficiency was cited (See LIC 9099-D) from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview and report reviewed with the Director of Health and Wellness. A copy of the report and appeal rights were emailed.the state’s words, verbatim · CDSS document, Jul 26, 2022 · control 29-AS-20220718165553

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Aug 5, 2022

87555 General Food Service Requirements (b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This following requirement was not met as evidenced by: Based on observation, the licensee failed to comply with the section cited above as the LPA observed 8 food items with use by dates of 6/13/22, 7/14/22, 7/23/22 and 7/24/22, and multiple items with best by dates of 10/17/21, 3/30/22, 7/11/22, 7/14/22 and 7/23/22, which poses an immediate health and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2022

Plan of correction: The Administrator shall submit a plan with procedures on how they will protect the safety, acceptability and nutritive values of food served. The plan shall be submitted by 08/05/2022. (Items in question were disposed of during the inspection.)

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today to follow up on self reported reports received. The LPA met with Administrator Jill Ford at 10:31am and explained the reason for today's inspection. The LPA met with the Administrator and Nicole Hozner, Director of Health and Wellness, in the Administrator's office. On 05/28/2022, Community Care Licensing Division (CCLD) received a faxed death report pertaining to Resident#1 (R1) who passed away on 05/28/2022. The LPA reviewed facility records and discussed R1's history with the Administrator and Ms. Hozner between 11:10 AM and approximately 2:00 PM. The LPA obtained copies of pertinent records and determined further investigation is needed. At 2:03 PM, the LPA began record review for Resident #2 (R2). On 05/22/2022, the LPA received an email at 8:38pm notifying the LPA of a memory care resident elopement on 05/22/2022. The Administrator reported the resident was found unharmed by law enforcement and a written report with more details would follow. On 05/27/2022, CCLD received a faxed incident report pertaining to R2 who eloped from the facility on 05/22/2022 at approximately 12:30 AM. The report states due to a new agency caregiver, Staff #1 (S1), misunderstanding instructions given by a facility caregiver, S1 assumed it was acceptable to allow R2 leave the secured memory care unit. At approximately 12:15am, S1 inputted the door code and allowed R2 to exit the memory care unit and observed R2 get on the elevator. At approximately 12:30am, the main lobby entrance door triggered the alert system notifying staff a resident had exited the community. An internal and external facility search was conducted by staff. At approximately 12:45am, Staff #2 (S2) called 911 to report a missing resident. At approximately 12:50am, police contacted S2 to report R2 had been found at a nearby McDonald's on Wendy drive. A separate police report was made by a bystander which made R2's return back to the facility quicker. Police returned R2 back to the facility at approximately 1:00am. S2 assessed R2 upon there return and did not observe any injuries. Report continued on LIC 809-C. At 12:50am, R2's POA was contacted via telephone. The report states they informed the care giving agency that S1 should no longer be assigned to work at the facility and to ensure agency staff have thorough dementia training when assigned in memory care. Record review revealed a Missing Resident Checklist, and Resident Elopement Assessment was conducted on 05/22/2022 for R2. Records also revealed R2 has a diagnosis of dementia and is not allowed to leave the facility unassisted. A map search reflects the McDonald's were R2 was found is 0.8 miles away from the facility and takes approximately 23 minutes to walk to. At approximately 3:30pm, the LPA me with Ms. Hozner who stated she spoke with S1 on 05/22/2022 after the incident and they stated they misunderstood and thought the resident could walk around freely in assisted living. Based on the information obtained, there is sufficient evidence to issue a deficiency as staff allowed R2 out of a secured unit when they are not able to leave the facility unassisted. During today's visit when the LPA arrived, there was a "post it note" on the facility door bell indicating the bell did not work and to knock on the door for assistance The facility's entry door has been locked from the outside since the pandemic, therefore concierge opens the front door for guests. The Administrator stated the door bell stopped working recently and a part had been ordered. The LPA inquired about the protocol for late night guests, deliveries, medical personnel, etc. when the concierge is gone for the day. The Administrator stated there was a phone number posted on the door for after hours guests that calls directly to the medication room. The LPA and Administrator checked the facility door and did not observe any phone number posted. The Administrator stated the number was previously posted and immediately posted the phone number on the door during the inspection. The Maintenance Director stated the door bell would still alert the staff's Ipod's when pushed although, Ms. Hozner along with the LPA, pushed the door bell and it did not alert the Ipod Ms. Hozner had with her. Based on this information, a deficiency will be issued. 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. Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights will be emailed.the state’s words, verbatim · CDSS document, Jun 10, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 10, 2022

