Royal Oaks Inn

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Medications are not administered as prescribed

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint visit with the purpose of delivering findings for the allegation listed above. Upon arrival, LPA met with Administrator Brandon Jakobovich. Entrance interview conducted. During an initial visit conducted on 06/17/2026, LPA conducted interviews with three (3) staff members between 10:29AM-11:20AM, toured the facility with Facility Designee at 11:21AM, reviewed medications for Resident #1 (R1) at 11:28AM and reviewed and obtained copies of documents relevant to the investigation. During the facility tour at 11:25AM, LPA observed and briefly spoke with R1. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with relevant parties. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation “Medications are not administered as prescribed:” The complaint alleges that R1’s medications that were prescribed for a scabies diagnosis were not administered as prescribed. LPA reviewed Medication Administration Record (MAR) and prescription orders for R1 during the initial visit. The dermatologist R1 visited on 05/05/2026 prescribed Ivermectin 3mg tablet with the following instructions: “take 3 tablets on day 0, day 1, day 7, day 8 and day 15.” The MAR provided to the LPA shows the medication was administered on the following dates: 05/07/2026, 05/08/2026, 05/13/2026, 05/14/2026, and 05/21/2026. On the MAR, instructions indicate “take 3 tablets (=9mg) by mouth once daily on day 1, 2, 7, 8, 15. Interview revealed R1’s hospice nurse marked the specific dates on a calendar that was in the medication room, which correspond with the schedule on the MAR, not the day indicators on the written prescription. Additionally, R1’s family member provided the LPA with a MAR that the facility printed on 06/02/2026. This printed MAR indicates R1’s Ivermectin was administered daily from 05/08/2026 through 05/18/2026 and 05/20/2026 through 05/22/2026. It is unclear which MAR reflects the actual administration of this medication, however, neither MAR reflects an accurate administration that matches the prescription orders. Further, no documentation was provided indicating the facility contacted R1’s prescribing doctor to obtain clarification on the discrepancy observed between the prescription and the MAR for R1’s Ivermectin. The complainant also alleged R1’s permethrin cream was not administered properly, as it was discontinued prior to the date indicated on the prescription orders. LPA observed Permethrin 5% topical cream was prescribed with the following instructions: “apply topically from neck down nightly for one week, then twice weekly until resolved.” MAR indicates the cream was applied daily from 05/08/2026 through 05/12/2026. In R1’s file, there was a document entitled physician order which was signed by RNCM for R1’s hospice provider. This order stated “please discontinue: permethrin cream.” No further instruction was provided and this order was not signed by a physician, however, the MAR indicates the cream was discontinued at 10:00AM on 05/13/2026. No documentation was provided signed by the prescribing doctor or any other communication with the prescribing provider indicating the medication should be discontinued. It should also be noted that start dates for both medications mentioned in this section reflect a start date of 05/10/2026, which contradicts the documentation in the MAR. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided. Allegation “Facility failed to communicate with resident’s responsible party:” It was alleged that facility staff did not communicate with R1’s family regarding the resident’s scabies diagnosis timely. Documents reviewed for R1’s dermatologist visit on 05/05/2026 indicates a diagnosis of scabies “proven through KOH prep.” Document indicated R1’s family member was present during the visit and “understands plan.” R1 returned to the facility following their 05/05/2026 appointment. Interview revealed R1 had a follow up appointment with the dermatologist on 05/14/2026. R1's family member accompanied R1 to this appointment. Interview with staff revealed the paperwork from R1’s dermatologist appointment was provided via hand delivery by R1’s family member on 05/14/2026 at 05:38PM. The document included information of R1's diagnosis and treatment plan and confirmed R1's family member was aware of the diagnosis at that time. Facility designee acknowledged receiving the paperwork documenting R1’s positive diagnosis on 05/14/2026 and notification was sent to all facility responsible parties via email on 05/18/2026 at 10:08AM. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 29-AS-20260609111158

