Aasta Assisted Living

Allegation investigated: Facilty staff did not administer medications to resident as prescribed The licensee did not provide assistance needed to meet the resident's home health needs Licensee did not allow resident's chosen third-party provider to provide services to the resident Facility is understaffed

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived at the facility unannounced to conduct subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPAs initially met with front desk staff. Executive Director (ED) Monica Reyes was contacted and arrived at the facility at approximately 10:50AM. Entrance interview conducted. During an initial complaint visit conducted on 04/05/2023, LPA Dulek interviewed ED over the phone at 01:00PM, LPA interviewed staff at 01:14PM, 01:22PM, and 02:45PM, LPA reviewed medications for Resident #1 (R1) at 01:45PM, and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA interviewed additional staff and reviewed copies of pertinent documents. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Facility staff did not administer medications to resident as prescribed:” The complaint alleges that Resident #1 (R1) requested PRN medication on 03/26/2023 in the evening, but was never administered the PRN (as needed) medication requested. LPA reviewed medication logs for R1, which indicate PRN pain medication was administered in the morning of 03/26/2023, but not the evening/night. The log indicated that R1 was administered their PRN pain medication 15 (fifteen) times during the month of March 2023. LPA was unable to interview R1, as R1 was agitated and refused interview during the LPA’s visit at the facility and LPA did not receive a response by telephone. So LPA could not confirm whether there were additional times the medication was requested and not administered. Staff interviewed indicated that residents can request PRN medication at any time of the day or night and there is always a medication technician on shift to administer the medication to the resident. The medication technician then records the medication on the electronic MAR as administered. The only exception is if it’s too close to the time the resident had taken a previous dose of the PRN medication. Staff interviewed indicate that R1 does call often for PRN medication and that the doses are administered. Based on interview and record review, 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 staff did not administer medications to resident as prescribed” is deemed UNSUBSTANTIATED at this time. Allegation: “The licensee did not provide assistance needed to meet the resident’s home health needs:” It was alleged that R1 had orders for physical therapy, which included daily walks with facility staff, but that facility staff were not walking with R1. LPA interviewed staff, who indicated that they walk with R1 once daily, typically to the dining room. Staff indicated there is a log in R1’s room where they can mark daily walks with R1. During the initial complaint visit, LPA asked R1 where the log was and R1 indicated they had thrown it away. Staff interview revealed that R1 frequently refused to participate in walking exercises, likely due to pain R1 reported experiencing. As LPA was unable to interview R1, LPA was unable to confirm whether walking exercises were offered to R1 and they were refused or if exercises were not offered. Based on interview and record review, 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 “the licensee did not provide assistance needed to meet the resident’s home health needs” is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C (p.3) Allegation: “Licensee did not allow resident's chosen third-party provider to provide services to the resident:” It was alleged that R1’s home health provider was changed and R1’s preferred provider was not allowed to continue providing services. Record review revealed that R1 was with one home health provider prior to R1’s hospitalization and when R1 was re-admitted to home health services that R1 was placed with Aasta’s preferred home health provider rather than the previous provider. Reporting party indicated that it was the facility who changed R1’s provider. Interview with facility management revealed that upon discharge from the hospital that the previous provider did not receive home health orders for R1 to resume services and that the provider changed due to the hospital discharge orders. Upon request, R1’s provider changed back to the previous provider shortly after. Documents reviewed indicated R1 was discharged from their preferred provider on 03/22/2023 and readmitted back to their preferred provider on 03/27/2023. LPA was unable to discuss the allegation with R1. Based on interview and record review, 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 “Licensee did not allow resident’s chosen third-party provider to provide services to the resident” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility is understaffed:” The reporting party stated that they believe the facility is understaffed, but no additional information was provided. LPA interviewed staff and reviewed staff schedules. Staff interviewed indicated that during the day there are sufficient amounts of care staff and activity staff present at the facility, as well as medication technicians, cleaning staff, dining staff and other various administration staff. Staff stated that there are call outs, but typically a staff will stay and work later or management staff will cover the shift. Residents interviewed felt their needs were met timely and that there is a sufficient number of staff. Based on interview and observation, 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 understaffed” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 29-AS-20230330150348

Allegation investigated: Resident is left soiled for an extended period of time Resident has missed meals due to staff neglect Staff do not clean resident's room timely Staff do not put resident's call button in a place accessible to resident

Licensing Program Analysts (LPAs) Kelly Dulek and Valeria Conway arrived at the facility unannounced to conduct subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPA initially met with front desk staff. Executive Director (ED) Monica Reyes was contacted and arrived at the facility at approximately 10:50AM. Entrance interview conducted. During an initial complaint inspection on 06/01/2023, LPA Dulek interviewed Licensee and ED at 12:35PM, LPA toured the facility along with ED at 12:51PM, interviewed staff between 1:09PM and 02:43PM, and LPA reviewed and obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all pertinent documents, attempted to interview Resident #1 (R1) telephonically, and interviewed other relevant parties. The following was then determined: Report Continued on LIC9099-C Unsubstantiated Allegation: “Resident is left soiled for an extended period of time:” The complaint alleges that R1 was not changed regularly. Review of R1’s physician’s report indicates that R1 does not have a bowel or bladder impairment, but that R1 is unable to care for their own toileting needs. The needs and service appraisal provided to LPA was incomplete and missing the pages related to incontinence care and assistance with toileting. Staff interviewed indicated that R1 requires assistance getting to the toilet and assist in changing R1’s briefs if needed by putting the briefs at R1’s ankles for R1 to pull up on their own. R1 utilizes the call light system when R1 requires toileting assistance. Staff stated that R1 regularly uses the call light and staff respond accordingly to assist R1. At the time of the initial complaint visit, R1 was hospitalized, and Administrator indicated that R1 only returned to the facility for a day or two prior to moving out of the facility. LPA attempted to reach R1 via telephone but LPA was unsuccessful. During an unrelated complaint visit on 04/05/2023, LPA observed staff assisting R1 in the restroom during the visit. Other residents interviewed felt their incontinence needs are being met and staff assist with toileting. 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 “resident is left soiled for an extended period of time” is deemed UNSUBSTANTIATED at this time. Allegation: “Resident has missed meals due to staff neglect:” LPA conducted interviews with staff and residents related to this allegation. Staff indicated that R1 used to consistently go to the dining room for all meals. Recently, R1 has been experiencing pain and does not wish to get out of bed in the morning to go to the dining room during breakfast hours. Staff stated they are bringing R1 room trays for breakfast for the last 2 (two) weeks or so instead. Care staff interviewed indicated kitchen staff prepare the trays, then the care staff bring R1 their room tray and they are not aware of a time when R1 did not get fed. Staff interviews revealed that R1 prefers hot breakfast, which is difficult as R1 does not get out of bed to eat until 10:00AM or 11:00AM and that breakfast is served at 07:00AM. Staff stated they bring oatmeal and juice to R1 and if R1 prefers a different choice, they will return to the kitchen and ask for an alternative. According to staff, R1 chooses not to eat lunch sometimes, per their preference. R1 reportedly told staff that they prefer to eat breakfast in the late morning, then they eat dinner in the dining room, with just a light snack in between when hungry. Staff indicated that when dining staff did not see a resident in the dining room, they prepare snacks for that resident, in case they were needed. LPA was Report Continued on LIC 9099-C (p. 3) unable to speak with R1, however, other residents interviewed indicated they receive all their meals and haven’t had problems related to obtaining food. 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 “resident has missed meals due to staff neglect” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not clean resident room timely:” The complaint alleges that R1’s room is left dirty and housekeeping is not provided regularly. R1’s needs and service appraisal indicates “daily housekeeping, deep cleaning once weekly.” During all of LPA’s facility visits, LPA has observed housekeeping staff with their carts tending to resident rooms. Interview with staff revealed that dedicated housekeeping staff clean each resident’s room daily, including making their bed, tidying the room up, and taking trash. Care staff assist with cleaning resident rooms, as time allows. Weekly, a deep clean is done on each room, per their schedule. Deep cleans include washing and changing resident sheets, cleaning the bathroom, vacuuming, dusting, mopping the floors and anything else needed. LPA observed R1’s room to be neat and tidy with no housekeeping concerns. Based on interview and observation, 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 “staff do not clean resident room timely” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff do not put resident’s call button in a place accessible to resident:” LPA interviewed staff and residents related to the facility’s pull cord system and response time. The facility contains a pull cord system; each resident room has one cord in the bed area/living space of the room and a second pull cord in the resident bathroom. When a resident pulls the cord, a light illuminates outside the resident room and on a switch boards located at the front desk and in the medication room. Interview with staff revealed there are some residents who have a hard time locating their pull cords in the event of an emergency, particularly at night. The cords are long and when a resident has the cord on their bed and are restless at night, the cord may fall on the ground. When staff come by to check on a resident, staff stated they check to ensure the resident’s pull cord is in an easily accessible location. LPA observed the pull cords in both R1’s bedroom area and in R1’s bathroom. The cord in R1’s bedroom is long and was observed to be on R1’s bed at the time of LPA’s visit. The cord in the bathroom area is shorter, but was observed to be accessible while in the bathroom near the toilet area. Residents interviewed indicated sometimes their pull Report Continued on LIC 9099-C (p.4) cord falls down, but that staff have been helpful in attaching a longer cord or trying to put the cord in a place that it is less likely to fall. Based on interview and observation, 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 “staff do not put resident’s call button in a place accessible to resident” is 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, Sep 26, 2024 · control 29-AS-20230524122929

Allegation investigated: Staff did not give resident medication as prescribed Staff did not address a change in residents’ condition

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPA initially met with front desk staff. Executive Director, Monica Reyes, was contacted and arrived at the facility at approximately 10:50 A.M. and explained the reason for the visit. Entrance interview conducted. On 08/12/2024, from 9:30 A.M. – 3:15 P.M., LPAs initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPAs toured the physical plant, interviewed staff, residents, resident Responsible Party (RP) and reviewed and obtained pertinent documents relevant to the investigation. It was reported that “Staff did not give resident medication as prescribed” as it was alleged that staff did not obtain the prescribed medication for Resident #1 (R1). Conitnued on LIC 9099-C Substantiated Continued from LIC 9099 Information gathered during the course of the investigation revealed that R1 resided at this facility from 06/24/2024 to 07/31/2024. On 08/02/2024, R1’s RP noticed a changed in condition and transported R1 to the hospital. The Centrally Stored Medication and Destruction Record (CSMDR) for R1 obtained and reviewed, reflected that R1 was prescribed Olanzapine once a day beginning in May 2024; however, the “Date Started” column was left incomplete by the facility as of 08/12/2024. Interview with Resident Care Coordinator revealed that the facility only assists with self-administration of medications based on the medication list signed by the physician and not what a resident brings during admission. LPAs reviewed R1 facility file and did not find a list of medication signed by any physician. Furthermore, LPAs requested Resident Care Coordinator and Med-Tech to provide a copy of the list of medication signed by R1’s physician, however neither the Resident Care Coordinator nor the Med-Tech on duty were able provide such document. Based on information gathered during the course of the investigation, there is sufficient evidence to determine that R1 was not assisted with self-administration of medication. Therefore, the above allegation “Staff did not give resident medication as prescribed” is deemed SUBSTANTIATED at this time. It was also alleged that staff did not address a change in residents’ condition. It was reported R1’s Private Caregiver noticed blood in R1s underwear on 07/15/2024 and on 07/19/2024; however, the facility did not make any efforts to obtain any medical attention for R1 even after being notified. Information gathered reflected that R1's PC observed blood on R1’s underwear on 07/15/2024 and notified both the facility staff and R1’s RP. Additionally, R1 was also displaying mood changes such as agitation and distress. However, there is no documentation to support that the facility contacted R1’s Primary Care Physician (PCP) or attempted to obtain R1 any medical services. On 07/19/2024, after observing blood in R1’s underwear again, R1’s RP contacted Kaiser and R1 was diagnosed with a Urinary Tract Infection (UTI). Continued on LIC 9099-C Continued from LIC 9099-C LPAs interview with administrator revealed that administrator could not recall the incident occurring. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that “Staff did not address a change in residents’ condition” has been SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed, and a copy of report issued. Continued from LIC 9099 It was reported that "Staff did not safeguard residents' personal items". The RP's concern is that R1’s personal items have gone missing from their room. A file review revealed that the Client/Resident Personal Property and Valuables form (LIC621) which is use to itemize R1’s personal belongings, did not list the missing item. Furthermore, R1 never notified and/or divulged information to facility management and/or staff about updating or adding items to R1's LIC 621 since being admitted to the facility. As a result, there is no documented record of what personal property may have been present in R1’s room during the time of the alleged loss. Interview with staff revealed that staff will follow protocol, notifying the administrator immediately. Interviews with the administrator indicates that staff, residents, and sometimes responsible parties, do inform if an item goes missing. When this occurs, the staff will assist in searching for the missing item(s). Although the allegation may have happened or is valid, based on the interviews 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 citation issued. Exit interview conducted, and a copy of report issued.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 29-AS-20240807114227

