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Allegation investigated: Staff did not meet the needs of the resident. Illegal Eviction.

Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint visit for further investigation and to deliver determinations on the allegations mentioned above. LPA met with the administrator Merlita Nepomuceno and the purpose of the visit was explained. On todays visit LPA Rios conducted further interviews with Nathan via telephone at 11:18 a.m. and interviewed Marlita again at approximately 11:40 a.m. Allegation #1: Staff did not meet the needs of the resident. It is alleged resident #1 (R1) could not feed themselves and staff did not assist. To investigate the allegation on 11/06/2020 due to the COVID-19 pandemic, LPA Shanahan meet with Nathan Nepo via Facetime. On 10/10/2023 LPA Rios met with administrator Merlita Nepomuceno at the facility and spoke with the licensee Nathan Napo via telephone. LPA Rios also interviewed staff present and attempted interviews with residents at approximately 12:40 p.m. At 3:40 p.m. LPA Rios obtained and reviewed, R1’s, Appraisal/Needs and Services Plan, Physician’s Report, Reappraisal, Unusual Incident/Injury Report and facility Progress Notes. (Continued to LIC9099-C) Unsubstantiated R1's, Physician's Report dated 03/04/2020 revealed R1 was "able to feed self", Appraisal dated 03/04/2020 reported R1 did not need help with eating. Interviews with the licensee revealed R1 had started to refuse to eat and he notified R1's family. According to the licensee, the facility had open communication with R1's family, informing them of R1's refusals. LPA reviewed facility progress notes from 03/20/2020 to 10/10/2020, notes revealed R1's refusals and the times R1's "family was made aware". According to the licensee, staff assisted R1 with eating but it was not "total care". Furthermore, interviews with the administrator and other staff revealed R1 had refused assistance for various things such as repositioning, incontinent care and eating. According to the licensee, due to residents decline in health and change in condition a Reappraisal and Appraisal/Needs and Services dated 10/07/2023 were conducted and facility noted R1 needed help with eating. R1 was transferred out of the facility on 10/10/2020. LPA Rios attempted to contact R1's family but was unsuccessful. Based on the information obtained, there was insufficient evidence to corroborate the allegation staff did not meet the needs of the resident. Therefore, the allegation is deemed Unsubstantiated at this time. Allegation #2: Illegal Eviction. It is alleged the licensee refused to take the resident #1 (R1) back on two different occasions when R1 was discharged from the hospital. To investigate the allegation LPA conducted interviews with the licensee and the administrator on 10/10/2023 and 10/17/2023. According to the licensee, R1 was never evicted. On the first occasion the facility was notified by the hospital that R1 was ready for discharge but the facility felt R1's wound was not getting better. Licensee notified R1's family, that it would be best for R1 to be in a "24/7 nursing care". Licensee states they did admit R1 back to the facility after both of R1's hospital discharges and continued to encourage R1's family to consider skilled nursing services because the facility and the wound care nurse believed R1's wound was not improving and the facility could not "address R1's current needs". According to licensee an eviction notice was not issued and unnecessary because R1's family decided to transfer R1 to "another board and care". Based on the information obtained, there was insufficient evidence to prove that R1 was Illegally Evicted. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 31-AS-20201102093332

Type of visit: Required - 1 Year

On 10/10/23 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Merlita Nepomuceno. LPA observed covid-19 signs at the front door and required postings were observed on a wall by the living area. LPA Rios explained the purpose of the visit to the administrator. At 10:20 a.m. LPA and administrator Merlita conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Cleaning products were stored in a locked cabinet under the kitchen sink. Medication stored in a locked kitchen cabinet. Bedrooms: There are four (4) bedrooms of which four (4) are designated for residents' use. Three of the bedrooms are currently occupied. Bedroom #3 is currently vacant. Rooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. LPA observed a full bed rail on resident #1's (R1's) bed. Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 10:40 a.m. and read between 105 and 120 degrees Fahrenheit. Common Areas: These included the living area and dining area. The common areas were clean and properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued to LIC809-C) The smoke alarms are battery operated and interconnected. LPA observed a carbon monoxide detector by the living area and kitchen. Staff #1 (S1) tested smoke and carbon detectors at 10:43 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen with purchase date 07/14/23. Surrounding Grounds: The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. A staff room that is maintained locked leads to the laundry room which leads to the garage. LPA observed a deep freezer with food. Detergents and cleaning products are kept in the laundry room locked. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:08 p.m. LPA's record review for resident #1 (R1), R1 had an order for a full bed rail but R1 is not terminally ill according to R1's physician's report. According to Licensee Nathan, R1 is receiving Hospice service for palliative care. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms at 12:35 p.m. Medications: At 1:43 p.m. LPA and administrator reviewed medication and medication records for proper documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit refer to LIC809-D. Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.the state’s words, verbatim · CDSS document, Oct 10, 2023