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 8, 2026

87465(a) (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 R1’s prescription Ivermectin was not documented as administered on the dates it was prescribed, which posed a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: Administrator agreed to provide documentation training to all staff handling medications and will submit proof of training to CCL by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10AM. Upon arrival, LPAs met with Administrator Holly Gold and explained the reason for the visit. Entrance interview conducted. Beginning at 10:04AM, the LPAs, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: At 10:04AM, LPAs toured the kitchen. The kitchen is kept inaccessible to residents. Knives and sharps were stored inaccessible to residents. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency food and water supply is stored in a locked storage room. COMMON AREAS: The common areas include two (2) lounges, two (2) outdoor patios, dining room, activity room, beauty salon, and book nook. LPAs observed required postings throughout the common areas. Common areas were observed to be properly furnished with enough seating to accommodate residents and had a screened fireplace. Fire extinguishers throughout the facility were fully charged and last serviced 05/19/2025. Fire system devices are tested annually by Perfect Connections and were tested 06/10/2025. BEDROOMS: LPAs inspected five (5) randomly selected bedrooms. Resident bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 10:17AM, LPAs observed baseboards in room 38 in disrepair. Administrator stated that baseboards will be repaired or replaced. Report Continued on LIC 809. LPAs observed two (2) rooms with missing window shade panels. Administrator stated that panels will be repaired. BATHROOMS: Resident bathrooms are shared between rooms with door access from each. Some bedrooms have private bathrooms that are not shared. LPAs observed bathrooms in each resident bedroom to be clean and properly supplied with functional grab bars and fixtures. LPAs observed pull cords by the toilet. Hot water was measured in four (4) bathrooms and were between 108.9-118.8 degrees F, which is within the required range. There are eight (8) shower rooms, however, four (4) are in use. Shower rooms were observed to be clean, sanitary, in operating condition with slip-resistant surfaces, and sufficiently stocked with linens and personal hygiene supplies. MEDICATION REVIEW: LPAs began medication review at 10:35AM and reviewed medications for three (3) residents. Medications are centrally stored in the medication room by the business office. Medications are prepped up to 24 hours in advance in medication cups. All medications reviewed were stored and documented per regulation. RECORDS REVIEW: Beginning at 11:08AM, LPAs reviewed five (5) personnel and five (5) residents files for documents including but not limited to: resident Admission Agreement, resident physician’s report, TB test, health screening, staff training and fingerprint clearance. All five resident files reviewed were in compliance with regulation at the time of the visit. LPAs observed one (1) staff member without a criminal record clearance. Administrator stated that the staff member will obtain a criminal record clearance and will not provide care until cleared. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/17/2025. During today’s visit, LPAs obtained a copy of the facility’s liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500 for criminal record clearance. Administrator was informed that failure to correct deficiency may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

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

Allegation investigated: Staff did not address an outbreak of scabies in the facility

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent complaint visit to deliver findings for the above allegation. LPA arrived at 11:00AM and met with Administrator Brandon Jakobovich. Entrance interview conducted. On 07/28/2025, the LPA interviewed three (3) Staff, three (3) Hospice Agency Staff, attempted one (1) resident interview, reviewed and obtained pertinent documents, and toured the physical plant. During today’s visit, the LPA and Building Manager conducted a safety check tour at 11:30AM. No immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff did not address an outbreak of scabies in the facility.” It was reported that Resident #1 (R1) had scabies, and the facility did not address the matter. It was alleged that R1 had neighboring residents – Resident #2 (R2) and Resident #3 (R3) – who also had scabies and persistent rashes that resulted in R1 contracting scabies. Record review revealed that R2 was admitted to the facility with persistent rashes that was actively treated by the facility and hospice. On 03/06/2025, R2 was prescribed Ivermectin for itching and on 06/16/2025 they were prescribed Permethrin and treated for scabies. Administrator Holly Gold stated that infection protocols were followed and R2’s condition subsided. Records confirmed R2 did not have any skin issues in July 2025. R3 was admitted to the facility with wound care addressed by hospice and prescribed Hydrocortisone with no documentation of rashes. R1 was diagnosed with skin cancer and reported by Staff #1 (S1) and Staff #2 (S2) to have very fragile skin due to R1’s age and condition. S2 stated R1 had recurrent skin issues that were addressed and treated accordingly and due to autoimmune and inflammation episodes, had on and off again rashes. The Reporting Party (RP) initially reported scabies in November 2024 to which the facility staff denied the observation. However, the facility and hospice proceeded to treat R1’s rashes with scabies medication. They observed the medications and Aquaphor were not effective and switched to Triamcinolone ointment. The Triamcinolone was observed to work well and R1’s rashes improved. The RP was persistent with the alleged scabies outbreak to which they had R1 undergo a scrape test through UCLA Health on 03/04/2025 and the test returned negative. The RP reported that in April to May 2025, R1’s rash came back. Record review and interview with Hospice staff confirmed that during this time, R1 transferred hospice agencies and was no longer prescribed Triamcinolone. Once R1 was received the ointment again, the rashes improved. Report Continued on LIC 9099-C The RP stated they addressed the scabies to the facility several times and did not observe the facility make any changes. Between 06/23/2025 and 07/02/2025, S2 conducted staff in-service training and addressed topics including resident rights, bruises, skin breakdown, and infection control and personal protective equipment (PPE) protocols. On 07/14/2025, Purcor Pest Solutions visited and treated all areas of the facility. Between 04/24/2025 and 07/23/2025, Purcor Pest Solutions reported zero (0) pest activity. The LPA also observed PPE placed outside R1’s unit for contingency measures for the alleged outbreak. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 22, 2025 · control 29-AS-20250723103455