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 10, 2024

87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being given to R1 which posed an immediate health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee will review requirements of this section and provide a written statement outlining their understanding of the requirements to CCL by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 10, 2024

87466The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...When changes such as unusual...physical health condition...responsible person, if any. This requirement was not met as evidenced by: Based on interviews, and records review Licensee/Administrator did not obtain timely medical attention for R1 which posed an immediate health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Administrator stated that she will submit a plan on how to ensure staff monitor residents for any change in condition and ensure that arrangement of medical care is proper and submit a plan of staff training regarding above regulation. Submit to CCL before POC due date.

Allegation investigated: Staff prohibiting resident from leaving the facility for visits Facility restricted visitation

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek conducted an unannounced 10-day visit complaint o the facility regarding the above noted allegations. LPAs met with Administrator Monica Reyes and explained the reason for the visit. During today's inspection, between 11:00 a.m. and 2:00 p.m., the LPA briefly toured the facility with the administrator, interviewed the Administrator, residents, caregivers and ombudsman. Additionally, LPAs conducted a file review, and obtained copies of pertinent documents relevant to the investigation. It was alleged that the staff prohibited resident from leaving the facility for visits of their choosing, it is the concern of the reporting party that Resident #1’s (R1’s) personal rights are being violated. Interview with R1 revealed Administrator told R1 that R1 couldn’t leave the facility. Staff interviews revealed that Administrator stated that R1 can only leave the community with one specific family member. Continued on LIC 9099-C Substantiated Continued LIC 9099 It was alleged that the facility restricted visitation by not allowing R1’s visitor to enter the facility. Reporting party indicated that R1’s visitor arrived at the facility and facility staff did not allow the visitor entry, both during visiting hours and after hours. It is the concern of the reporting party that facility’s visitation hours are very strict and not flexible. Based on interview and record review it was observed that facility has a “verbal” visiting hours of 8:30 a.m. to 5:00 p.m. Admission agreement does not show what are visitation hours for the facility nor is the facility’s visitation policy posted. Staff interviews conducted revealed that on 09/03/2024, there was a conversation between Administrator and staff where Administrator told employees not to allow R1 to have visitors after hours. Administrator stated that after hours visitations must be approved prior to loved ones coming to visit any residents. Staff interview revealed that a resident can allow entry to a visitor after hours. On 09/09/2024 R1 had an after hours visitor, however facility staff did not inform R1 of the visitor’s arrival and staff did not allow entry until a third party intervened. Based on the information obtained, the allegations are deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Exit interview. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 11, 2024 · control 29-AS-20240909154531

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 25, 2024

87468.1(a)(6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on interviews and record review, the Administrator did not comply with the section cited above when staff was told not to allow R1 to leave the community with one specific family member, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Administrator agrees to submit a statement of understanding on regulation 87468.1(a)(6) and get staff trained by a third party on personal rigths by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(21) · Plan of correction due date: Sep 25, 2024

87468.2(a)(21)To consent to have their relatives and other individuals of their choosing visit during reasonable hours, privately, and without prior notice. This requirement is not met as evidenced by: Based on interviews and record review, the Administrator did not comply with the section cited above when staff did not allow visiitors during reasonalble hours, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Administrator agrees to submit a statement of understanding on regulation 87468.2(a)(21) and post visitation hours around the facility's common areas. POC due date.

Allegation investigated: Staff did not prevent residents from wandering away from the facility Staff do not respond to residents call for assistance in a timely manner Staff do not ensure that residents are adequately fed

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met briefly with Administrator Monica Reyes but she had to leave for an appointment. LPA was assisted by the Resident Care Coordinator (RCC) Esmeralda Elizarraraz. LPA explained the reason for the visit. During today's visit, 8/16/2024, LPA conducted interviews with nine (9) residents starting at 12:52 p.m. On 7/8/2024, LPA had conducted interviews with administrator starting at 10:42 a.m., interviews with multiple staff starting at 11:38 a.m., record review starting at 2:50 p.m., and interviewed one resident starting at 3:14 p.m. Regarding the allegation: Staff did not prevent residents from wandering away from the facility. The complaint indicated there were two elopements on Saturday, 6/29/2024. LPA interviewed staff who worked that day. Nobody was aware of any elopements. The staff in memory care denied that any memory (continued on LIC9099C) Unsubstantiated (continued from LIC9099) care resident left the facility. Staff stated the assisted living resident who allegedly eloped can actually leave the facility without supervision. LPA spoke with that resident, resident 1 (R1). R1 stated they enjoy walking outside of the facility. They do not go far, usually they just walk around the perimeter of the facility. R1 recalled being asked by staff not to go in the area next to the barranca so they avoid that area now. LPA confirmed on R1's physician's report they could leave without assistance. Based on interviews and record review, this allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff do not respond to residents call for assistance in a timely manner. LPA interviewed a total of ten (10) residents. Residents stated staff usually respond to their calls for assistance within ten (10) minutes or less. A couple residents indicated they have had to wait up to twenty (20) minutes during busy times in the morning when everyone is waking up. None of the residents were concerned about wait times for assistance. Some residents voiced concern that the facility could use more staff sometimes but they personally did not feel neglected nor did they feel they had to wait for too long. The staff who were interviewed by LPA all indicated they try to respond to any calls for assistance immediately or within ten (10) minutes. Based on interviews, this allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff do not ensure that residents are adequately fed. LPA interviewed a total of ten (10) residents. All residents indicated they like the food and they get plenty of food. They can have second helpings of food too. All the residents stated if they do not like what is being served they can ask for another option such as a burger, sandwich, veggie burger, quesadilla, etc. All the residents stated if they were not able to make it to a mealtime, for example if they left for an appointment and returned after the lunch period, they can still get something to eat. They can request the meal be set aside or they can just ask for a sandwich or something like that upon their return. They can also just request a snack, such as yogurt. Staff who were interviewed by LPA also stated meals are set aside in the refrigerator and heated up if a resident does not want to eat during the mealtime. They also provide residents with sandwich options or other snacks. Based on interviews, this allegation is deemed Unsubstantiated at this time. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 29-AS-20240701105839

Allegation investigated: Staff are making inappropriate comments towards residents

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit regarding the above noted allegation. LPA met with Resident Care Coordiantor (RCC) Esmeralda Saucedo Elizarraraz and explained the reason for the visit. The Administrator was out of the facility during LPA's visit. At 2:33 p.m. LPA conducted an interview with RCC. At 2:50 p.m. LPA conducted a telephone interview with Administrator Monica Reyes. At 3:00 p.m. LPA reviewed pertinent records. At 3:15 p.m. LPA conducted an interview with Resident 1 (R1). (continued on LIC9099-C) Unsubstantiated (continued from LIC9099) During the interviews with LPA, the Administrator and RCC denied making any inappropriate comments toward R1. There have been discussions with R1 regarding incontinence care and R1's rights regarding such care. R1 indicated they did not have any complaints. They denied being spoken to in a rude or inappropriate manner by staff. R1 stated "Everything's ok." They stated they get assistance with the care they require. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 29, 2024 · control 29-AS-20240523090009

Allegation investigated: Staff did not treat resident with dignity or respect.

Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA was greeted by the administrator Monica Reyes and LPA explained the reason for the visit. At 12:33 LPA interviewed the administrator. At 12:51 LPA reviewed records for resident 1 (R1). At 1:28 p.m. LPA interviewed R1. At 1:47 p.m. LPA interviewed staff 1 (S1). The complaint indicated R1 had gone to the front desk to have documents faxed but the staff treated R1 disrespecfully when the resident requested a fax confirmation sheet. However, R1 is not physically capable of going to the front dest on their own and chooses to stay in their room unless they must leave for an appointment. R1 takes all their meals in their room. R1 communicated to LPA that was not what happened. R1 stated it was "not a major issue" and did not wish to pursue this complaint. (continued on LIC9099-C) Unsubstantiated (continued from LIC9099) During the interview with S1, they were not aware of R1 needing to fax any documents recently but recalled approximately one month ago R1 needed to fax documents but did not have the fax number. S1 stated they never laughed at R1 or made fun of them. S1 told R1 they would hold the documents and give them to their conservator when the conservator visited. Neither the administrator or S1 witnessed any staff treat R1 with disrespect. The administrator stated approximately three weeks ago they had a meeting with R1, staff and R1's conservator to ensure that R1's concerns about certain staff were addressed. The administrator stated they have gone out of their accommodate R1's needs and wishes. Based on the interview with R1, this complaint was not correct and R1 did not wish to pursue the complaint. Therefore, the allegation staff did not treat resident with dignity and respect is deemed unsubstantiated at this time. No deficiencies observed. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 14, 2024 · control 29-AS-20240509154156

Allegation investigated: Neglect/Lack of Care and Supervision - the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury.