Allegation investigated: Physical Abuse

On 1/26/2023, Licensing Program Analyst (LPA) Melissa Ruiz conducted a subsequent complaint visit for the purpose of issuing the completed investigative report conducted by CCL’s Investigative Branch (IB). On 3/08/22, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s, Investigation Branch as an assignment to obtain relevant information. The complaint was accepted by CCL IB and was assigned to Investigator Lorraine Patterson. LPA met with the Administrator Nathan Nepomuceno and the purpose of the visit was explained. On 03/09/22 LPA Shanahan conducted an unannounced visit and collected relevant documents pertaining to the allegation. IB Investigator Patterson conducted file review and interviews from 03/11/20220 – 03/22/2022 with various witnesses. IB Investigator Patterson conducted a visit on 05/17/22 and during that visit, conducted interviews with two (2) residents, and the Administrator. (cont. on LIC9099-C) Unsubstantiated It is alleged that R1 sustained physical abuse while in care. Investigation revealed that on 03/04/22, R1 arrived at the facility via ambulance from R1’s former care. R1’s son was also present during R1’s admission. An interview conducted with facility Administrator on 5/17/2022, revealed that R1 did not have a fall or incident on the day of their arrival. An interview with R1’s son on 3/22/2022, revealed that he was there when R1 was transported to the facility via gurney. R1’s son stated he did not observe R1 to be in any pain, nor did R1 report any pain. R1’s son stated he does not believe R1 sustained any physical abuse at the facility but was injured during transport from R1’s former care to the facility. An interview with medical personnel, revealed that they could not assess where R1’s bruising came from, but that it “could be considered consistent with being held or moved” in a “bear hug”. Interviews conducted with two (2) residents on 5/17/2022, revealed that both residents feel same and comfortable living at this facility. Both deny seeing or experiencing any abuse or neglect. Record review revealed that staff documented various observations dated from 3/4/2022 – 3/8/2022 regarding R1. On 3/4/2022, staff documented R1’s arrival via gurney and noted, “There is redness on the right upper quadrant/ and under the breast.” On 3/05/2022, staff noted that R1 had bruising in the abdomen, at the same place where the redness was observed on 3/4/2022. On 3/7/2022, staff noted that the abdominal bruising was extended to R1’s breast/chest area. R1’s son was notified and R1’s physician was called, to which R1’s physician instructed staff to send R1 to the Emergency Department. Staff called 911, and R1 was transported to AV Hospital. On 3/8/2022, staff documented R1’s discharge from AV Hospital, and staff annotated “no significant findings”. Record review also revealed that there was a LASD police report, to which showed that Deputies arrived at AV Hospital on 3/8/2022. Police report reflects that a Deputy spoke to R1, to which R1 stated that they believed that being picked up and moved caused their injuries. Deputies were unable to determine if a crime occurred. Due to a lack of supporting evidence and interviews, the allegation that resident sustained physical abuse is unsubstantiated at this time. No deficiencies issued. Exit interview conducted. Report signed and delivered. Appeal rights delivered.the state’s words, verbatim · CDSS document, Jan 26, 2023 · control 31-AS-20220308110716

Type of visit: Required - 1 Year

On 9/29/22 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Merlita Nepomuceno. LPA observed covid-19 signage, hand sanitizer, PPE supplies and a visitor sign in log. LPA was asked by staff to sign in using the infection prevention sign in log. The purpose of the visit was explained and an entrance interview was conducted. LPA initiated a physical plant tour at 12:15 a.m., Facility is a Residential Care Facility for the Elderly which was licensed for 6 residents, five (5) non-ambulatory, of which one (1) may be bedridden. Facility has been approved for a hospice waiver for six (6). LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 6/23/2022. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a temperature of 76 degrees Fahrenheit. LPA observed there to be sufficient stock of one week non-perishable foods and two day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water. No deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.the state’s words, verbatim · CDSS document, Sep 29, 2022

Type of visit: Required - 1 Year

At 10:00 am, Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff (S1) who granted access to the home and later met with licensee Jonathan Nepomuceno. This is a 5-bedroom, 2-bathroom single story residential care facility for the elderly. A physical tour was conducted at 10:20 am and observed the following: Infection control: Proper signage was observed outside the home and along the main entrance of the facility. Upon entrance, staff took LPA's temperature and was asked to sign-in the visitor’s log but was not asked any infection control questions. Hand sanitizer was available, and all trash cans were observed to have closed tight fitting lids. Sufficient PPE supplies were observed. LPA reminded licensee to review their mitigation plan with all staff to ensure all visitors are thoroughly screened upon entry. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps, cleaning supplies and medications are centrally stored in a locked cabinet in the kitchen. Smoke detectors/carbon monoxide were located throughout the facility. At 10:45 am, they were tested and are functional. Facility maintains a comfortable temperature of 76.0 F. Resident rooms: There are four (4) bedrooms designated for resident use, one (1) bedroom is designated for live-in staff. All bedrooms are properly furnished, cleaned and have appropriate bedding and linens. Bathrooms: The hot water temperature measured at 108.8 F. Towels and washcloths are not shared. The garage is attached to the home and is used for storage, and a laundry area. Extra towels and linens were readily available. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water. No deficiencies cited. An exit interview was conducted. A copy of this report was provided. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 8, 2021