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as S1 allowed R2 to leave the secured memory care unit unassisted resulting in S2 eloping from the facility which is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2022

Plan of correction: An elopement drill was conducted with staff and S1 will no longer work at the facility. Plan of correction is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jun 10, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview, the licensee failed to comply with the section cited above as a phone number was not posted on the locked entry door for after hour guests, emergencies, deliveries, etc. to alert staff of their presence which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2022

Plan of correction: A sign with the medication room phone number was posted on the front door during the inspection. Plan of correction is cleared.

Allegation investigated: Due to lack of care and supervision, resident developed a pressure injury while in care

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation regarding the above allegation initiated by LPA Rosales on 10/27/2020. LPA met with Senior Executive Director Jill Ford and explained the reason for the visit. Entrance interview conducted. On 10/26/2020, the Department received a complaint which alleged that due to lack of care and supervision, Resident #1 (R1) had sustained a Stage IV pressure injury while in care and the facility continued to retain this resident without informing nor requesting an exception from CCLD to retain this resident. This allegation was referred to CCLD Investigation Branch (IB) on 10/26/2020 and assigned to Investigator Christine Ferris. On 10/27/2020, due to the situation surrounding Coronavirus-19 (COVID-19) and to implement mitigation measures, LPA Rosales conducted an initial virtual complaint from 11:04AM to 11:43AM. LPA Rosales virtually REPORT CONTINUED ON LIC 9099-C Substantiated toured the facility with Administrator and requested pertinent staff and resident documents. On 11/03/2020, 11/04/2020 and 11/05/2020, Investigator Ferris conducted telephone interviews with pertinent parties. On 11/13/2020, Investigator Ferris conducted in person staff interviews at the facility. Investigator Ferris then reviewed R1’s medical records and other pertinent documentation obtained from the facility. The following was concluded: Documents reviewed revealed that R1 was admitted to the facility on 02/06/2020. At that time, although R1’s physician’s report indicated “history of skin breakdown” no open wounds were noted upon admission. In fact, Home Health report dated 02/11/2020, indicated “blanchable redness on bilateral buttocks. Caregiver, (family member), Assisted Living LVN all notified.” Instruction was provided to the caregivers on changing R1’s position regularly, managing incontinence timely, and keeping the skin clean and dry. By 02/14/2020, Home Health records indicate “patient observed with dressing on sacrum area. When dressing removed, observed open wound on sacrum…caregiver, (family member,) Assisted Living LVN all notified. Caregiver stated she had the nurse look at the area this am and he applied the dressing.” By 02/18/2020, the wound was noted “much larger and deteriorating.” On 02/20/2020, the wound was recorded as a Pressure Ulcer Stage IV. Interviews conducted during the course of the investigation revealed that facility staff were aware R1 had developed a “bad pressure injury” prior to being placed on hospice. Record review revealed that R1 was placed on hospice effective 02/21/2020, although the pressure injury was noted a week earlier on 02/14/2020. Based on all information obtained, the above allegation “due to lack of care and supervision, resident developed a pressure injury while in care” is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The Senior Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted and civil penalty issued. A copy of this report and appeal rights were issued via email. 11/04/2020 and 11/05/2020, Investigator Ferris conducted telephone interviews with pertinent parties. On 11/13/2020, Investigator Ferris conducted in person staff interviews at the facility. Investigator Ferris then reviewed R2’s medical records and other pertinent documentation obtained from the facility. The following was concluded: Documents reviewed revealed that R2’s care plan contained service plan for cardiac alerts to be performed by care staff and included information on signs and symptoms to observe R2 for and to alert LVN/Med Aide if observed. Additionally, R2’s care plan indicated presence of a pacemaker alert since 01/18/2019. On 10/09/2020, a faxed copy of R2’s death report was received in the Woodland Hills Regional Office. Death report indicated on 09/19/2020, R2 was admitted to the hospital due to shortness of breath and chest pain. R2 returned to the facility on 09/30/2020. Record review revealed R2’s physician’s report was updated upon discharge from the hospital on 09/30/2020, indicated R2 had a diagnosis of end stage heart disease. R2 was then admitted to hospice on 10/01/2020 with a diagnosis of Congestive