Licensing Program Analysts (LPAs) Martha Arroyo and Kelly Dulek conducted a subsequent complaint visit to deliver findings for the above allegation. LPAs met with Administrator, Monica Reyes and explained the reason for the visit. On 01/25/2023, the Department received a complaint regarding an allegation of Neglect/Lack of Supervision. It was alleged that the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury. The complaint was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Douglas Real. On 01/26/2023, from 1:30 p.m. to 3:45 p.m., Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced initial complaint inspection for the allegation listed above. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... LPA Dulek met with the Administrator Monica Reyes and explained the reason for the visit. The LPA interviewed the Administrator at 1:30 p.m., and at various times throughout the visit. The LPA toured the facility with the Administrator at 1:50 p.m. and gathered copies of pertinent documents. No immediate health and safety concerns were identified during the facility tour. On 01/28/2023, Investigator Real conducted interviews with R1’s resident representative; on 02/13/2023, from around 1:00 p.m. to 4:00 p.m., with a hospice employee and facility employees; on 02/14/2023, at around 11:00 a.m., with Witness #1 (W1); on 03/14/2023, from around 10:00 a.m. to 11:00 a.m., with facility employees; on 04/10/2023 and 04/11/2023, from around 2:25 p.m. to 2:30 p.m., with facility residents; and on 04/23/2023, at around 2:42 p.m., with a hospice nurse. In addition, Investigator Real reviewed Physicians Preferred Hospice records, 01/24/2023 video camera footage of R1’s bedroom at the facility, R1’s Physician Report, and other case-related documents. The case was also referred to the Departments Program Clinical Consultant (PCC) for review. A review of R1’s Physician Report, dated 08/22/2022, indicated the primary diagnosis was metastatic breast cancer and secondary diagnosis was listed as back pain. R1’s health status was listed as poor and R1 was identified as confused and disoriented. On 08/25/2022, R1 was placed on hospice care with Physicians Preferred Hospice and had an order for oxygen as needed (PRN). On 10/01/2022, R1 was admitted to the facility. The video camera footage reviewed of R1’s room on 01/24/2023 revealed a med tech placed an oxygen tank next to R1’s bed and attached R1 to the tank via nose tube at around 9:16 a.m. The med tech checked on R1 later, around 10:40 a.m. and again at 11:35 a.m. No further checks by the med tech were done. Throughout the day various caregivers checked on R1. However, none of the caregivers nor the PM med tech checked on R1’s oxygen tank level until around 6:56 p.m. Continued on LIC 9099C... Continued from LIC 9099C... The video footage further revealed a med tech checked on R1 at 6:00 p.m. at which point it appeared the tank was discovered to be empty. At around 6:45 p.m., the video shows R1’s resident representative checked the oxygen tank and replaced the tank with another machine around 7:00 p.m. According to information obtained from Investigator Real’s interviews, R1’s resident representative felt R1 suffered brain damage because the oxygen had run out in the oxygen tank. However, records reviewed did not reflect a medical diagnosis of R1 suffering brain damage. The hospice employees reported R1 was on hospice and R1’s health had declined to the point they began using supplemental oxygen as a comfort care measure. The hospice staff had no abuse or neglect concerns regarding the facility employees. W1 regularly visited R1 in the facility and had no abuse or neglect concerns and did not believe R1 suffered any brain damage due to the oxygen tank running out. PCC review reflected that per facility staff and hospice nurses, the resident was not observed to be deprived of oxygen beyond slight shortness of breath as her baseline, there was no evidence that indicated the resident lost consciousness during that period, the lack of oxygen did not result in serious injury that meets the definition of Serious Bodily Injury as defined in Section 15610.67 of the Welfare and Institutions Code. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore the allegation “Neglect/Lack of Care and Supervision - the facility staff did not ensure Resident #1 (R1) had oxygen resulting in brain injury” is deemed Unsubstantiated at this time. Citations for violations unrelated to the complaint allegation will be cited on a separate report. Exit interview. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 29-AS-20230125131322

Allegation investigated: Facility did not assist resident with obtaining medical care Facility staff did not assist resident with administering medications as prescribed

Licensing Program Analysts (LPAs) Kelly Dulek and Martha Arroyo conducted a subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPAs met with Monica Reyes at 02:16PM. Entrance interview conducted. During the initial complaint visit conducted on 01/12/2023, LPA interviewed Administrator at 09:50AM and at various times throughout the visit, toured the facility with Administrator at 11:08AM, interviewed staff at 11:21AM, 12:42PM, and 01:04PM. LPA also gathered copies of pertinent documents. A referral was made to CCLD’s Investigations Branch (IB), was accepted for investigation, and assigned to IB investigator Douglas Real. Investigator Real received and reviewed a copy of Resident #1 (R1)’s hospital records and conducted either telephonic or in-person interviews with facility staff, residents and other pertinent parties on the following dates: 02/09/2023, 02/13/2023, 04/10/2023, and 04/11/2023. The following was then determined: Report Continued on LIC 9099-C Substantiated The complaint alleges that the facility staff did not assist Resident #1 (R1) in obtaining medical care nor did the facility assist the resident with self-administration of prescribed medications, both of which led to R1’s worsening medical conditions and subsequent hospitalization. Record review revealed that R1 had an extensive medical history, however R1’s medical conditions were managed through use of prescribed medications. Interviews revealed that R1, among many other residents, use the facility-contracted pharmacy provider. Around October 2022, the facility began to change contracted pharmacy providers to Concierge RX Pharmacy. The new pharmacy had a policy requiring residents to keep a card on file for all potential payments. R1 was one of approximately 8 (eight) residents who did not have a card on file. Interviews revealed that the pharmacy contacted these residents and/or their responsible parties to rectify the payment situation, and all residents’ payments except for R1’s were resolved. Interviews also revealed that the pharmacy attempted to contact R1’s brother, however, it was confirmed R1 was their own responsible party. It is unclear why R1’s brother was contacted, but interviews revealed facility staff did not directly assist the resident in rectifying the payment method. Beginning in November 2022, Concierge RX Pharmacy filled medication orders for residents residing at Aasta Assisted Living, including R1. However, R1 still did not have a credit card to keep on file, so the pharmacy did not deliver R1’s medications for December 2022. Facility staff indicated they sent faxes to R1’s primary care physician to inform the medical provider that R1 had not received their medications, however the facility’s fax machine did not provide confirmation the faxes were sent nor received. Interview with R1’s primary medical care provider revealed the facility staff never contacted the physician via telephone and no faxes were received at the medical office. R1’s physician was unaware R1 had not received medication in December 2022. Review of R1’s Medication Administration Record (MAR) revealed that R1’s MAR was marked as “med not available” on 12/01/2022, but was initialed as administered on 12/02/2022 and the entry for 12/03/2022 was empty. Interview revealed that R1’s MAR was incorrectly marked and R1 did not have any medications on any date in December 2022. By 12/22/2022, it was observed that R1 wasn’t feeling well and was experiencing shortness of breath. On this date, facility staff offered to take R1 to the bank to request a debit card, however R1 wasn’t feeling well and declined an outing to the bank. Although R1 was experiencing shortness of breath and difficulty breathing, facility staff did not call 9-1-1 nor was additional medical care requested for R1. On 12/23/2022, facility staff did take R1 to the bank to order a debit card, however, at this point R1 had already been without medication for 23 days since 12/01/2022. Over the next week, R1’s difficulty breathing worsened and on 12/31/2022, Report Continued on LIC-9099-C 9-1-1 was called. R1 was admitted to the hospital on the same day and noted to be severely hypoxic – with fluid in their lungs. Medical professionals indicated that R1’s shortness of breath and difficulty breathing were likely caused by a buildup of fluid in R1’s lungs. R1 was previously prescribed medications to prevent buildup of fluid in their lungs, but this medication was not provided to R1 from 12/01/2022 to the date of R1’s hospitalization on 12/31/2022. R1, who used the facility-contracted pharmacy, relied on the facility to obtain and provide medications and the facility staff failed to do either. None of the staff attempted to notify R1’s physician by telephone nor did any staff attempt to get the resident’s prescription medications at a different pharmacy. Although the Admission Agreement, signed by R1 on 07/18/2021, indicates that “I authorize the Community to place an emergency order for medication(s) that has not been timely provided by me or my pharmacy,” at no time in December did the facility staff place an emergency order for R1’s medications. Interviews with facility staff confirmed their efforts to assist R1 in obtaining their medications were insufficient. Based on interview and record review, there is sufficient evidence to support the allegations, therefore, the allegations “facility staff did not assist resident in obtaining medical care” and “facility staff did not assist resident with administering medications as prescribed” are deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). A $1000 immediate repeat civil penalty for the citation related to CCR 87464(f)(1) is assessed today. Another $250 civil penalty is assessed for the citation related to CCR 87465(a)(4) for a repeat violation. The Administrator Monica Reyes was informed that additional civil penalties might be assessed based on health and safety code 1569.49(f). Exit interview conducted. A copy of the report and appeal rights were provided. The complaint alleges that R1 died as a result of neglect and/or lack of care and supervision, as R1 did not receive their medications, nor did the facility staff assist R1 in obtaining medical care. Record review revealed that R1 had an extensive medical history, however R1’s medical conditions were managed through use of prescribed medications. Record review and interview revealed that R1 did not receive their medications in the month of December 2022 due to the facility’s contracted pharmacy requiring a specific payment method, which R1 did not have access to. R1 was observed on 12/22/2022 to be experiencing shortness of breath and trouble breathing. Over the next 9 days, R1’s condition worsened, resulting in facility staff calling 9-1-1 on 12/31/2022 due to R1’s trouble breathing. R1 was admitted to the hospital the same day due to progressively worsening shortness of breath. R1 was severely hypoxic on transfer to the hospital. A chest x-ray was done and the findings indicated bilateral lung infiltrates (right greater than left) and moderate right pleural effusion. Upon admit to the hospital, R1 was treated with aggressive diuresis, but did not respond well and had worsening azotemia (according to WebMD, azotemia is a buildup of blood urea nitrogen and creatine in the blood.) R1 had consultations with cardiology and pulmonary and initially agreed to undergo further cardiac work-up but changed their mind and decided to be on palliative care. R1 began palliative care on 01/04/2023. R1 passed away at the hospital on 01/07/2023. R1’s cause of death was listed as acute diastolic congestive heart failure secondary to critical aortic stenosis. Other causes were listed as urinary tract infection, hypertension and coronary artery disease. Although R1 was prescribed medication to prevent buildup of fluid in R1’s lungs which is caused by R1’s chronic heart failure, R1’s physician, when interviewed, would not speculate if R1’s death was caused by not getting their medication in December. Based on interview and record review, although the allegation may be valid, but at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Neglect/Lack of Care & Supervision – questionable death” is deemed UNSUBSTANTIATED at this time. No citations issued related to this allegation. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 29-AS-20230110153850

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 25, 2024

87464(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 and record review, the licensee did not comply with the above cited section, as facility staff did not assist R1 in rectifying the payment issue with the facility-contracted pharmacy nor assist R1 in obtaining medical care which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administrator agreed to submit a plan on how the facility will ensure residents' basic services will be met and provide proof to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 25, 2024

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 facility staff did not assist R1 in obtaining their medications, so no prescribed medications were available to administer for the month of December 2022, which posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administrator agreed to provide an inservice with an alternate outside vendor. The training will be scheduled and Administrator will provide proof of the scheduled training by POC due date. Following the training, Administrator will send proof of completion to CCL.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Martha Arroyo and Kelly Dulek conducted an unannounced Case Management Deficiency visit in conjunction with complaint visit (CC#29-AS-20230125131322). Upon arrival, LPAs met with Administrator, Monica Reyes. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Based on the review of the medical records, DSS investigative findings, and other miscellaneous documents, the facility AM med tech placed R1 on supplemental oxygen via a portable oxygen tank (PRN) on 01/24/2023 around 9:15 a.m. The facility employee last checked on R1 around 11:30 a.m. and no one checked on R1’s oxygen tank level or oxygen saturation level until around 6:50 p.m. In addition, it appears a lack of communication between facility employees resulted in the AM and PM caregivers not knowing who placed R1 on oxygen. The PM med tech failed to regularly monitor R1’s oxygen and oxygen tank level. Numerous facility employees checked on R1 throughout the day and attended to R1’s other needs but failed to address R1’s oxygen needs or change out the empty oxygen tank. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 25, 2024

Additional Personal Rights of Residents in Privately Operated Facilities. 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 evidence by: Based on interview, and record review, the licensee did not comply with the section above, as facility staff failed to regularly monitor R1’s oxygen and oxygen tank level, which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The Administrator will review Regulation 87468.2 and submit a plan on how the facility will ensure residents basic services/needs will be met. Submit to CCL no later than 03/25/2024.

