Aegis Gardens

Allegation investigated: Illegal Eviction.

On 10/6/2023 at 9:55 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed three (3) staff members. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022 and June/July 2023), and eviction letter of a sample of 5 of 5 residents. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, an illegal eviction was given to the resident and the resident’s representative. Based on interviews and record reviews conducted, all 3 staff stated if a resident’s level of care increases and the facility can not meet the care needs for the resident any longer, an eviction notice is given to the resident and the resident's representative explaining the reason for eviction. The facility determined R1’s change of condition by ongoing evaluation for R1 and conducting reappraisals which informs the facility of R1’s higher level of care on June 7, 2023. On July 8, 2022, R1 was admitted into Aegis gardens and an appraisal was conducted. The facility was able to meet R1’s care needs, however, over the course of time, R1’s care needs increased, and the facility was not able to meet R1’s care needs. The facility conducted re-appraisals for R1 when R1’s care increased. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Director of Operations, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230718160825

Allegation investigated: Licensee initiated eviction process in retaliation against resident.

On 10/6/2023 at 9:25 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed three (3) staff members at 12:50 PM. LPA requested and obtained the following documents: Staff roster with contact information, Residents’ roster, Admission agreement, Physicians reports, Individualized service plans (ISPs), Individualized service assessment (ISA), progress notes (July 2022, and June/July 2023), and Physicians report form of a sample of 5 of 5 residents. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, licensee initiated eviction process in retaliation against resident. Based on interviews conducted, all three (3) staff members stated the reason for eviction is due to a higher level of care. All 3 staff stated when a resident’s care increases, and the facility can not meet a resident’s needs any longer, an eviction process is applied. This eviction process was not due to retaliation of R1. Reporting Party (RP) did not disclose any information to LPA regarding the reason the eviction process was based on retaliation. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Director of Operations, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230711115733

Allegation investigated: Staff improperly administered resident's medication.

On 10/6/2023 at 9:35 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed five (5) staff members and five (5) residents. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022), and Medication administration record (MAR) of a sample of 5 of 5 residents. Continue on Lic9099-C Substantiated Continue from Lic9099 It was alleged that, Staff improperly administered resident's medication. Based on record review conducted, LPA communicated with RP and it was confirmed that R1’s medication was crushed and given to R1 without a physician’s order on July 8, 2023. On July 11, 2023, a request was sent to the primary physician to crush medication for R1 and on July 12, 2023, R1’s physician approved request to crush medication for R1. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D Exit interview conducted with Director of Operations, and a copy of this report provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230712154204

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

87465(e) Incidental Medical and Dental Care:(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician... This requirement is not met as evidenced by: Based on observation, and record review, the licensee did not comply with the section cited above by crushing R1's medication prior to submitting a physicians order to R1's primary physicians to crush medication which poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Administrator agreed to submit a self-certification on section 87465(e) Incidental Medical and Dental Care by explaining how will this be avoided in the furture and to understand the reguation. All med techs, administrators, health service directors, nurses, and care directors will date and sign self-certification and submit to CCL by POC due date.

Allegation investigated: Staff did not treat residents with dignity and respect. Staff did not include resident's responsible party in the reappraisal process. Facility is charging resident for services not agreed upon.

On 10/6/2023 at 9:45 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed five (5) staff members and five (5) residents. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022), and Medication administration record (MAR) of a sample of 5 of 5 residents. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, Staff did not treat residents with dignity and respect and staff did not include resident's responsible party in the reappraisal process. Based on interviews and record review conducted. All 5 staff stated that the care given to residents is good and that the staff tends to residents’ care needs at all times. Residents are treated with respect and cared for when residents needs assistance with anything. 4 of the 5 residents interviewed stated that they do not have any concerns with care and that they are treated well in the community. During record review, LPA communicated with S1 and confirmed that there was a re-appraisal conducted for R1 and R1's representative was notified. It was alleged that, Facility is charging resident for services not agreed upon. Based on interviews and record reviews conducted, family staff communicated with LPA and confirmed that RP was notified regarding R1's level of care is increasing, and that the facility wants to hold a meeting to further speak about R1’s care. Staff stated that R1 is in need for a one on one due to resident’s higher level of care. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Director of Operations, and a copy of this report providedthe state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230712154204

Allegation investigated: Staff did not dispense medication according to doctor's orders.