Allegation investigated: Licensee does not ensure that infection control practices are maintained

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation with the purpose of delivering findings for the allegation listed above at 01:37PM. LPA met with Licensee Brandon Jakobovich. Reason for the visit was explained. During the initial visit on 12/09/2024, LPA conducted a brief physical plant tour, conducted interviews with four (4) staff members, two (2) staff from outside agencies, and three (3) residents, reviewed and obtained copies of pertinent documents relevant to the investigation, and discussed allegation with Administrator Gold and Licensee Jakobovich. It was alleged that the infection control practices are not maintained at the facility as Resident #1 (R1) contracted possible scabies. The complainant alleges that R1 had chronic skin irritation, believed to be scabies, while residing at the facility which cleared after R1 moved out. Interviews conducted with R1’s responsible parties explained that three (3) members began exhibiting skin irritation symptoms after visiting the facility. Per responsible parties, symptoms of the visitors and R1 cleared after using a Permethrin treatment, a topical medication used to treat scabies and head lice. Report Continued on LIC 9099-C. Unsubstantiated However, it was also stated that R1 and other members were seen by multiple doctors, including at least two (2) dermatologists, and that a biopsy of R1’s skin was collected, all of which did not result in a scabies diagnosis. It was further stated that R1’s skin condition differed from the other members and that R1’s skin condition began and ended on the same timeline as one of R1’s medications; responsible parties also speculate that R1’s condition could have been an allergic reaction to the medication used during the same time as the skin condition. Responsible parties further stated that not all visiting members contracted the skin condition that the three (3) members did and that it is still unclear what the skin condition could have been as there were no official diagnoses and scabies was never confirmed. During the initial visit, LPA observed and interviewed the three (3) residents at the facility who had varying skin conditions or rashes. LPA observed the resident’s rooms, checked mattresses, bed covers, and pillows, and observed residents’ skin. The rashes observed by LPA differed from each other and did not resemble R1’s skin condition. LPA did not observe any indications of bed bugs, lice, or other such parasitic insects in residents’ rooms. LPA interviewed staff who stated that at no point did they have symptoms of scabies or skin irritation after caring for residents and that no skin-related outbreaks have occurred at the facility. Online research states that scabies mites can be transmitted by direct skin-to-skin contact with an infected person, however, no staff members or other residents exhibited scabies symptoms or symptoms similar to R1. LPA also reviewed the facility’s infection control policy and interviewed the Licensee and Administrator who were knowledgeable in infectious disease prevention and control. No concerns were noted. The facility has handled recent unrelated outbreaks by following proper procedure and protocol. No evidence of past scabies or skin-related outbreaks were confirmed. Licensee and Administrator stated that a chemical sheet for the facility was pulled for review for possible irritants to R1, and that R1’s responsible parties were informed that alternative soaps, shampoos, detergents, and lotions could be provided for facility staff to use on R1, as there were concerns of irritants in the products. Per Licensee and Administrator, no staff or other residents contracted anything resembling scabies at any point. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation “Licensee does not ensure that infection control practices are maintained” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 29-AS-20241206113504