Allegation investigated: Staff are not ensuring that resident is provided with a comfortable mattress. Staff are not addressing resident's burn injury

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegations. Upon arrival, the LPA met with the Executive Director (ED), Monica Reyes, and was explained the reason for the visit. Entrance interview conducted. During today's inspection, between 09:35 a.m. and 4:00 p.m., the LPA interviewed the Administrator, two (2) staff, resident #1, R1's hospice nurse, and R1's case manager, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. Report will continue on LIC9099-C. Unsubstantiated Regarding the allegations: Staff are not ensuring that resident is provided with a comfortable mattress and Staff are not addressing resident's burn injury it is the reporting party’s concern that Resident #1 (R1) had sustained level one degree burns on their elbow and their left side of their body from their mattress. To investigate the complaint the LPA conducted a tour, conducted a file review of R1’s records, and conducted interviews. At 10:30 a.m. the LPA conducted a brief tour of R1’s bedroom and observed R1’s bed. The LPA observed a thin air mattress on top of a foam mattress. The LPA touched the air mattress, and the foam mattress and both mattresses did not feel hot. The LPA did not observe or felt any heat coming from the mattresses and did not feel any metals inside the air mattress. File review of R1’s records revealed that R1 is on hospice and has a doctor’s order for a hospital bed with half rails and an alternating pressure (APP) mattress from their hospice agency. Staff interviews revealed that they have not seen any burn injuries on R1 or any other resident. In addition, the administrator stated that residents on hospice are provided with beds from their hospice agencies. Interview with R1’s hospice nurse, revealed that R1 is seen once a week or as needed, a full body assessment is done at every visit, and R1 has not been observed with burn injuries. R1’s hospice nurse also revealed that R1 has a callus on their left elbow from always having their elbow on the same place and lack of circulation. Furthermore, the hospice nurse revealed that R1’s skin is looking better, and that even though R1 is a high risk for skin problems and that the bed is helping they can replace the bed at any time if there’s any concerns. Lastly, R1’s case manager from R1’s conservator’s office revealed that they do not have any concerns regarding R1’s bed causing the resident burns. Based on the information gathered, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations that " Staff are not ensuring that resident is provided with a comfortable mattress” and " Staff are not addressing resident's burn injury,” 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, Mar 1, 2024 · control 29-AS-20240223083928

Allegation investigated: Licensee did not provide resident's records as requested

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation noted above. LPA met with Executive Director (ED) Monica Reyes at 11:00 a.m. and explained the reason for the visit. On 1/24/2024, LPA Teresa Camara spoke with the complainant. The complainant confirmed the resident’s records they had requested were received on 1/23/2024 and the concern has been resolved. Therefore, the allegation "Licensee did not provide resident's records as requested" is deemed Unsubstantiated at this time. No deficiencies observed. Exit interview conducted and report issued to the ED. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 25, 2024 · control 29-AS-20240123211311

Allegation investigated: Staff neglect resulted in a resident leaving the facility unsupervised.

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 10:08AM and initially met with facility staff. LPA met with Executive Director (ED) Monica Reyes at 11:00AM. Entrance interview conducted. During today's visit, LPA interviewed staff at 10:10AM, 10:20AM and between 12:26PM to 01:50PM, interviewed ED at 11:02AM, toured the facility with ED at 11:47AM, and LPA reviewed and obtained copies of documents pertinent to the investigation. The following was then determined: The complaint alleges that Resident #1 (R1) left the facility unassisted and was found in the community, was confused and had fallen. The Regional Office had also received an incident report on 01/16/2024 indicating that on 01/15/2024, R1 had left the facility and was found in the community. LPA sent an email to the ED requesting documents for R1, which were received on 01/18/2024. Record review indicated that R1 resides Report Continued on LIC 9099-C Substantiated in the facility's Assisted Living unit. Initial documents sent to LPA included a medical assessment dated 10/24/2022 and indicated R1 is able to leave the facility unassisted, although R1 was marked with a diagnosis of dementia and being non-ambulatory and unable to evacuate without assistance. LPA interviewed management staff, who indicated this is R1's most recent assessment and that faxes to R1's physician to request a new medical assessment went unanswered. However, during today's visit, LPA reviewed R1's medical assessment dated 10/24/2023 which indicates that R1 has a diagnosis of dementia and cannot leave the facility unassisted. Care assessment dated 10/21/2023 and filled out by Aasta facility staff indicates R1 requires "some supervision in the home and needs attendance when outside the home or tends to wander". Interviews revealed that staff were aware R1 tends to wander, had attempted to leave the facility previously, and due to these behaviors R1 was on status checks every 15 minutes throughout the day and night. On the day of the incident, staff had seen R1 around 04:30AM in the hallway. At approximately 05:30AM, the facility received a phone call from paramedics asking about R1, who had been found in the community. Management interviewed indicated that when the phone call was received the facility staff were unaware that R1 had left the facility. Additionally, interviews also revealed that on the day and time R1 left the facility, there was 1 (one) caregiving staff working in Memory Care, and one Med Tech/caregiver working in Assisted Living. An additional Memory Care caregiver arrived at the facility at 05:30AM, however, during the overnight shift there were only 2 (two) facility staff present for 55 residents residing in the facility. Interview revealed it is unclear how R1 exited the building, R1 was found approximately 1 mile from the facility and staff were unaware of R1's whereabouts at the time emergency responders inquired. Based on interview and record review, there is sufficient evidence to support the allegation, therefore, the allegation that "staff neglect resulted in a resident leaving the facility unassisted" 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. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 29-AS-20240118113952

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 8, 2024

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 and record review, the licensee did not comply with the above cited section, as R1 was on 15-minute status checks, yet on 01/15/2024, R1 left the facility unassisted and was found a mile away before staff were aware R1 left, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Executive Director agreed to provide additional vendorized training to staff on resident basic care and supervision and provide proof to CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management visit to address deficiencies observed during facility tour and interviews conducted today. LPA met with Executive Director (ED) Monica Reyes. Entrance interview conducted. During an unrelated visit conducted at the facility today, LPA interviewed staff at 10:10AM, 10:20AM and between 12:26PM to 01:50PM, interviewed ED at 11:02AM, toured the facility with ED at 11:47AM, and LPA reviewed and obtained copies of documents. Interviews revealed that during the overnight shift from 10:00PM to 05:30AM, there were 2 (two) staff present at the facility for 55 residents residing in the facility. The two staff present are responsible for administering medications, checking multiple residents at 15 minute intervals, answering any phone calls and residents' calls for assistance, as well as all assistance with activities of daily living. The facility consists of an Assisted Living (AL) unit and a separate locked Memory Care (MC) unit and there were 2 staff present for the entire building, including both AL and MC. Interviews revealed that on this particular date that a staff had called out and that typically there are 3 staff present during this shift. Interviews revealed there have been previous times there were the same number of staff present, but no dates were clearly identified during today's visit. 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. Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 1, 2024

87411 (a) Facility personnel shall at all times be sufficient in numbers....the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section, as during the overnight shift on 01/14-01/15/2024, there were 2 staff present to care for all residents in AL and MC, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Administrator agreed to provide a thorough staffing plan and schedule reflecting sufficient staff coverage, as well as an LIC 500 to include management coverage to CCL by POC due date.

Allegation investigated: Licensee issued an unlawful eviction notice to resident in care

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 04:08PM and met with Executive Director (ED) Monica Reyes. Entrance interview conducted. During today's visit, LPA interviewed ED at 04:10PM and LPA reviewed and obtained copies of documents pertinent to the investigation. The following was then determined: On 11/07/2023, LPA Dulek received an email from ED Reyes, which contained an eviction notice for Resident #1 (R1). On 11/08/2023, LPA reviewed the eviction notice and replied to the ED indicating the eviction notice did not contain all the requirements per regulation. LPA requested the ED make changes to the submitted eviction notice and resubmit to CCL for approval. ED acknowledged receipt of the email, however, to date has not sent a revised eviction notice for R1. Interviews revealed that R1 has resided at this location prior to Report Continued on LIC 9099-C Substantiated the change of ownership, which occurred on 05/01/2021. R1 had a written agreement under the previous ownership indicating certain terms outside the department approved Admission Agreement. This agreement was made under the previous ownership, and until recently, Aasta had complied with all terms of the previous agreement. Interview revealed that Aasta Administration has had multiple conversations with R1's family member related to obtaining a current Admission Agreement and R1's failure to comply with signing a new agreement is the reason for the eviction notice being issued. ED indicated that the revised letter will contain documentation related to the reasons for the eviction and dates of discussion with R1 and/or their family member. Based on interview and record review, the allegation that "Licensee issued an unlawful eviction notice to resident in care" 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. ED was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 29-AS-20231108105233

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683(a) · Plan of correction due date: Nov 27, 2023

1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations...shall set forth in the notice to quit the reasons relied upon for the eviction...quit shall include all of the following: 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 an eviction notice was issued for R1, which did not contain reasons for the eviction, nor the required language contained in the above section, which poses a potential personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Executive Director agreed to rewrite the eviction notice to comply with HSC 1569.683 and will submit the revised copy to CCL by POC due date prior to re-issuing the eviction notice to R1 and/or their family member.

Allegation investigated: Licensee did not assist resident with self-administration of medications as prescribed

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegations listed above. LPA arrived at the facility at 11:25AM and met with Wellness Director Esmeralda Elizarraraz. Executive Director (ED) Monica Reyes arrived at 12:20PM. Entrance interview conducted. During today's visit, LPA interviewed Wellness Director at 11:30AM, ED at 12:20PM, toured Memory Care with ED at 12:40PM, reviewed medications for Resident #1 (R1) at 12:47PM, and staff between 01:32PM and 2:20PM. LPA also reviewed and obtained copies of documents pertinent to the investigation. The following was then determined: During the medication review, R1's medication Mirtazipine 15mg bottle indicated there were 30 count and the medication was started on 08/03/2023. Mirtazipine is ordered once daily and administered in the morning. 36 days elapsed from the date the bottle was opened to the date R1 was hospitalized on 09/07/2023, however REPORT CONTINUED ON LIC 9099-C Substantiated 12 pills remain in the bottle, indicating only 18 doses were administered over the 36 day period. Medication Administration Record (MAR) reviewed did not indicate any medications were refused and contained blank spaces or x marked on different dates, instead of initials indicating the staff administered the medication. R1's medication ripseriDONE 2mg tablet originally contained 60 pills and 38 remain in the bottle during today's count. The MAR indicates the bottle was opened on 08/19/2023 and 20 days elapsed from that date to R1's hospitalization. RisperiDONE is ordered twice a day, therefore 39 doses should have been administered from the start date, but only 22 doses were utilized. Again, MAR was missing staff initials and had x marked on various dates, but no doses marked as refused. R1's Divalproex Sodium 125mg TBEC originally contained 240 capsules and during today's count 176 capsules remain. This medication is ordered 4 capsules to be administered twice a day. Start date is marked on the MAR as 08/18/2023 and on the bottle as 08/19/2023, so either 20 or 21 days have elapsed since the start date to the time of R1's hospitalization, so if the medication was administered as ordered, either 160 or 168 capsules should have been used. However, only 64 capsules were used. Again, R1's MAR has blank spaces or x marked on various dates but no refusals indicated. Based on interview and medication review, there is sufficient evidence to support the allegation, therefore, the allegation that "Licensee did not assist resident with self-administration of medications as prescribed" 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. As this is a repeat violation, civil penalty issued in the amount of $250. Failure to correct the deficiency may result in additional civil penalties. Exit interview conducted. A copy of the report, civil penalty and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 15, 2023 · control 29-AS-20230908154939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 29, 2023

87465 Incidental Medical and Dental Care Services (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the above cited section, as 3 medications for R1, based on start date and assumed daily administration did not contain the appropriate amount of doses and MAR was inaccurate, which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2023

Plan of correction: Administrator agreed to conduct a medication audit for all residents and a training for all medication technicians on proper medication administration and documentation and provide proof of training and medication audit to CCL by POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Licensee does not ensure food of good quality is served to residents in care Staff does not ensure dietary restrictions are followed for residents in care