On 9/27/2023, at 1:46 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10- day complaint investigation visit on the above allegation. LPA was greeted by Gigi Tamayo- Registered Nurse (RN), Angel Lee, Director of operations and explained the purpose of the visit. During visit, LPA collected the following documents for R1, R2, R3, and R4: Residents roster with contact information, staff roster, Incident reports (June and August 2023), Physicians reports, doctors’ orders (June and August 2023), and Medication administrative record (MAR). LPA interviewed 4 staff members at 2:36PM. Continue on Lic9099-C... Substantiated Continued from Lic9099... It was alleged that; Staff did not dispense medication according to doctor's orders. Based on Interviews, and record review conducted, S1, S2, S3, and S4 stated that S4 accidentally grabbed the incorrect eye drop bottle and was about to administer medication to resident on 8/19/2023. Reporting Party (RP) noticed S4 was going to use the incorrect eye drops, and RP stopped S4 before administering the eye drops into R1's eyes. S5 was a witness when RP realized S4 grabbed the incorrect eye drop bottle. The correct eye drops for R1 was grabbed and administered to R1 accordingly. S4 was suspended from the community until the investigation was finished. On 6/23/2023, a different staff had provided multiple drops into R1's right eye and should have only gotten one drop. LPA conducted record review, which confirmed that S4 made a medication error dated 6/23/2023, which was self reported to CCL. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted with RN, and a copy of this report provided along with appeal rights.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 15-AS-20230822140553

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 30, 2023

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not making sure the physicians order for R1's eye drop medication is being used accordingly. On 6/23/2023, facility staff administered the incorrect amount of eye drops into R1's right eye which poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator agreed to set a plan to complete monthly medication training and to complete comtentency check lists every month and to submit proof of medication training and comtentency check list to CCL by POC due date.

Type of visit: Case Management - Other

On 9/29/2023, starting at 10:10 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 8/23/2023. LPA met with Gigi Tamayo, Registered Nurse (RN) and informed her the reason for visit. During visit, LPA obtained original report dated 8/23/2023 from RN. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2023

Type of visit: Case Management - Other

On 9/22/2023, starting at 10:07 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 8/24/2023. LPA met with Emily Poon, General Manager (GM) and Gigi Tamayo Registered Nurse (RN), and informed them the reason of visit. During visit, LPA obtained original report dated 8/24/2023 from RN. No deficiencies are being cited on this date. Exit interview conducted with GM, and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 22, 2023

Type of visit: Case Management - Other

On 9/7/2023 starting at 9:05 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 6/9/2023. LPA met with Gigi Tamayo, RN and informed her the reason for visit. During visit, LPA obtained original report dated 6/9/2023 from RN. No deficiencies are being cited on this date. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 7, 2023

Allegation investigated: Due to lack of supervision, resident had multiple falls. Staff stole residents’ belongings. Staff did not keep resident’s personal information confidential. Staff discouraged resident in using pendant frequently. Due to insufficient staffing, resident was transported to the dining room an hour early.