Heart Failure/Atrial Fibrillation. R2 had a Do Not Resuscitate (DNR) order in place as of 10/01/2020. R2’s death report indicated on 10/02/2020 at 5:00PM, R2 was noted unresponsive and unable to obtain vital signs. R2 was pronounced dead on 10/02/2020 at 5:05PM by hospice care staff. Death report for R2 indicated immediate cause of death was congestive heart failure with underlying causes listed as atrial fibrillation and hypertension. Based on all information obtained, there is insufficient evidence to support the allegation, therefore the above allegation “facility did not provide adequate care and supervision, which resulted in R2’s death” is deemed UNSUBSTANTIATED at this time. Additionally, the complaint the Department received on 10/26/2020 contained an allegation that the “facility is retaining a resident with active tuberculosis (TB).” LPA Dulek had received a phone call from Administrator Jade Alma-Harris on 10/20/2020 indicating Resident #3 (R3) had recently moved into the facility. Upon admission, R3’s physician’s report indicated no evidence of TB, but did not indicate a date a TB test was administered. Administrator Alma-Harris confirmed R3 had resided at another RCFE prior to moving into the facility and had no known TB exposure. Due to the physician’s report missing a TB test date, the resident had an on-site visit from a mobile doctor. The doctor took a chest x-ray and the results appeared questionable, so the doctor conducted a blood test. Results of the blood test indicated a TB infection. Ms. Alma-Harris contacted Ventura County Public Health, who directed the facility to retest R3, as R3 had no known TB Report Continued on LIC 9099-C exposure and the result may be due to latent TB infection or a false positive. The following day, on 10/21/2021, a doctor conducted additional testing and confirmed R3 did not have any evidence of active TB. LPA Dulek reviewed records provided for R3 and confirmed R3 had a negative TB test on 10/21/2020. Based on all information obtained, there is insufficient evidence to support the allegation, therefore the above allegation “facility is retaining a resident with active tuberculosis” is deemed UNSUBSTANTIATED at this time. The complaint also contained an allegation that the facility has a scabies outbreak. LPA Dulek, along with Executive Director Jill Ford reviewed electronic medical records for 28 of 28 residents residing in the Memory Care unit during the time period the complaint was received. Although many resident medical records and care notes did indicate residents had a rash, there was no indication of a scabies diagnosis for any of the 28 resident records reviewed. Interview with Ventura County Public Health (VCPH) indicated there were no reports to VCPH at the time of the allegation. VCPH nurse indicated Permetherin cream is used to treat scabies infections and is only prescribed for scabies. 3 of the 28 resident records reviewed indicated Peremethrin cream was prescribed to the resident, however all 3 of 3 residents’ physicians indicated an alternate diagnosis. One indicated a diagnosis of dermatitis, one indicated a mild rash, and the other indicated primary care physician “does not believe the resident has scabies.” Based on record review, although the allegation may be valid, at this time, there is insufficient evidence to support the allegation. Therefore, the allegation that “facility has a scabies outbreak” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 29-AS-20201026131122

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Apr 6, 2022

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Licensee did not provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 30, 2022

Plan of correction: LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 04/06/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today. The LPA met with Administrator Jill Ford at 3:10 PM. During the course of the investigation of complaint control #29-AS-20220322104533, the LPA observed two staff, Staff #1 (S1) and Staff #2 (S2) were not associated to the facility. S1's date of hire is 02/03/2022 and S2's date of hire is 03/16/2022.. This deficiency warrants an immediate civil penalty. This is also a repeat violation of the same citation that was issued on 11/22/2021. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalties assessed. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Jennifer Miller, Business Office Manager. A copy of the report and appeal rights was emailed. On 03/23/2022, the LPA amended the 03/22/2022 report as civil penalties were assessed incorrectly for Staff #2 (S2) as S2 only worked at the facility for two days. The amended Civil Penalty Assessment - Caregiver Background Check LIC 421BG now reflects civil penalties in the amount of $100 a day for 30 days for S1 and $100 a day for 2 days for S2. The amended report was reviewed with Administrator Jill Ford over the telephone at 2:59 PM. A copy of the report and appeal rights were emailed to the Administrator for signature.the state’s words, verbatim · CDSS document, Mar 22, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 22, 2022