Licensing Program Analyst (LPA) Kelly Dulek initiated an initial complaint visit for the above listed allegations. LPA arrived at 09:52AM and met with Wellness Director Esmeralda Elizarraraz at 10:00AM. Administrator was contacted via telephone and arrived at the facility at 12:50PM. Entrance interview conducted. During today's visit, LPA toured the facility with Wellness Director at 10:04AM, interviewed residents from 10:40AM to 11:18AM and at 11:24AM and 12:35PM, observed staff delivering lunch and observed lunch in the dining room at 11:22AM. LPA toured the kitchen and took photos of the food supply at 11:36AM Additionally, LPA interviewed staff from 11:33AM to 12:02PM. The following was then determined: It was alleged that the facility does not ensure the food is of good quality and that residents' dietary restrictions are not followed. Interviews revealed that the menu is posted, the kitchen staff prepare the food REPORT CONTINUED ON LIC 9099-C Unsubstantiated that is listed on the menu, following low sodium recipes. Most residents interviewed reported being happy with the food. Some residents indicated the food is bland, but LPA observed that salt and pepper are available on dining room tables. Staff interviewed indicated they do not add oil or butter to the fruit and only use a little oil when sautéing the vegetables when the recipe calls for sauteed vegetables. LPA observed in the kitchen a board indicating the residents' dietary restrictions and/or dietary preferences. Staff interviewed were aware of different residents' diets and their preferences. Staff interviewed indicated that food for Resident #1 (R1), who is referred to in the complaint allegations, is prepared separately when recipe calls for added oil or butter. For R1, the salmon is steamed and all vegetables for R1 are either boiled or steamed. LPA observed a variety of foods in the pantry, refrigerator, and freezer. Posted menu items were available at the facility and today's meal observed followed the posted menu. Fresh fruits and vegetables were observed. LPA observed diced fruit, which was alleged to be coated in oil or butter. LPA did not observe any coating on the fresh diced fruits; they appeared to contain only fruit and some of the fruit's own juices. Residents interviewed reported no concerns with oil or butter on the fruits served. Based on interview and observation, although the allegations may be valid, at this time there is insufficient evidence to support the allegations or that a violation occurred; therefore, the allegations that "Licensee does not ensure food of good quality is served to residents in care" and "Staff does not ensure dietary restrictions are followed for residents in care" 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, Aug 30, 2023 · control 29-AS-20230828164902

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kelly Dulek initiated a Case Management visit today with the purpose of confirming the removal of Individual #1 (I1) from the facility. LPA arrived at 09:52AM and met with Wellness Director Esmeralda Elizarraraz at 10:00AM. Administrator was contacted via telephone and arrived at 12:50PM. Entrance interview conducted. The Woodland Hills Regional Office (RO) received a Default Decision and Order with an effective date of 09/08/2023, indicating that I1, who had sought employment with the facility, is prohibited from employment in any facility licensed by the Department. Prior to today's visit, LPA reviewed the facility's Guardian roster to ensure I1 is not associated to the facility. During today's visit, LPA interviewed Wellness Director at 10:00AM and confirmed that I1 never worked, trained, or interacted with any residents in the facility. I1 was a prospective employee, but did not obtain background clearance, therefore, the facility did not hire I1. LPA did not observe I1 in the facility during the visit. The facility Management is aware that I1 cannot be hired or present in the facility. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Aug 30, 2023

Allegation investigated: Facility staff did not assist with resident's medication as prescribed Facility staff are not trained for the job assigned to them Insufficient staffing

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection with the purpose of delivering findings for the allegations listed above at 12:04PM. The LPA met with Administrator Monica Reyes and explained the reason for today's visit. Entrance interview conducted. During today's visit, LPA interviewed residents from 02:33PM to 03:05PM. During an initial complaint visit conducted on 06/01/2022, LPA toured the facility including kitchen and all food service areas with Administrator at 12:40PM, conducted staff and resident interviews at 12:03PM, 12:47PM, and 1:52PM. LPA also gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed all pertinent documents and interviewed staff and residents during unrelated facility visits. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: "Facility staff did not assist with resident's medication as prescribed:" It was alleged that Resident #1 (R1) was not assisted with their insulin and diabetes medication. LPA interviewed R1 and their family member, as well as other facility residents and facility staff. Interviews revealed that at the time of the complaint allegation, the facility employed Licensed Vocational Nurses (LVNs) to provide diabetic care to all applicable residents. At the time of the complaint and through 08/03/2022, there were at least 2 LVNs employed at the facility who administered all diabetic medications. After 08/03/2022, most residents' medications were changed to oral diabetes medications for self-administration. The residents requiring injections were able to be assisted with to hand-over-hand administration of injectable medications. As thus, medication technicians were able to assist residents with diabetes medication assistance and LVNs were not needed full time at the facility. LPA reviewed medication administration record (MAR) for R1, which indicated R1 refused blood sugar check on 5 dates in May 2022. R1 also refused their bedtime insulin pen injection on 05/21/2022 and 05/22/2022. Interviews revealed that R1's physician was informed of R1's medication refusal. Interview with R1 and other residents revealed that medications are offered regularly and on time. Staff interviews revealed that R1 wasn't always compliant with taking their medications as ordered, but they were offered daily and documented when refused. Based on interview and record review, 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 that "facility staff did not assist with resident's medication as prescribed" is deemed UNSUBSTANTIATED at this time. Allegation: "Facility staff are not trained for the job assigned to them:" It was alleged that facility staff are not properly trained for medication administration, specifically related to diabetes medications. LPA reviewed records and interviewed facility management and staff regarding training procedures. All training records for medication technician staff reviewed were compliant with regulation. At the time of the complaint allegation, only LVNs were administering diabetes medications. As they are licensed medical professionals, additional medication training was not required per regulation. Following the change to medication technicians assisting residents with self-administration of injectable medications, an additional in-service training related to diabetes care was provided for all facility medication technicians. Interviews revealed that staff complete training on both a computer system and shadowing prior to administering any medications. Training practices reviewed during the course of the investigation were Report Continued on LIC 9099-C compliant with regulation at that time. Based on interview and record review, 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 that "Facility staff are not trained for the job assigned to them" is deemed UNSUBSTANTIATED at this time. Allegation: Insufficient staffing:" The complaint alleges that the facility does not employ sufficient staffing, resulting in long wait times for residents when they push their call buttons. LPA reviewed the facility staff schedules and conducted interviews. Staff interviewed reported that as the facility census is lower than it has been, therefore less staff needed. Depending on how busy the care staff are determines the wait times. Additionally, there are a few residents that require a 2-person assist and when the staff are assisting those residents, other residents may have to wait a bit longer for a response, but this scenario doesn't occur often. During the daytime, care staff, management, and med techs are all available to assist residents when needed. At night, there are less residents requiring assistance as most residents are sleeping, therefore, less staff are employed during those hours. R1 indicated staff do come and check on their incontinence needs every 2 hours during the night shift. Interview with R1 revealed they could not reach their pull cord when they fell, resulting in R1 calling 9-1-1 for assistance. R1 indicated the problem was not with insufficient staffing, but rather with the location of the pull cord when R1 fell. R1 acknowledged that the facility staff had given R1 a longer pull cord to try to alleviate the problem, but that the location of R1's bed made it difficult to keep the pull cord in an easily accessible spot. When LPA asked R1 about moving their bed to make the pull cord more accessible, R1 refused. 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 "Insufficient staffing" is 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, Aug 14, 2023 · control 29-AS-20220523161429

Allegation investigated: Staff do not administer resident's medications in a timely manner Food service is inadequate Staff did not safeguard resident's personal items Resident is not accorded privacy

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today. The LPA arrived at 10:23AM and met with Administrator Monica Reyes. The LPA informed Administrator of the reason for today's inspection. During today’s visit, LPA reviewed documents previously provided and interviewed staff and residents between 01:05PM and 03:21PM. During an initial complaint inspection conducted on 09/01/2021, LPA Dulek conducted a facility tour with Administrator Robert Gutierrez and Resident Care Coordinator at 11:22 AM, conducted staff interviews between 11:50AM and 12:51PM as well as between 1:29PM and 1:58PM, conducted a medication review at 1:06PM and gathered copies of documents pertinent to the investigation. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff do not administer resident's medications in a timely manner:” It was alleged that Resident #1 (R1)’s medications were administered up to 3 hours late at times. At the time of the allegation, R1 had moved out of the facility, so LPA was unable to review R1’s medications. However, LPA obtained R1’s Medication Administration Record (MAR) for the month of August 2021. MAR reviewed indicated R1’s medications were initialed as administered daily as prescribed until the date of R1’s move out, with the exception of R1’s Certrizine 5mg, which was marked as not administered, as the medication was unavailable. Staff interviewed indicated that medications scheduled at a certain time can be administered up to an hour prior to the scheduled time to an hour after the scheduled time. For example, if a medication is scheduled at 8:00AM, a medication technician could administer that medication anywhere from 07:00AM to 09:00AM and still be within an appropriate timeframe for medication assistance. Staff interviews revealed that if a medication was administered outside the appropriate timeframe, this would be reflected on the MAR as an exception, documented, and reported accordingly. Resident interviews revealed that medications are provided to the residents on time as prescribed. As R1 had moved out of the facility prior to the complaint investigation, LPA was unable to interview R1 or observe R1’s medications more thoroughly. Based on interview and record review, 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 that “staff do not administer resident’s medications in a timely manner” is deemed UNSUBSTANTIATED at this time. Allegation: “Food service is inadequate:” The complaint alleges that food was not provided to R1 for two (2) days. During an initial complaint visit, LPA obtained copies of the facility menu and foods offered. During an unrelated visit, LPA observed dinner service as well as food trays delivered to residents. LPA also observed lunch time in Memory Care during an annual visit. Each time LPA observed meals to be served to all residents in the dining room and in Memory Care. LPA observed the food in Memory Care is brought on a cart into the Memory Care unit and the care staff serve the residents the pre-plated foods. Residents have been seated at the table and the assigned care staff assist those who require feeding assistance. Staff interviews revealed that there are a few residents who prefer to stay in their rooms during mealtimes, particularly during the pandemic. Care staff hand deliver plates to those residents who choose to remain in their rooms. Staff interviewed could not recall a time when a Memory Care resident did not receive a meal or complained of not receiving a meal. Based on interview and Report Continued on LIC 9099-C observation, 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 that “food service is inadequate” is deemed UNSUBSTANTIATED at this time. Allegation: “Staff did not safeguard resident's personal items:” The complaint alleges that R1’s personal items went missing from R1’s room and were unable to be located. LPA reviewed R1’s LIC 621 (personal property and valuables) dated 07/29/2021 and corresponding photographs provided by R1’s family member. LPA observed items circled on the photographs and marked as missing. Items included 2 packs of flash cards, a flowered scarf, and one item that appears to be a dark colored blanket. Interview revealed that R1 did indicate items were missing often and every time R1 could not locate an item, staff assisted them in looking for the item. Staff interviewed indicated to their knowledge, items were usually located and returned to R1. R1 was unable to be interviewed for the complaint investigation, as they no longer resided at the facility at the time of the initial complaint investigation. Other residents interviewed indicated they maintain their personal belongings in their own rooms and have not had items that were lost, only temporarily misplaced. Staff interviewed indicated R1’s family moved all R1’s personal belongings out of the facility. When the move out occurred, items were not marked on the LIC 621 as “personal property/valuables removed” at that time, so it is unclear which items, if any, were not safeguarded. Based on interview and record review, 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 that “staff did not safeguard resident’s personal items” is deemed UNSUBSTANTIATED at this time. Allegation: “Resident is not accorded privacy:” The complaint alleges that staff have “ruffled through [R1]’s drawers” and staff have been overheard asking R1 who they are on the phone with. Record review revealed that R1 resided in the Memory Care unit and while R1 was independent with dressing themselves, R1 did require reminders for most ADLs. Additionally, R1 was noted to be “alert and oriented with bouts of confusion and forgetfulness.” Staff interviews revealed that R1 reported to staff regularly that something was missing from their room. Staff would offer to help R1 locate any missing item and at R1’s request, would help look for and attempt to locate missing items. As a part of that assistance, staff did assist the resident in looking around their room for the missing item, which did include looking in R1’s dresser drawers. Interviews also revealed that staff frequently check on all Report Continued on LIC 9099-C residents, including R1, by stopping in their rooms to do a visual and/or verbal check to ensure the resident’s health and safety. R1 was on the phone regularly when they would come in R1’s room to complete the health and safety check. Staff did inquire if R1 was on the phone when they enter R1’s room and when R1 indicated they were on the phone, staff would leave the room and allow R1 privacy. Interview with residents revealed that residents feel they are accorded privacy at the facility. 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 that “resident is not accorded privacy” is 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, Jul 17, 2023 · control 29-AS-20210823081259