On 8/30/2023 at 5:30 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a complaint investigation visit and to deliver findings on the above allegations. LPA met with Gigi Tamayo, Register nurse (Rn) and explained the purpose of today’s visit. During the course of the investigation, LPA obtained the following documents: Staff roster with contact information, Physicians report, Incident reports, death report, after visit summary, physicians fax report, Individualized service plan (ISP), property and values form, progress notes (October 2022, December 2022, January 2023, and May 2023). During today’s visit, LPA interviewed five (5) staff and five (5) residents at 5:36 PM. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that; Due to lack of supervision, resident had multiple falls, and staff stole resident’s belongings. Based on interviews conducted, Rp stated that she believes that it is not the facilities fault for resident having a fall. All 5 staff members stated residents are able to use their pendant to call for staff at any time when a resident is requesting assistance from staff members. Staff members have confirmed with LPA that a safety checks are done by staff to ensure all residents are okay and safe. R1, R2, R4, and R5 stated that their belongings were not missing while in care by staff. It was alleged that; Staff did not keep resident’s personal information confidential, and Staff discouraged resident in using pendant frequently. Based on interviews conducted, All 5 staff and all 5 residents stated that staff allows residents to push their pendants any time they want without any restriction when a resident needs assistance. It was alleged that; Due to insufficient staffing, resident was transported to the dining room an hour early. Based on interviews conducted, All 5 staff and all 5 residents stated that staff takes residents to the dining area 20 to 30 minutes prior to mealtime. Staff have also stated some residents enjoy going to the dining area early so resident can watch staff prepare for meals and speak to staff while waiting for their meals. S5 stated staff will knock on the resident’s door as a reminder to go to the dining room. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED. Exit interview conducted with RN, and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2023 · control 15-AS-20230608092900

Allegation investigated: Facility staff did not seek medical attention for resident in a timely manner.

On 2/15/2024 at 10:10am, Licensing Program Analysts (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to redeliver complaint findings for the above allegation. LPAs met with Angel Lee, Director of Operations, and explained the purpose of the visit. Gigi Tamayo, Health Services Director arrived at 10:30am. During the course of the investigation, LPA L. Fici interviewed four (4) staff members, five (5) residents, Reporting Party (RP), obtained and reviewed the following documents: staff roster, resident roster, the physician’s report, incident reports, progress notes, medication administrative record (MAR), and communication documents between the facility and the physician for R1. Continued on LIC9099C. Unsubstantiated The department received additional information from RP and all documents, and the interviews conducted by former LPA, L. Fici, was re-reviewed by LPA, L. Hall. LPA met with and delivered the amended report. Allegation: Staff did not seek medical attention for a resident in a timely manner. The RP stated it took the staff approximately 45 minutes to contact 9-1-1 for resident (R1). Based on interviews and record review, including 2 incident reports, R1 was given the wrong medication (belonging to another resident) around 8:00am on May 28, 2023. The staff (S1) notified S4 (registered nurse) around 9:24am of the error, this was the time S1 had realized the mistake had occurred. S4 immediately conducted an assessment with R1, including taking vitals in the presence of R1’s family. The vitals were stable and R4 informed R1’s doctor via fax of the error. Around 10:15 am R1 was observed to be ‘sleepy’ and vitals were rechecked and observed to have changed. At this time, 9-1-1 call was immediately made and R1 was transported to Kaiser Hospital. R1 was discharged back to the facility on May 29, 2023. Based on record review of communication between the facility and the physician. It indicates that the facility had sent notification to the physician at 10:07am on May 28, 2023, that contained the medication that was taken and R1’s vitals that were taken when S4 was first notified. The physician replied on May 30, 2023, that R1 had been seen in the emergency department. Review of previous complaint dated June 1, 2023, control #15-AS-20230601140155, the Health Service Director (HSD) submitted a plan that will provide training in medication errors, assess the medication assistance process, and make the necessary changes to prevent errors. The Health Service Director also will enforce documentation standards for medication policy per the plan submitted to Community Care Licensing Department. Based on Interviews conducted, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with RN, and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2023 · control 15-AS-20230613151024

Allegation investigated: Staff charged residents for services not received.