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20241206113504). The purpose of the visit is to issue a citation for deficiencies observed during the initial complaint investigation. During the visit on 12/09/2024 between 10:30AM – 11:20AM, LPA reviewed four (4) resident files and observed Resident #1 (R1) and Resident #2 (R2) with a dementia diagnosis without a current physician’s report for 2024 (both dated 08/17/2022). Administrator Holly Gold stated that the residents are seen by hospice nurses and doctors and that the forms have been sent to the doctor to be filled out. However, Administrator was unable to provide physician’s reports for 2023. R1 and R2 also did not have current appraisals of needs and services with R1’s dated 03/19/2021 and R2’s dated 09/03/2021. Administrator stated that they have R1’s current appraisal and provided LPA with an unsigned copy dated on 03/21/2024. Administrator signed the copy today, 12/09/2024, with the date 03/21/2024, but resident or responsible party of resident remained unsigned at the time of the visit. Administrator stated that the appraisal has been reviewed with R1’s family. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Dec 23, 2024

87705 Care of Persons with Dementia (c) Licensees who accept...residents with dementia shall be...ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1 and R2 have dementia and did not have an annual medical assessment and reappraisal which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: Licensee and Administrator stated they will obtain current medical assessments and reappraisals for R1 and R2 and submit proof to CCL by 12/23/2024.

Allegation investigated: Physical abuse by staff led resident sustaining a large bruise.

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint investigation for the allegation listed above at 10:08AM. LPA met with Administrator Holly Gold and Licensee Brandon Jakobovich. Entrance interview conducted. During today's visit, LPA interviewed eight (8) staff, two (2) residents, conducted a health and safety check at 11:50AM, and reviewed and obtained copies of pertinent documents. At approximately 12:05PM, LPA discussed allegations with Licensee and Administrator. Report Continued on LIC 9099-C Unsubstantiated It was alleged that physical abuse by staff led resident to sustain a large bruise. Interviews with Licensee, Administrator, Staff #1 (S1), and Staff #2 (S2) agreed that on 10/08/2024, Resident #1 (R1) asked S1 to leave their wheelchair by the bed before S1 left R1’s room, but S1 did not feel it would be safe since it would prompt R1 to attempt to transfer from the bed alone and risk a fall. R1 got agitated and swung the phone pull cord at S1, which then led to S1 grabbing R1’s hand to remove the pull cord. S2 stated they were nearby and heard R1 yelling “stop hitting me.” S2 stated they immediately went to R1’s room and observed R1 holding the pull cord and S1 trying to remove the pull cord before R1 could hurt S1. S2 stated that S1 was not hitting R1, but R1 claimed that S1 slapped their hand. S1 denied the claim and told S2 they were trying to remove the pull cord. S2 stated they told S1 to leave the wheelchair by R1’s bed and to leave the room so R1 could calm down. S2 stated they did not observe marks on R1 or S1 and that there have been no other incidents with R1. The complainant alleged that a large bruise was observed on R1’s right arm that was different colors, indicating the bruise could be older. The complainant stated that R1 has a condition which gives R1 an unsteady gait and has caused multiple falls, and that it is possible the bruise is from a previous fall. However, the complainant stated that R1 stated multiple times that facility staff hit R1. According to the complainant, R1 did not initially state that S1 hit R1 and R1 denies every hitting S1. LPA interviewed R1 who stated that they “feel safe” but there was an incident two weeks ago where staff “punched” R1. R1 stated they do not remember the staff member, what they look like, or what events led up to the incident. R1 was unable to provide additional details to LPA. R1 stated they were told that the staff member would be kept away from them. The complainant, S1, Licensee, Administrator, and S2 also confirmed that S1 will not tend to the resident and is covering a different section of the facility. The complainant, R1, Licensee, and Administrator, all confirmed that R1 stated they do not want S1 to lose their job. Report Continued on LIC 9099-C The Licensee conducted an investigation and had undetermined findings due to S1 and R1 having different accounts of the incident. Family of R1 stated they felt the incident was handled in a satisfactory way. Record review of R1’s medical records indicate that R1 is prescribed a daily 81 mg dose of Aspirin, a blood thinner medication that could cause easy bruising. A physician’s report dated 08/06/2024 and appraisals dated 08/08/2024 indicate that R1 has an abnormal gait, mild cognitive impairment, requires a walker and wheelchair, is able to self-transfer out of bed or chair, and is a high fall risk. Licensee and Administrator stated that although the physician’s report documents that R1 is able to self-transfer, that determination might not be accurate because the physician’s report was completed at a skilled nursing facility and not by R1’s primary care provider. S2 stated that S1 does not like to leave wheelchairs by residents’ beds so that residents are more inclined to call staff for transfer assistance rather than attempting to transfer alone. S2 stated that this has prevented many falls, but that they told S1 to leave the wheelchair by R1’s bed anyway due to R1’s request. Staff #3 (S3), Staff #4 (S4), and the Administrator confirmed that R1 had 1-2 falls when R1 first moved into the facility, but that there have not been falls within the last month. S3 stated that R1 is alert sometimes, but also has moments of forgetfulness where R1 cannot recall events, repeats phrases, and exhibits dementia symptoms. During staff interviews, S1, S2, and Staff #5 (S5) who showered R1 on 11/16/2024 and 11/13/2024, stated they did not observe any marks or bruises on R1. Licensee and Administrator stated they were not aware of any marks or bruising on R1. However, at 3:48PM, LPA observed a 2-inch purple bruise on R1’s upper right arm with larger yellow and green hues surrounding the purple mark. LPA asked R1 about the bruise, R1 initially stated they were punched by a staff member but then stated that they do not remember where the bruise came from. LPA reviewed a body check conducted by Guardian Angel Home Health on 10/22/2024, that documented that R1 did not have any bruising. Based on interviews, record review, and observation, the Department does not have sufficient evidence to corroborate the allegation. 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 “Physical abuse by staff led resident sustaining a large bruise” is deemed UNSUBSTANTIATED at this time. No deficiencies issued. Exit interview conducted. A copy of the report provided.the state’s words, verbatim · CDSS document, Nov 18, 2024 · control 29-AS-20241115145747