Allegation investigated: Facility staff did not ensure resident's blood sugars were being monitored properly while in care

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection for the allegation listed above at 10:23AM. The LPA met with Administrator Monica Reyes and explained the reason for today's visit. Entrance interview conducted. During today's visit, LPA interviewed staff at 11:20AM, conducted staff and resident interviews between 01:05PM and 03:21PM. During an initial complaint inspection at the facility on 01/26/2023, LPA interviewed Administrator at 01:30PM and at various times throughout the visit, LPA toured the facility with Administrator at 01:50PM, and gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed pertinent documents and interviewed residents related to this complaint during unrelated facility visits. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: “Facility staff did not ensure that resident's blood sugars were being monitored properly while in care:” Resident #1 (R1) had high blood sugar and A1C levels and reporting party was concerned that R1’s blood sugars were not properly being monitored. LPA reviewed physician’s orders and documents obtained at the facility. Interview with R1 revealed the facility staff check R1’s blood sugar by helping R1 to poke their finger and measure blood sugar. However, R1 could not recall how long the facility has been assisting with measuring their blood sugar level. Physician’s orders dated 10/05/2022 indicate orders for “Accucheck am and record.” Med room staff sent a fax to R1’s physician on 10/10/2022 asking to “clarify the following orders. Pharmacy was unable to read.” Date stamp for return fax from R1’s physician was cut off, so LPA was unable to identify when the response was received. The faxed document was provided to the LPA during the 01/26/2023 visit, so it is clear that by the time of the visit, the facility had received the document, yet R1’s blood sugars were not monitored or recorded. Interviews revealed that the facility staff were unaware of the 10/05/2022 doctor’s orders or the 10/10/2022 clarification of doctor’s orders and indicated it wasn’t until February that R1’s physician wrote an order for R1’s blood sugar to be monitored. On 02/08/2023, med room staff sent a request to R1’s physician for a blood sugar check twice a day, per R1’s request. R1’s physician replied the same day and indicated to “check blood sugar (before breakfast, before dinner) daily and notify” physician within parameters given. Record review revealed that the facility staff began assisting R1 in checking their blood sugar beginning on 02/09/2023. However, record review revealed that the original doctor’s orders for Accucheck were written on 10/05/2022 and were not followed. Therefore, based on record review and interview, there is sufficient evidence to support the allegation and the allegation that “facility staff did not ensure that resident’s blood sugars were being monitored properly while in care” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 9099-D). Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Allegation: “Facility staff did not ensure that resident received medication while in care:” The complaint alleges that facility staff did not ensure R1 received their diabetes medications, resulting in high blood sugar and A1C levels. Physician’s report indicates R1 can administer their own insulin pen with assistance. Interview with R1 revealed that facility staff regularly assist R1 with their diabetes medications, throughout the day as ordered by R1’s physician. Staff interviewed indicated that the medication technician sets up the insulin pen with the proper amount of insulin. Staff stated R1 is cooperative with medications, but sometimes, R1 requires hand-over-hand assistance for their diabetes care. LPA reviewed medication logs for R1 during the time of the complaint allegation. Medication logs indicate R1 received all 3 (three) injectable medications related to diabetic care as prescribed during the month of the complaint allegation. Interview with R1 revealed that the staff do assist R1 with medications and that the medication technicians come into R1’s room to administer injectable medications four (4) times daily. Staff interviews revealed that medications are administered and initialed either in the electronic MAR or paper MAR as appropriate for each resident. 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, therefore, the allegation that “facility staff did not ensure that resident received medication while in care” is deemed UNSUBSTANTIATED at this time. Allegation: “Facility staff did not ensure that resident had a change of clean clothing while in care:” LPA reviewed the care assessment and service plan dated 10/25/2022 and labeled updated care plan for R1. Care plan indicates R1 is independent in dressing. Physician’s report dated 05/17/2022 indicates R1 requires supervision with grooming and hygiene needs, but is independent for dressing. During an unrelated visit on 06/13/2023, LPA interviewed R1 at 04:58PM. R1 indicated they pick out their own clothing and dress themselves. Laundry is washed twice weekly; it is taken on the resident’s designated laundry day and is delivered back to the resident’s room the same day by the housekeeping staff. LPA observed that all of R1’s clothing was clean, including what R1 was wearing during the visit. Staff interviews revealed that R1 is relatively independent, picks out their own clothes, and dresses themselves independently. Therefore, based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation; as thus, the allegation that “facility staff did not ensure that resident had a change of clean clothing while in care” is deemed UNSUBSTANTIATED at this time. No citations issued in relation to the above allegations. Exit interview conducted with Administrator. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 29-AS-20230125094625

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Jul 21, 2023

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication...skilled professional. 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 physician ordered blood glucose testing on 10/05/2022 and the facility staff was unaware of the orders and R1's need for medical assistance, which posed an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2023

Plan of correction: Administrator agreed to conduct an inservice on section 87628 Diabetes for all medication technicians and provide proof of training to CCL by POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. LPA arrived at 10:23AM and met with Administrator Monica Reyes. LPA explained the reason for today's visit. Entrance interview conducted. Previously, during a visit conducted on 07/07/2023, LPA Dulek had received a copy of the facility's current Admission Agreement. LPA had also previously received and reviewed copies of current residents' Admission Agreements. LPA compared both the copies of residents' Admission Agreements, the blank copy provided on 07/07/2023 and the Admission Agreement that had been submitted with the facility's application and approved at the time of licensure on 05/01/2021. LPA noted the Admission Agreements used with current residents as well the blank copy to be used with new admissions contained discrepancies from the Department approved Admission Agreement. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 809-D). Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Administrator Monica Reyes. Today's reports and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Jul 31, 2023

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation...changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval... This requirement is not met as evidenced by: Based on observation and record review, the Licensee did not comply with the above cited section, as the Licensee made changes to the facility's Admission Agreement and did not submit the changes to the Department for approval, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2023

Plan of correction: The Administrator agreed to discontinue use of the modified Admission Agreement effective immediately. The Licensee will submit to CCL the modified Admission Agreement by POC due date and obtain written approval prior to utilizing the new Admission Agreement and attachments.

Allegation investigated: Facility no longer has control of the property

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection with the purpose of delivering findings for the above allegation. The LPA met with Administrator Monica Reyes. Entrance interview conducted. During an initial complaint visit conducted on 05/05/2022, LPA toured the facility with Administrator Robert Gutierrez at 1:33 PM, conducted Administrator interview at 12:48PM, and LPA gathered copies of pertinent documents. During the course of the investigation, LPA reviewed pertinent documents and conducted telephone interviews with relevant parties. The following was then determined: It was alleged that the licensee no longer had control of the property, as the lease agreement between the property owner and the licensee had a specification related to approval of a HUD loan, which was not Continued on LIC 9099-C Unsubstantiated secured as agreed upon in the initial lease. At the time of the complaint, the licensee had yet to submit the documents related to the HUD loan. However, an amendment to the lease was agreed upon between the licensee and the property owner, extending an additional 18 months to receive HUD approval. Interviews revealed that the HUD loan application was submitted shortly after the complaint was received and approval for the HUD loan was granted on 02/01/2023, which is within the timeline agreed upon in the lease amendment. Interviews revealed that at no time did the licensee lose control of property. Based on interview and record review, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation that “facility no longer has control of the property” is 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, Jul 7, 2023 · control 29-AS-20220502122736

Allegation investigated: Facility failed to seek timely medical attention for resident in care Licensee did not allow resident(s) to select their own health care provider

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection with the purpose of delivering findings for the above allegations. The LPA met with Administrator Monica Reyes. Entrance interview conducted. During an initial complaint visit conducted on 08/13/2021, LPA Dulek conducted an interview with Administrator at 12:16PM, conducted facility tour at 1:05PM, and gathered copies of documents pertinent to the investigation. Throughout the course of the investigation, LPA reviewed copies of pertinent documents and conducted interviews with staff and residents regarding these allegations during unrelated facility visits. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegation: Facility failed to seek timely medical attention for resident in care: It was alleged that Resident #1 (R1) fell while at the facility, resulting in a fractured femur and the facility did not send R1 to the hospital due to R1 receiving hospice services. Record review revealed that R1 fell on the following dates: 07/01/2021 resulting in a small abrasion to R1’s cheek, 07/03/2021 with no visible injuries noted, and 07/04/2021, which resulted in a bump to R1’s forehead, R1 “moaning with facial grimacing to touch and pressure to right leg.” According to the incident report and internal incident report, the fall occurred at 09:40PM. Hospice nurse notes dated 07/04/2021 indicate “called daughter and left voicemail. Gave option to bring to hospital or to keep [R1] comfortable at this time. Per [facility med tech,] [R1’s] daughter currently on vacation.” Internal incident report dated 07/05/2021 at 12:00AM indicates hospice “requested that [R1] not be sent to hospital because [R1] is admitted on hospice. A nurse will visit to reassess [R1] during daytime.” Additional internal incident report dated 07/05/2021 at 11:50AM indicates when staff arrived at the facility for the morning shift and was making morning rounds, R1’s “right hip was warm to touch and [R1] was screaming in pain.” Incident report further states facility staff called hospice, who indicated “working on trying to send a tech to get an x-ray done.” At 11:45AM, facility received a call from hospice giving authorization to call 9-1-1 and send R1 to the hospital. Progress notes dated 07/06/2021 indicate R1 sustained a right femoral fracture due to the fall that occurred on 07/04/2021. Although R1 is on hospice, the fall, which resulted in a bump on R1’s forehead and femoral fracture are not related to the expected course of R1’s terminal illness. As thus, regulations related to hospice care and informing hospice rather than calling 9-1-1 do not apply to the incident involving R1. Documentation provided reflects that R1 fell on or around 09:40PM on 07/04/2021 and although staff indicated R1 was “screaming in pain,” 9-1-1 was not called until 11:50AM on 07/05/2021. Therefore, based on interview and record review, the allegation that “facility failed to seek timely medical attention for resident in care” is deemed SUBSTANTIATED at this time. Allegation: Licensee did not allow resident(s) to select their own health care provider: The complaint alleges that the Licensee is forcing staff to refer residents to Aasta hospice and home health and forcing families to switch providers. During the course of the investigation, LPA spoke with family members of facility residents directly, as well as reviewed the list of providers, facility Admission Agreement, and a letter that was sent to residents’ families by the Administrator. According to the letter sent from the Administrator, Aasta’s hospice and home health preferred companies are as follows: Aasta Home Health Report Continued on LIC 9099-C and Hospice, Free Spirit Hospice, and Faithful Hospice, all of which appear to be companies owned by the Licensee. The letter further states that “services provided through our partners are included in our monthly pricing. Residents who choose a hospice and/or home health provider other than one of our preferred partners will be charged $500 per service per month for the duration of services.” Families interviewed indicated that they were approached by facility staff and asked to change providers or to enroll in hospice services with one of their providers if the resident was not already receiving hospice services. Although the letter indicates residents can choose an alternate provider, an additional charge will be added to their services for choosing an alternate provider, which is not indicated in the Department-approved Admission Agreement. Families interviewed indicated the additional cost was a factor in choosing their health care provider. Based on interview and record review, there is a preponderance of evidence to support the allegation, therefore, the allegation “Licensee did not allow resident(s) to select their own health care provider” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of today's reports and appeal rights were provided. Allegation: Illegal Eviction: It was alleged that after Resident #1 (R1) sustained a fall at the facility, which resulted in a fractured femur, the Licensee did not readmit R1 to the facility. Interview revealed that R1 did not return to the facility, however the facility did not evict R1. R1 had an unpaid balance for services rendered at the facility and prior to the facility issuing an eviction notice, the fall occurred, and R1 did not return. LPA attempted to call R1’s family member to confirm information provided by the facility, however, LPA did not receive a call back. LPA reviewed records sent to CCL during the time of the complaint and an eviction notice for R1 was not sent to CCL for approval. Interviews with staff confirmed R1 did not return following their hospitalization and the family retrieved R1’s personal belongings some time after the incident. Based on interview and record review, 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 “illegal eviction” is deemed UNSUBSTANTIATED at this time. Allegation: Staff are not sufficient in numbers and competent to provide services necessary to meet resident needs: The complaint alleges at the time of the complaint, the facility is short staffed, with only 1 or 2 caregivers on the floor. Interviews revealed that the facility was utilizing staffing agency to supplement facility staffing. According to interviews, at all times, there is a minimum of 2 caregivers present in each side of the facility – Meadows and Assisted Living. Staff interviewed indicate there have been times of lower staffing, which makes it difficult to manage, but the medication technician will step in and help as well as during the day there is management staff and additional extra staff that come assist the residents as needed. Residents interviewed indicate that at times they do have to wait for assistance, but that the care provided is sufficient and their needs are being met. 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 “staff are not sufficient in numbers and competent to provide services necessary to meet resident needs” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegations. Exit interview conducted. A copy of today's reports were provided.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 29-AS-20210805085248