On 8/23/2023, at 1:46 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10- day complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Gigi Tamayo- Registered Nurse (RN) and explained the purpose of the visit. During visit, LPA reviewed the following documents: Residents roster, Identification and Emergency Information (Lic601), Admissions agreement, Statement billing log, Aegis gardens contract, and Needs and service plan of a sample of 6 of 6 residents in care. LPA interview S1, S2, and S3 at 3:36 PM, and representatives of R1, R2, R3, R4, R5, and R6 at 4:45 PM. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, Staff charged residents for services not received. Based on interviews and record review conducted, S1, S2, and S3 stated that tray service was complimentary during the time when the facility had a Covid-19 outbreak, and no residents were charged. All three staff stated tray service is the only service that is complimentary during a Covid-19 outbreak. LPA confirmed with S1, S2, and S3 that if tray service was charged, a refund is granted back to the residents’ representative. LPA interviewed and spoke to R1- R6’s representatives, and they have all stated that were was no extra charge made by Aegis Gardens for tray services during COVID-19 outbreak. In addition, R1-R6 were not charged for escorting and eating supervision during the time of Covid-19 outbreak dated for October 16 - November 17, 2022, January 01-23, 2023, and February 06-16, 2023. LPA reviewed residents’ statement invoices which indicated there were no extra service charges made to the residents’ representatives by Aegis Gardens. Based on Interviews and record review conducted, Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with RN, and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 15-AS-20230817132333

Type of visit: Case Management - Other

On 7/19/2023 at 1:08 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a Case Management. LPA met with Gigi Tamayo, Registered nurse (RN). When LPA L. Fici opened a 10-day initial complaint visit (15-AS-20230711115733) on 7/19/2023. R1 was hospitalized on 1/30/2023, and returned to the community on 2/4/2023. LPA observed R1 with a restricted health condition and reviewed R1's file and observed facility did not request an exemption before re-admitting R1 with a restricted health condition. S1 stated that the facility did not request an exemption. The following deficiency was observed: - On 7/19/2023, LPA reviewed R1's file and did not observed an exemption for a restricted health condition. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 19, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87612(a)(2) · Plan of correction due date: Jul 26, 2023

87612(a)(2) Restricted Health Conditions: (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (2) Catheter care as specified in Section 87623. This requirement is not met as evidenced by: Based on observation, and record review, the licensee did not comply with the section cited above by not submitting a exception for a restricted health condition for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 19, 2023

Plan of correction: Administrator agreed to request an exception for R1 for a restricted health condition to CCL by POC due date.

Type of visit: Required - 1 Year

On 7/5/2023 starting at 1:20 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Emily Poon, Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6003257740) is valid and expires on 3/25/2024. The facility’s fire clearance was approved for eighty-five (85) non- ambulatory residents, which forty-three (43) may be bedridden and 4 residents may be on hospice. Upon entry, LPA observed five (5) staff and seven (7) residents present during inspection. Starting at 1:50 PM, LPA toured facility with ADM including but not limited to sixty-four (64) bedrooms and 69 bathrooms, kitchen, common area and backyard. The facility consists of 64 total private bedrooms which 10 bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ bathroom was measured at 117.7 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 7/20/2022. First aid kit was observed to be complete. Continue on Lic809-C Continued from Lic809 Starting At 2:23 PM, LPA reviewed 10 of 10 staff records. At 3:16 PM, LPA reviewed 10 of 10 residents' record. At 4:26 PM, LPA reviewed a sample of 10 of 10 residents' medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/12/2023: · LIC 308 Designation of Administrative Responsibility · LIC 500 Personnel Report · LIC 610D Emergency Disaster Plan (9 Pages) · Liability Insurance No deficiencies cited during visit. Exit interview conducted with ADM, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 5, 2023

Type of visit: Case Management - Other

On 6/23/2023 starting at 11:25 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 6/9/2023. LPA met with Gigi Tamayo, Registered Nurse (RN) and informed her the reason for visit. During visit, LPA obtained original report dated 6/9/2023 from RN. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Jun 23, 2023