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to... 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as two staff (S1 &S2) are not associated to the facility which poses an immediate health and safety concern to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: This is a repeat violation of a citation issued on 11/22/2021. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days. Civil penalties of $100 a day will continue to accrue until proof S1 & S2 are associated or proof they no longer work at the facility.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today. The LPA met with Administrator Jill Ford at 10:04 AM and explained the reason for today's inspection. On 02/17/2022, Community Care Licensing received a written report of an incident occurring on 02/12/2022 regarding Resident #1 (R1) which involved Staff #1 (S1). On 02/18/2022, LPA Ashley Morgan followed up on the written report telephonically with Administrator Jill Ford and requested pertinent documentation, including a copy of the report of Suspected Dependent Adult/Elder Abuse form (SOC 341) that was cross reported to the appropriate agencies. On 02/22/2022, LPA Lopez emailed the Administrator requesting the pertinent documentation and a copy of the SOC 341 again. During today's inspection, the LPA met with and interviewed Administrator, Jill Ford, Director of Health and Wellness, Nicolle Hoznor, , LVN Vivian Reyes, Business Office Manager, Jennifer Miller, and three staff members between 10:04 AM and 1:30 PM. LPA also reviewed facility records and obtained pertinent copies. The LPA has determined further investigation is needed and will return at a later date to complete the investigation. During today's inspection, the LPA also followed up on a self reported incident of which on 01/29/2022, three memory care residents eloped through the delayed egress patio and were observed by staff in front of the building unassisted. No injuries were reported and family members were informed. The LPA spoke with the Administrator on 02/01/2022 regarding the incident and it was reported staff in the memory care did not hear the alarm as they were busy with other residents. Report continued on LIC 809-C. During today's inspection, the LPA conducted a tour of the Memory Care unit at 1:34 PM with Administrator Jill Ford, LVN Vivian Reyes, and Maintenance Director Jace Evans. The memory care outdoor patio has two delayed egress doors that exit the patio and lead into the backside of the property and surrounding areas. Mr. Evans tested the far right delayed egress door while the LPA stayed inside the memory dining room area. The alarm was heard very faintly from inside the dining room and would not be able to be heard audibly in any other part of the memory care unit. Mr. Evans stated the caregiver's iPods are also alerted when the alarm is activated. During the inspection, it was observed that all the caregiver iPods were in the medication room area docking station and no staff had any iPods on their person. Therefore, no memory care staff would be alerted if the delayed egress doors were opened. During the inspection, Mr. Evans stated a modification could be made so that the alarm would alert staff audibly inside the memory care when activated. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and the report and deficiency were discussed with the Administrator. A copy of the report was emailed.the state’s words, verbatim · CDSS document, Mar 2, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 11, 2022

87468.1 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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation and interviews, the licensee failed to comply with the section cited above as the delayed egress system is not loud enough for staff to her audibly inside all areas of the memory care and staff were observed to not be using iPods which would alert them of the egress system which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2022

Plan of correction: The Administrator shall submit proof by 03/04/2022 that all staff have received training regarding the facility policy of all staff having an iPod on them during their work shift and also ensuring the Ipods are always charged and staff have access to their iPod log on and delayed egress training. By 03/11/2022, the Administrator shall submit proof a modification has been made so that the alarm is audibly heard inside the memory care.