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 14, 2023

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 fell on 07/04/2021, resulting in a fractured femur and the facility did not call 9-1-1 until 11:50AM on 07/05/2021, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2023

Plan of correction: Administrator agreed to conduct staff training on section 87465(g) at the all-staff meeting on 07/11/2023. Administrator will provide proof of training to CCL upon completion.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(18) · Plan of correction due date: Jul 14, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (18) To select their own...hospice agency, and health care providers in a manner that is consistent with the resident’s admission agreement...to these personal rights. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the facility Admistrator sent a letter urging residents to use the facility's preferred providers or an additional monthly charge will apply, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2023

Plan of correction: Administrator will discuss with the Licensee and will contact LPA by POC due date for an action plan for compliance with this section.

Allegation investigated: Staff are not responding timely to residents’ alerts

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint inspection with the purpose of delivering findings for the above allegation. The LPA met with Administrator Monica Reyes. Entrance interview conducted. During an initial complaint visit conducted on 11/02/2022, LPA interviewed Facility Designee at 12:35PM, toured the facility, including kitchen and all food service areas with facility Designee at 12:50PM, took photos of relevant facility areas, and conducted a telephone call with Licensee at 01:50PM. LPA also gathered copies of pertinent documents. During a subsequent complaint visit conducted on 06/13/2023, LPA conducted interviews with staff between 12:52PM and 2:15PM, observed dinner service in the dining room, conducted resident interviews between 04:58PM and 05:45PM, and gathered copies of documents pertinent to the investigation. Throughout the course of the investigation, LPA interviewed additional residents and staff during unrelated facility visits, as well as reviewed documents. The following was then determined: Report Continued on LIC 9099-C Substantiated It was alleged that facility staff are not responding timely to residents’ alerts. LPA interviewed staff and residents related to the call button system and wait times. The facility utilizes a system where residents have a pull cord in their rooms near their bed, as well as one in the resident’s restroom, which triggers a light on the outside of the resident’s door as well as a light in the main dining room and at the front desk. During the day, front desk staff call on the walkie talkie when the panel lights up to inform care staff to go assist the resident. During the night, when front desk staff are not present, the care staff are responsible for walking around and paying attention to the call light panel. Resident interviews revealed that depending on the time of day and how busy the staff are, the time elapsed from pulling the cord to a staff responding to their room can be anywhere from a few minutes to an hour, but most often it’s 15-20 minutes before the staff respond. One resident indicated the staff “take their sweet time” when responding to the call light. Staff interviews revealed that while the workload is usually manageable, at times, the residents have to wait some time for assistance during the busier times of the day. Therefore, based on interview, the allegation that “facility staff are not responding timely to residents’ alerts” is deemed SUBSTANTIATED at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 9099-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided. Allegation: Staff is unaware of emergency water supply: During the initial complaint visit, LPA toured the facility and observed the facility’s emergency water supply. LPA took photos of the supply located in the kitchen pantry. Dining staff interviewed indicated they are aware of where to find the emergency supply and were able to articulate to the LPA where the water is located. LPA spoke with staff identified in the emergency disaster plan to oversee the emergency supply and those staff were also aware of the emergency supply location. Additionally, the facility has 2 automatic water dispensers located in the common areas of the facility. In the event of a power outage, the water dispensers will still function, and residents will continue to have available drinking water. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff is unaware of emergency water supply” is deemed UNSUBSTANTIATED at this time. Allegation: Staff are not posting food menus: It was alleged that although menus were placed at each dining table, the weekly dining menu was not posted at the facility. LPA visited the facility multiple times throughout the investigation and took photos of the posted menu at each visit. Interview with Administrator revealed that menus are printed weekly and posted on Monday mornings. One Monday morning two weeks prior to the initial complaint visit, there had been a car accident near the facility, which caused a power outage at the facility. The facility’s emergency generators had kicked in to ensure continuity of care to the residents and food preparation was uninterrupted, but the weekly menu was unable to be printed prior to breakfast service. When Administrator arrived at the facility, the menu was printed and posted at that time. Daily menus were available on each dining table and the dining staff did have a printout of the weekly menu. Additionally, residents had previously received a copy of the weekly menu in their rooms. Interviews revealed that menus are posted and there have been no concerns with communicating to the residents the daily or weekly food choices. Based on interview and observation, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff are not posting food menus” is deemed UNSUBSTANTIATED at this time. Allegation: Staff are not providing nutritious foods: It was alleged that in the bistro area, there were no snacks available other than popcorn. LPA observed the Bistro 3 (three) times during the course of the investigation. At each visit, LPA observed fruit, sandwiches in the refrigerator, as well as snacks available in the Bistro. Interview revealed that the food in the Bistro is Report Continued on LIC 9099-C restocked 4 (four) times a day by the kitchen staff. There are some residents who will take all the food left out in the Bistro, so that is being addressed. Residents interviewed indicated there are snacks available all day, such as sandwiches, various fresh fruits, Jello, and pudding. Residents stated they can get their own snack from the Bistro or they can ask the caregiver or med tech to bring them almost any food of their choosing at any time of the day. Based on interview and observation, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff are not providing nutritious foods” is deemed UNSUBSTANTIATED at this time. Allegation: Staff are not properly safeguarding the facility grounds: It was alleged that doors to empty rooms were found unlocked, which could be a potential safety hazard to residents in care. Administrator interview revealed that there are rooms that were left unlocked for the purpose of staff offering facility tours during the weekend when Administrator was not present at the facility. The rooms are vacant and set up with furnishings such as a bed, dresser, and chair. During the initial complaint visit, LPA checked all doors during the facility tour and none were found to be unlocked. LPA asked Administrator to unlock vacant rooms for observation during the facility visits. LPA found no hazardous items in any of the vacant rooms that had been previously unlocked for the purpose of offering tours. Based on interview and observation, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “staff are not properly safeguarding the facility grounds” is deemed UNSUBSTANTIATED at this time. No citations issued for the allegations addressed above. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 29-AS-20221028153640

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 10, 2023

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, the facility did not comply with the above cited section, as residents reported having to wait on average 15-20 minutes for staff assistance when residents use their call buttons, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2023

Plan of correction: Administrator agreed to conduct a staff inservice related to resident call lights on 07/11/2023. Administrator will provide proof of training to CCL upon completion of training.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kelly Dulek and Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 09:13AM. LPAs were greeted by facility staff and initially met with Esmeralda Elizarraraz and explained the reason for today’s visit. Administrator Monica Reyes arrived shortly thereafter. Entrance interview conducted. Beginning at 09:44AM, the LPAs, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: The facility consists of 107 total bedrooms, of which LPAs observed 10 resident bedrooms; 2 in the Meadows (Memory Care) and 8 in Assisted Living. All resident rooms observed were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At 09:52AM, in Resident #1 (R1)’s room LPAs observed the following: Mucus DM Extended Release, Vicks VapoRub, Beta Prostate Max, Calmoseptine, A&D Ointment, Remedy Phytoplex Clear-Aid Ointment and other various medications. RESTROOMS: Each resident room contains its own private restroom. Resident restrooms observed contained sufficient grab bars and non-skid surfaces. At 10:02AM, in Room 415, water temperature measured at 126.7 degrees Fahrenheit. At 10:08AM, in Room 403, water temperature measured at 124.1 degrees Fahrenheit. COMMON AREAS: Consisting of the lobby, library, activity room, dining room, bistro, and movie room in the Assisted Living side and activity room and dining room in the Meadows side. The LPAs observed common areas to be relatively clean and properly furnished at the time of the visit. The LPAs observed the fire extinguishers to be fully charged and last serviced on 02/08/2023. All hardwired smoke alarms as well as Continued on LIC 809-C fire doors and sprinkler system were inspected during the fire inspection which took place on 05/18/2022 and were functional at that time. During today’s visit, at 04:36PM, carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level throughout the building. Cleaning supplies and disinfectants are stored locked per regulation. The LPAs observed cameras in the common areas. A working telephone is present. The LPAs observed the required postings in the common area. OUTDOOR SPACE: At 10:37AM, the LPAs observed the building and grounds in both Assisted Living and Memory Care. Multiple seating areas were observed with tables and chairs and shaded seating areas for resident use. RECORD REVIEW: Began at 11:12AM, LPAs reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. 5 of 5 staff files reviewed contained all documents, except documentation of required initial and annual training. Administrator indicated staff have completed all required training but was unable to access the records due to the internet not functioning at this time. 5 resident files were reviewed. 2 of 5 resident files reviewed did not contain a current reappraisal, however current appraisals were completed during today’s visit. Remaining files reviewed were observed to be in compliance. MEDICATION REVIEW: Began at 01:28PM. Medications for 5 residents were reviewed. At 01:30PM, Resident #2 (R2)’s medication Multaq 400mg was observed. PM dose was not initialed as administered on the April Medication Administration Record (MAR) at all, however 11 pills were not remaining in the bubble pack and bubble pack was started on 04/01/2023. At 01:39PM, Resident #3 (R3)’s medication Vitamin B-12 100mg, which is ordered weekly on Mondays. Start date is indicated as 04/01/2023 and the package originally contained 5 pills. 2 pills remain in the bubble pack, however only 2 Mondays have passed in April. At 01:49PM, LPAs observed Resident #4 (R4)’s medication Hydrocodone APAP 10-325. Bubble pack originally contained 30 doses of 2 pills each. 12 doses remain in the bubble pack and the start date is listed as 04/09/2023. MAR reviewed indicated 14 doses have been administered since 04/09/2023, leaving 4 doses of 2 pills each unaccounted for. At 01:51PM, R4’s Metformin HCL 1000mg was observed. 2 bubble packs Report Continued on LIC 809-C originally contained 60 doses. Each bubble pack has 18 remaining doses, however MAR indicates 23 doses have been administered, leaving one dose unaccounted for. At 02:09PM, R1’s pm medication Melatonin 5mg was observed, which originally contained 30 doses, start date is listed as 03/23/2023. 20 days have elapsed since the listed start date. Therefore, 10 doses should remain, however LPAs observed 8 remaining doses in the bubble pack. KITCHEN: At 03:32PM, LPA Dulek observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply. At 03:34PM, LPA observed 12 cans of Annie’s Cheesy Ravioli with a best by date of 09/04/2022. At 03:35PM, LPA observed 4 cans of Hunts Tomato Paste with a best by date of 02/27/2023. At 03:35PM, LPA observed 4 cans of Siniora Chicken Luncheon Meat with a sell by date of 02/25/2021. At 03:37PM, LPA observed 3 cans of condensed milk with a best by date of 10/22/2022. At 03:42PM, LPA observed 2 packages of tofu in the refrigerator with a use by date of 03/30/2023. INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. INTERVIEWS: Throughout today’s visit, LPAs interviewed 4 (four) staff and 4 (four) residents. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 12, 2023