Type of visit: Case Management - Deficiencies

During the course of investigation of a complaint (15-AS-20230608092900), Licensing Program Analyst (LPA) L. Fici learned that resident (R1) sustained a fall on 10/16/2022, 12/20/2022, and 5/9/2023. Review of records revealed the facility did not submit incident reports to CCL on a timely manner. LPA discussed with Gigi Tamayo, RN, Emily Poon, Administrator, and Angel Lee, Director of operations, the above incidents, and Title 22 Reporting Requirement. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12-month period may result in civil penalty. Exit interview conducted with RN, and a copy of this report given along with appeal rights.the state’s words, verbatim · CDSS document, Jun 9, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jun 16, 2023

87211(a)(1) Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by not submitting incident reports (Lic624s) to CCL regarding R1's falls which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 9, 2023

Plan of correction: Adminisatror agreed to read and understand section 87211(a)(1)- Reporting Requirements, and to submit a signed self-certification to CCL by POC due date.

Allegation investigated: Staff mismanaged resident's medications. Staff overmedicated resident.

On 6/6/2023, at 12:05 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10- day complaint investigation visit and to deliver complaint findings on the above allegations. LPA was greeted by Gigi Tamayo- Registered Nurse (RN) and explained the purpose of the visit. During the visit, LPA interviewed one (1) resident, and two (2) staff members. LPA obtained the following documents: Staff & resident roster, current staff medication training log, Staffs medication error statement, Physicians report, Incident reports (May 2023), Progress notes (May 2023), and medication administrative record (MAR). Continue on Lic9099-C Substantiated Continued from Lic9099 It was alleged that, staff mismanaged resident’s medications, and staff over-medicated resident. Based on interviews and record review conducted, S1 confirmed with LPA that S2 mistakenly gave R1 eleven (11) types of oral medications from another resident in care on 5/28/2023. While interviewing S2, S2 confirmed with LPA that she mistakenly gave 11 types of oral medications to R1 on 5/28/2023 at approximately 8:15 AM. S1 submitted an incident report regarding medication error on 5/29/2023. LPA reviewed discharge notes for R1, which indicates that R1 had a medication overdose due to taking incorrect medication. LPA reviewed incident reports, progress notes and staff medication error statement from S2 and S3 which indicated that R1 was given the wrong medication and R1 had a medication overdose on 5/28/2023. Facility staff called 911 for further evaluation, and R1 was admitted to the hospital and returned to the facility the next day 5/29/2023, at approximately 5:30 PM. Based on LPAs interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted with RN, appeal rights given along with a copy of this report.the state’s words, verbatim · CDSS document, Jun 6, 2023 · control 15-AS-20230601140155

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 7, 2023

87411(a) Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not giving R1 the correct medications and mistakenly giving R1 another residents medication which posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2023

Plan of correction: Administrator agreed to submit a plan to LPA to conduct additional medication in-service training with a skilled nurse and to have training signed by all med techs and to submit proof of signed in-service training to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 7, 2023

87465(c)(2) Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by overmedicating R1 with incorrect medication that did not belong to R1 which posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 6, 2023

Plan of correction: Administrator agreed to submit a plan to LPA to write a self-certifcation on section 87465(c)(2)-Incidental Medical and Dental Care and to have all med techs read, understand, and have it signed and to submit a copy of the signed self-certifcation to CCL by POC due date.