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 Business Office Manager Hannah Robertson at 12:28 PM and explained the reason for today's visit. Administrator Jill Ford was not available for today's visit. Today's annual has an emphasis on infection control practices and procedures. The LPA, along with Hannah Robertson, and Maintenance Director Jace Evans conducted a physical plant tour of the inside and outside of the facility to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations and the Health and Safety Code. Common areas - Upon entry into the facility, there is central screening station for signs and symptoms of COVID-19 and to record contact information. Signs regarding infection control are posted in the common areas and common bathrooms. The complaint poster and other required postings were observed by the resident mail boxes. The smoke detectors and fire system is serviced annually. Fire extinguishers observed were serviced within the last 12 months. Medications are centrally stored in the medication rooms in the memory care unit and on the third floor in Assisted Living. Kitchen/Dining area: The LPA toured the kitchen, and kitchen storage areas with Christian Torres, Director of Culinary Services. The menu was posted. The freezers and refrigerators stored food at the appropriate temperatures. The facility has a sufficient supply of perishable and non-perishable food. Although, the facility did not have any bottled water or any other type of stored water for use in case of an emergency. Resident Apartments: A random selection of 10 resident apartments were observed between 12:55 PM and 2:08 PM. The smoke detectors were tested in each room and were operational. The hot water temperature was tested in apartments 109, 104, 220, 259, 234, 248, 224, 309, 305, and 403 and measured between 114.8 and 120 degrees F. Report continued on LIC 809-C. Resident bathroom showers were observed to have grab bars and non-skid strips. Resident apartments were observed to be furnished appropriately. The signal system was tested and is operational. A tour of the memory care unit located on the second floor was conducted. During the tour at 1:34 PM, the LPA observed the laundry room to be unlocked. In the laundry room there was bleach and other cleaning supplies in an unlocked cabinet. The outside memory care patio was observed which is secured by delayed egress gates. The delayed egress gate was tested and found to be operational. During the inspection, it was observed that Staff #1 (S1) was not associated to the facility. INFECTION CONTROL: During today’s visit, the LPA spoke with the Business Office Manager Hannah Robertson regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility has at least a 30 day supply of Personal Protective Equipment (PPE). 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 LPA requested an updated LIC 610E be submitted. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalties assessed. Failure to correct the deficiencies may result in civil penalties. Exit interview and report reviewed with Ms. Robertson. A copy of the report and appeal rights was emailed.the state’s words, verbatim · CDSS document, Nov 22, 2021

Allegation investigated: Facility staff is not allowing the LTCO to have confidential meetings with residents

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above at 10:54 AM. LPA Dulek met with facility Administrator Jill Ford and Regional Director of Operations Tammy Doss and discussed the reason for today's visit. Entrance interview conducted. During today's visit, LPA conducted a facility tour at 12:02PM with Sales and Marketing Director Melissa Saldibar and gathered copies of pertinent documents. During an initial complaint investigation on 4/20/2021, LPAs Dulek and Emily Peraldi interviewed Administrator Martha Berard at 11:25AM and conducted staff interviews from 11:52AM - 12:10PM and again at 12:35PM. LPAs Dulek and Peraldi, along with facility staff Annabelle Amaya conducted a facilty tour at 12:14PM. LPAs also obtained copies of staff schedule, resident roster, visitor logs and other pertinent documentation relevant to the investigation. Report Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 Additionally, LPA Dulek conducted interviews with other relevant parties telephonically on 4/21/2021 and 4/22/2021. The following was then determined: Record review revealed that LTCO representatives had visited at the facility on 4/9/2021. There were two LTCO representatives signed in on that day. Interviews revealed that the LTCO representatives were not escorted throughout the facility and were allowed to move freely and visit whomever they chose. One LTCO representative went inside a resident room and remained there the entirety of their visit. One LTCO representative walked around the facility and it was the LTCO representative who chose not to meet privately with any residents during that visit. Based on all information gathered, the Department does not have sufficient evidence to prove the complaint allegation. Therefore, the above allegation “Facility staff is not allowing the LTCO to have confidential meetings with residents” is deemed UNSUBSTANATIED at this time. Exit interview conducted. No citations issued. A copy of this report was provided to the Administrator via email.the state’s words, verbatim · CDSS document, Sep 9, 2021 · control 29-AS-20210413145029

Allegation investigated: Facility trash is not emptied on a regular basis.

Read the state’s words on page 2 of the record →