The state marks this report as 13 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. LPA arrived at 12:28PM and met with Facility Designee Monica Reyes. LPA explained the reason for today's visit. Entrance interview conducted. Previously, on 09/27/2022, LPA Dulek had received text message communication from Executive Director David Aguiniga indicating he was leaving his employment at the facility. On 09/30/2022, LPA received a telephone call from Carolina Garcia Trejo indicating she would be acting as Consultant/Administrator for the facility effective on that date. LPA called Licensee Narinder Kumar on 10/07/2022 and left a message regarding the facility Administrator and requested a return call. LPA did not receive a call back. LPA sent an email on 10/07/2022 outlining the necessary timeline and documents to comply with Title 22 requirements. LPA did receive an email message on 10/12/2022 indicating the Consultant/Administrator will contact LPA soon and Consultant/Administrator will comply with the requirements. LPA did not receive a call from the Administrator, but LPA did reach out via telephone to the Consultant during a previous visit at the facility on 10/20/2022. At that time, LPA received a copy of Consultant/Administrator's Administrator Certificate. However to date, LPA still has not received any other paperwork designating Consultant as Acting Administrator. During today's visit, LPA spoke to the Licensee over the phone regarding the Consultant's qualifications, other facilities, and responsibilities. Interview revealed Consultant has not been present in the facility in over a week and is currently acting as Administrator at 2 other large facilities. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 809-D). Failure to correct the deficiency may result in civil penalties. Exit interview conducted with Designee Monica Reyes, today's reports and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Nov 2, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 9, 2022

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator...shall be on the premises a sufficient number of hours to permit adequate attention... documentation. This requirement is not met as evidenced by: Based on interview and record review, the facility does not have an active Administrator, as the Administrator left before 09/30/2022 and a qualified replacement has not been designated, which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 2, 2022

Plan of correction: Licensee agreed to secure a qualified Administrator to oversee the facility operations while Designee's application for an Administrator Certificate is processed. Documents for a qualified Administrator will be sent to CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a Case Management – Deficiencies visit at this facility. LPA arrived at 12:00PM and met with Facility Designee Monica Reyes. LPA explained the reason for today's visit. Entrance interview conducted. At 02:07PM, LPA spoke with Facility Consultant/Acting Administrator Carolina Garcia Trejo, who indicated Facility Designee is authorized to sign reports for the facility. Beginning at 01:07PM, the LPA along with facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards. At 01:40PM, LPA reviewed the personnel report in the Guardian system. Review of Guardian website revealed Staff #1 (S1) who has been working in the facility since 09/30/2022 has a background clearance, but is not associated to this facility. S1 stated they were unaware they needed to be associated to this facility. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 809-D). Civil Penalties assessed in the amount of $500. Failure to correct the deficiency may result in additional civil penalties. Exit interview conducted, today's reports and appeal rights were provided via email. Civil penalties issued.the state’s words, verbatim · CDSS document, Oct 20, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 21, 2022

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...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 interview and record review, the facility did not comply with the above cited section, as S1 has been employed and working at the facility since 09/30/2022 and is not associated to the facility, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2022

Plan of correction: Designee agreed to transfer S1's background clearance to the facility prior to S1 returning to the facility. Designee will send CCL proof of S1's association to the facility prior to S1 returning to the facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kelly Dulek conducted a case management visit today to address deficiencies observed during a facility tour. LPA met with Executive Director (ED) David Anguiniga and explained the reason for the visit. Entrance interview conducted. During today's visit, LPA, along with ED toured the facility beginning at 10:17AM. During the facility tour, at 10:19AM, the door to the beauty salon, containing Barbicide liquid and scissors was observed unlocked and accessible to residents in care. At 10:22AM, crushed medications were observed on top of a medication cart, accessible to residents in care. At 10:34AM, in the memory care unit, a can of Febreze air freshener and several tubes of Calmoseptine cream were observed on a cart, accessible to residents in care. At 10:36AM, in the memory care unit, drawers containing scissors, nail clippers, hair detangling spray, incontinence wash, and Calmoseptine cream were observed to be unlocked, Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview was conducted with Executive Director David Anguiniga. Today’s reports and appeal rights were reviewed and provided via email.the state’s words, verbatim · CDSS document, Sep 7, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Sep 7, 2022

87705 (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, during facility tour, scissors were observed in both the beauty salon at 10:19AM and in the memory care unit activity room at 10:36AM accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 7, 2022

Plan of correction: Items were secured in a locked location during today's visit. Administrator agreed to provide training to all staff on section 87705(f) to all staff and provide proof to CCL to include name of trainer, date/time of training, topics covered, and a roster of attendees by 09/21/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Sep 7, 2022

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, during facility tour, Barbicide liquid was observed at10:19AM, crushed medications were observed at 10:22AM, Febreze was observed at 10:34AM and Calmoseptine cream was observed at 10:34AM and 10:36AM accessible to residents with dementia which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 7, 2022

Plan of correction: Items were secured in a locked location during today's visit. Administrator agreed to provide training to all staff on section 87705(f) to all staff and provide proof to CCL to include name of trainer, date/time of training, topics covered, and a roster of attendees by 09/21/2022.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of a subsequent visit following up on a self-reported incident report received in the Woodland Hills Regional Office on 05/04/2022. LPA met with Administrator Robert Gutierrez and explained the reason for today's visit. Entrance interview conducted. The written incident report contained information regarding an incident involving Resident #1 (R1) and Resident #2 (R2) that occurred in R2's room on 05/04/2022. During today's visit at 12:25PM, LPA, along with Administrator, reviewed the camera footage for the date of the incident. LPA interviewed Administrator throughout the visit, and LPA and Administrator toured the Memory Care at 12:58PM. No immediate health and safety concerns were observed during today's visit. LPA has determined further investigation is needed. The LPA will return at a later date to continue the investigation. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, May 10, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident report received in the Woodland Hills Regional Office on 05/05/2022. LPA met with Administrator Robert Gutierrez and explained the reason for today's visit. Entrance interview conducted. The written incident report contained information regarding an incident involving Resident #1 (R1) and Resident #2 (R2) that occurred in R2's room on 05/04/2022. During today's visit, LPA interviewed Wellness Director at 12:33 PM and Administrator at 12:38 PM regarding the incident. Additionally, LPA gathered documents pertinent to the investigation. No immediate health and safety concerns were observed during today's visit. LPA has determined further investigation is needed. The LPA will return at a later date to continue the investigation. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, May 5, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:29 PM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with Wellness Director Elda Morales and discussed the reason for the visit. Administrator Robert Gutierrez arrived at the facility at 12:48 PM. Entrance interview conducted. At 1:33 PM, the LPA, along with 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: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked. COMMON SPACES: Indoor common areas consisting of the lobby, library, Garden Room, Activity Room, dining room, Bistro, and movie room in the Assisted Living side and Activity Room and dining room in Memory Care are clean and properly furnished. A working telephone is present. The LPA observed the required postings in the common area. Fire extinguishers throughout the building were observed to be fully charged and last serviced on 02/15/2022. All hard-wired smoke alarms and carbon monoxide detectors as well as fire doors were tested during the fire inspection on 4/2/2021. The locked medication room is located in the Assisted Living side of the facility. Facility laundry room is located next to the activity room. All supplies are locked in the laundry room. Report Continued on LIC 809-C Building and grounds were observed throughout today’s visit. Patio area observed with tables and chairs and shaded seating areas for resident use. RESIDENT ROOMS/RESTROOMS: The facility has 107 bedrooms total – 24 in memory care and 83 in Assisted Living. Each resident room contains it's own restroom. Due to the situation surrounding Coronavirus 19 (COVID-19) and to implement mitigation measures, LPA did not observe occupied resident bedrooms/restrooms during today's visit. An empty recently remodeled resident room was observed to be clean and in good condition; the restroom contained sufficient grab bars and non-skid surfaces. INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, May 5, 2022

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility to conduct a Post Licensing visit. LPA observed construction in the front lobby, so there is an alternate entrance and front desk set up nearby. Upon arrival, front desk staff conducted a COVID-19 screening and contacted the Administrator Robert Gutierrez. Entrance interview conducted. LPA, along with 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. Today's evaluation included, but was not limited to, building and grounds, resident rooms, bathrooms, common areas, personal accommodations, hot water temperature in resident bathrooms, kitchen and food supplies. Currently the facility is undergoing renovations; LPA and Administrator conversed extensively about the plans to minimize resident impact during construction. There is an adequate amount of perishable and nonperishable foods. LPA observed fire extinguishers recently serviced and fully charged. Centrally stored medicines are kept in a locked medication room. First Aid kit is complete. Grab bars were present in the bathrooms. LPA observed appropriate and sufficient furnishings and lighting in each room. Hygiene items are being provided. Administrator provided documentation of fire alarm system testing, which took place on 7/15/2021, with no functional defects found. LPA observed disaster plan posted hallway. LPA observed COVID-19 postings throughout the facility. LPA observed a 30-day supply of PPE. LPA reviewed a sampling of resident medications and records. LPA reviewed a sampling of staff records. During facility tour, in the Memory Care unit, at 12:17PM, LPA observed a can of Febreze air freshener in Resident #1 (R1)’s room. At 12:20PM, LPA observed Neutrogena face wash and 2 (two) tubes of toothpaste in Resident #2 (R2)’s room. Both rooms were observed unlocked and located in the Memory Care unit. During a review of resident records starting at 1:17PM, LPA observed that some resident Admissions Report Continued on LIC 809-C Agreements have not been updated since the Change of Ownership took place on 5/1/2021. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jul 22, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jul 23, 2021

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: During facility tour, LPA observed Febreze Air Freshener spray and Snuggle air freshener in a resident room in the Memory Care unit, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2021

Plan of correction: During today's visit, Administrator removed the items from the resident's room. Administrator agreed to conduct an additional training on section 87705 with staff and submit proof of training to CCL by 8/4/2021.