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20241115145747). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation. During the visit on 11/18/2024, LPA observed Staff #1 (S1) without a criminal record exemption and Staff #2 (S2) without a criminal record clearance transfer. Licensee Brandon Jakobovich stated that S1 will submit a new livescan and obtain a criminal record exemption and that S2’s criminal record clearance will be transferred and associated to the facility. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Civil penalties were issued in the amount of $1000. Failure to correct the deficiency may result in additional civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Nov 19, 2024

87355Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement was not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as S1 did not have a criminal record exemption and S2 did not have a transfer of criminal record clearance which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2024

Plan of correction: The licensee stated that S1 will submit a new livescan by tomorrow and obtain a criminal record exemption and that S2 will be associated to the facility. Licensee will submit proof to CCL by 11/19/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:25AM. Upon arrival, LPA met with Administrator Holly Gold and explained the reason for the visit. Entrance interview conducted. Beginning at 09:32AM, the LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: The common areas include two (2) lounges, two (2) outdoor patios, dining room, activity room, beauty salon, and book nook. LPA observed required postings throughout the common area. Common areas were observed to be properly furnished with enough seating to accommodate residents and with appropriately screened fireplace. The facility maintained a comfortable temperature. LPA tested auditory exit device at 09:51AM, exits were observed to have functioning auditory devices and were operational at the time of the visit. Fire extinguishers throughout the facility were fully charged and were last serviced 04/09/2024. Fire system devices are tested annually and were last tested 06/06/2024. BEDROOMS: LPA inspected eleven (11) randomly selected bedrooms between 09:42AM – 11AM. Resident bedrooms were properly furnished with a bed, night stand, chest of drawers, closet space, and sufficient lighting for each resident. Bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 09:42AM, LPA observed stained carpets in room 1. At 09:51AM, LPA observed food crumbs and stains on the carpet in room 38. At 10:52AM, LPA observed a hole about 4 inches in size on the lower portion of the bathroom door, a broken dresser with a loose drawer that poses a safety hazard if it were to fall, and stained carpets in room 44. Administrator immediately replaced the broken dresser and will schedule a carpet shampooing. Report Continued on LIC 809 BATHROOMS: Resident bathrooms are shared between rooms with door access from each. Some bedrooms have private bathrooms that are not shared. LPA observed bathrooms in each resident bedroom to be clean and properly supplied with functional grab bars and fixtures. LPA observed pull cords by the toilet. Hot water was measured in five (5) bathrooms and was between 106.1 – 117.4 degrees Fahrenheit, which is within the required range. There are eight (8) shower rooms, however, four (4) are in use. Shower rooms were observed to be clean, sanitary, in operating condition with non-skid surfaces, and sufficiently stocked with linens and personal hygiene supplies. KITCHEN: At 10:21AM, LPA toured the kitchen. The kitchen is kept inaccessible to residents in care. Knives and sharps are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:22AM, LPA observed a dented can of tomatoes, staff discarded can immediately, and observed enchilada sauce stored in an old cottage cheese container without dates or labels. Kitchen staff stated that the enchilada sauce was made one week ago. At 10:23AM, LPA observed two (2) containers of expired Lactaid Milk (expired 09/16/2024 and 09/29/2024). Staff immediately discarded expired items. At 10:28AM, LPA observed unlabeled and undated meats stored in the freezer that were gray in color and had freezer burn. Kitchen staff stated they will go through the freezer and remove all unlabeled and undated items. MEDICATION REVIEW: LPA began medication review at 10:29AM and reviewed medications for three (3) residents. Medications are centrally stored in the medication room by the business office. Medications are prepped up to 24 hours in advance in medication cups. All medications reviewed were stored and documented per regulation. RECORDS REVIEW: Beginning at 11:14AM, LPA reviewed five (5) personnel and five (5) residents files for documents including but not limited to: resident Admission Agreement, resident physician’s report, TB test, health screening, staff training and fingerprint clearance. All five (5) personnel and resident files reviewed were in compliance with regulation at the time of the visit. Report Continued on LIC 809 INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 08/17/2024. INTERVIEWS: During today’s visit, LPA interviewed three (3) residents and three (3) staff. During today’s visit, LPA obtained a copy of the facility’s liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 1, 2024