Type of visit: Case Management - Incident

On 6/6/2023 at 10:20 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit regarding an incident report received on 5/20/2023. LPA met with Gigi Tamayo (RN) and explained the purpose of the visit. Incident report dated for 5/18/2023 revealed that Resident 1 (R1) reported ingesting calligraphy ink during facilities activity. RN stated that resident was doing calligraphy as part of resident’s activity in the facility. S1 informed RN that the resident had black ink all over her hands and mouth. S1 observed resident's hands and mouth with black ink, S1 asked S2 to help clean resident’s hands and mouth, and S3 informed RN about the incident. Facility staff took R1's vital signs and assessed her if R1 had any pain from ink. Facility called 911 for further evaluation. R1's representative was notified, poison control was notified and RN stated that poison control could not find much information if the ink was harmful to ingest. R1 returned to the facility on 5/18/2023 with no concerning health issues. LPA collected the following documents: After visit summary, and Physician's visit report form. No deficiencies cited during visit. Exit interview conducted with RN and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 6, 2023

Type of visit: Case Management - Other

On today’s date around 1:10 PM. Licensing Program Analyst (LPA) L. Fici and Licensing Program Manager (LPM) Y. Flores-Larios arrived unannounced to conduct a case management visit. LPA and LPM met Health and Services Director, Cathy Zhou and explained the purpose of the visit. During inspection conducted on 7/20/2022, census was reported as 97; however, facility is licensed for 85. LPA and LPM requested residents roster which reflected census of 73. LPA and LPM conducted an interview with Emily Poon- General Manager (GM). GM stated that the census is 97% as they only have two vacant apartments at the moment, Facility capacity is under 85. Current census is 73. LPA and LPM confirmed facility is not over capacity. No deficiencies cited on todays visit. Exit interview conducted with General Manager. Copy of report was handed to provider.the state’s words, verbatim · CDSS document, Aug 4, 2022

Type of visit: Required - 1 Year

On today’s date 7/20/22 around 1:00pm, Licensing Program Analysts (LPAs) L. Fici and J. Sampair arrived unannounced to conduct an annual Infection Control Inspection. LPAs met with Health service director, Cathy Zhou and explained the purpose of visit. LPAs toured facility with service director including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, Covid questionnaires, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Continue on Lic809-C Continued on Lic809-C The following forms are to be updated and submitted to CCLD By 7/27/22. - LIC500- Personnel Report - An updated copy of Administrator certificate No deficiencies cited on todays inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 20, 2022

Type of visit: Case Management - Incident

On 7/20/22 at 10:40AM, Licensing Program Analysts (LPAs) J. Sampair and L. Fici arrived unannounced to conduct a case management visit concerning a 7/3/22 incident report. The LPAs met with Health and Services Director, Cathy Zhou. In the 7/3/22 report, Staff 5 (S5) was accused by Resident 2 (R2) of hitting their spouse, Resident 1 (R1) on 7/2/22. Facility notified Ombudsman, but not the police. During this case management visit, the LPAs reviewed records and conducted interviews of residents and staff. The record review of S5 found no previous complaints and up-to-date training. During the interviews of three (3) staff members and one (1) resident, though neither were R1 or R2 due to their current condition, the LPAs found concurrence with the findings of the internal investigation that there was "no evidence" that S5 had hit R2. S5 returned to work on 7/5/22. LPAs collected the following documents: staff roster, resident roster, and a copy of internal investigation. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 20, 2022

Type of visit: Case Management - Incident

On 12/30/2021 at 1:40PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit regarding an incident report received on 12/28/2021. LPA met with Health and Services Director, Cathy Zhou and Emily Poon, General Manager. Incident report dated 12/28/2021 revealed that Resident 1 (R1) reported abuse from Staff 5 (S5). Facility notified law enforcement and R1's responsible party. LPA interviewed three (3) of four (4) staff. LPA was not able to interview Resident 1 (R1) due to diagnosis. Interview with Staff 1 (S1) revealed that S5 was the caregiver for R1 on the day of the incident. R1 was being assisted by S5 in the bathroom when the incident occurred. R1 reported the incident to Staff (S4). S4 reported the incident to S1. S5 was suspended immediately and after the investigation was terminated on 12/28/2021. Facility will be conducting an abuse training for all staff on 1/5/2022. LPA collected the following documents: Staff roster, Resident roster, and training documents for S5. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 30, 2021