Allegation investigated: Facility staff did not assist resident with self administered medications as prescribed Facility staff did not accurately document resident's medication administration

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 01:58PM and met with Administrator Brandon Jakobovich. Entrance interview conducted. During today's visit, LPA interviewed Administrator, conducted staff interviews 02:24PM and 02:33PM, and LPA reviewed medications for 3 (three) residents. During the initial complaint visit conducted on 04/23/2024, LPA interviewed Administrator at 01:40PM, toured the facility at 02:18PM, LPA observed Resident #1 (R1), reviewed R1's file and obtained copies of pertinent documents, and at 02:48PM, LPA reviewed medications for 3 (three) residents, including R1. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated The complaint alleges that medications for Resident #1 (R1), who has a diagnosis of dementia, are not being administered as prescribed and not documented accurately on their medication list, as reflected by inaccurate expiration dates listed on the Medication Administration Record (MAR). Interview with both Administrators indicates that R1 has resided at the facility since 2022, previously with their spouse. After their spouse passed away, R1's son became their responsible party. R1's son then did not pay the facility fees and was non-responsive to management's attempts at correspondence. Facility staff indicated they faxed requests to R1's physician for medication refills, however received response faxes indicating R1 was no longer their patient. Administrator contacted the facility's pharmacy provider for R1's medications and Administrator paid the balance on R1's account so that R1's medications would be refilled. In October 2023, Administrators contacted Adult Protective Services (APS) to file a report on R1's son, as the facility was still unable to reach him and R1 continued to accrue a balance at the facility and pharmacy. The facility contracted pharmacy continued to provide medications for R1 through the end of December 2023, after APS had assisted R1 in obtaining medical insurance through a new provider and had brought R1's medications to the facility. Interview revealed that the facility's pharmacy provides the MAR records for the residents at the facility, based on their most recent medication list provided to them. As R1 did not have a physician for some time, and even when R1 got new medical insurance and APS took R1 to the doctor, no new medication list or prescription orders were provided to the facility or the pharmacy. Interview revealed that without getting new orders or a new medication list, the pharmacy will not remove any medications from the MAR, even at the facility's request. Facility staff interviewed indicated that at no time did R1 go without medications. Medications reviewed during both facility visits revealed that the medications were documented and administered as prescribed, on both the centrally stored medication record and the MAR. Based on interview and record review, although the allegations may be valid, at this time there is insufficient evidence to support the allegations, therefore, the allegations that "Facility staff did not assist resident with self administered medications as prescribed" and "Facility staff did not accurately document resident's medication administration" are deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, May 15, 2024 · control 29-AS-20240422132222