Alexander Gardens

Allegation investigated: Staff do not ensure resident is allowed to have visits from family or friends. Staff do not allow resident to have access to a telephone. Staff take away resident's personal belongings.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to issue final findings for the above stated complaint allegations. Upon arrival, LPA Kontilis met with Administrator Mitch Leichter and explained the purpose of the visit. On 1/20/2026, LPA Kontilis conducted an initial complaint visit to obtain documents and conduct interviews from 12:10 pm to 2:45 pm,. On 2/3/2026, LPA conducted a subsequent complaint visit to conduct additional interviews from 11:40 am to 3:45 pm. On 2/11/2026, LPA conducted a subsequent complaint visit to conduct additional interviews from 10:48 am to 1:10 pm. LPA conducted additional interviews on 2/26/2026 and 2/27/2026. On the allegation, Staff do not ensure resident is allowed to have visits from family or friends: It has been alleged that facility staff isolated and restricted Resident 1 (R1) from certain visitors and staff “turned away” certain visitors of R1. Records reviewed and interviews conducted revealed staff screened R1’s calls when Please continue to 9099-C, Pg 2. Substantiated certain people known to R1 tried to reach R1 via the facility’s landline telephone and the callers were toldthey needed to get the “okay” from a representative of R1. Interviews revealed and records reviewed indicated staff were provided a list of individuals who were not allowed contact with R1 physically and/or telephonically. Interviews and records reviewed further revealed that staff complied with the “no contact” directions, even after Long Term Care Ombudsman (LTCO) informed the Administrator of Resident’s Rights regarding visitations, telephonic contact, and taking residents on outings. Based on the interviews conducted and records reviewed, the allegation Staff do not ensure resident is allowed to have visits from family or friends is deemed Substantiated at this time. On the allegation, Staff do not allow resident to have access to a telephone: It has been alleged that facility staff “removed” R1’s personal phone leaving R1 telephone access only through the facility’s landline telephone and only with the assistance of facility staff, and staff “blocked” certain callers from the facility phone. Interviews conducted revealed staff followed direction from R1’s Medical Power of Attorney (POA) to screen calls and to only allow certain individuals to talk to R1. Interviews conducted revealed staff diverted R1's calls when individuals called for R1, staff directed the callers to contact R1’s POA hence the calls were diverted from R1. Interviews conducted and records reviewed revealed R1’s personal mobile telephone was taken away by staff at the request of R1’s POA. Interviews conducted further revealed R1 was convinced their phone was broken and needed to be repaired. R1 stated they were at times challenged with the mobile device but did not want their phone to be taken away from them. R1 further stated they finally relinquished their phone thinking it was for repair and asked for it back after two days; but staff did not return their phone for at least one week. Based on interviews conducted the allegation that Staff do not allow resident to have access to a telephone has been deemed Substantiated at this time. On the allegation, Staff take away resident’s personal belongings: It has been alleged that facility staff “removed” R1’s personal mobile telephone leaving R1 to only have telephone access through the facility landline and only with the assistance of staff. Interviews conducted and records reviewed revealed R1’s personal mobile telephone was taken away by staff at the request of R1’s POA. Interviews conducted further revealed R1 was convinced their phone was broken and needed to be repaired. R1 stated they were at times challenged with the mobile device but did not want their phone to be taken away from them. R1 further stated they finally relinquished their phone thinking it was for repair and asked for it back after two days; but staff did not return their phone for at least one week. Interviews conducted and records reviewed, staff admitted R1’s phone was taken away from R1 and placed in staff’s desk without R1’s knowledge. Interviews Please continue to 9099-C, Pg 3 conducted revealed staff stated R1 demonstrated signs of anxiety due to losing their phone and purse; reorganizes their closet and belongings several times a day; kept losing their phone wherein family said to take it away and they would come and get it; and R1 had eye issues and could not navigate the buttons causing R1 stress. Based on interviews conducted the allegation that Staff take away resident’s personal belongings is Substantiated at this time. LPA provided Provider Information Notification (PIN) PIN 25-04-ASC Updated Authority of Conservators and Agents under Powers of Attorney Related to Residents’ Rights. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 29-AS-20260115090140

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Mar 4, 2026

87468.1(a)(11) Residents...shall have all of the...personal rights: (11) To have their visitors...and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by: Based on observation and interviews conducted, the licensee did not comply with the section cited above when staff did not allow R1's visitors without approval from others which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator agrees to use an outside vendor and/or the Department’s Technical Support Program to utilize their resources and provide training to Administrator and Staff. Administrator agrees to participate in the training along with Facility’s Managers/Directors. Administrator agrees to provide written documentation of the date the training will be held, Managers/Directors who will be attending; who will be conducting the training, and description of the training. Administrator agrees to send information to LPA via email no later than due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Mar 6, 2026

87468.1(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(12) …to keep and use their own personal possessions… This requirement is not met as evidenced by: Based on observation and interviews conducted the licensee did not comply with the section cited above when staff did not safeguard R1’s belongings when staff took R1’s mobile telephone which poses a potential personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator agrees to use an outside vendor and/or the Department’s Technical Support Program to utilize their resources and provide training to Administrator and Staff. Administrator agrees to participate in the training along with Facility’s Managers/Directors. Administrator agrees to provide written documentation of the date the training will be held, Managers/Directors who will be attending; who will be conducting the training, and description of the training. Administrator agrees to send information to LPA via email no later than due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: Mar 6, 2026

87468.1(a)(14) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls... This requirement is not met as evidenced by: Based on observation and interviews conducted, the licensee did not comply with the section cited above when staff did not allow R1 to receive calls from others which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator agrees to use an outside vendor and/or the Department’s Technical Support Program to utilize their resources and provide training to Administrator and Staff. Administrator agrees to participate in the training along with Facility’s Managers/Directors. Administrator agrees to provide written documentation of the date the training will be held, Managers/Directors who will be attending; who will be conducting the training, and description of the training. Administrator agrees to send information to LPA via email no later than due date.

Allegation investigated: Resident eloped from the facility due to lack of staff supervision.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA met with Administrator Mitch Leicter and explained the purpose of the visit. LPA Kontilis conducted the initial visit on 2/25/2026 from approximately 12:21 pm to 4:15 pm at which time Long Term Care Ombudsman (LTCO) Diane See accompanied LPA during the visit. From approximately 12:40 pm to 4:15 pm, LPA conducted interviews and obtained documents pertaining to the investigation. On the allegation, Resident eloped from the facility due to lack of staff supervision: Reporting Party voiced concern for Resident 1’s (R1’s) safety. Reporting Party reported that R1 left the facility on foot “entirely unsupervised”, R1 walked on public streets to their private residence without facility intervention, supervision, or awareness. Reporting party further reported that R1 was located at the family residence at which time, the family member returned R1 to the facility. Interviews conducted revealed R1 was active and repeatedly tried to exit through the facility front door on 2/6/2026 at approximately 2:30 pm. Records reviewed and interviews conducted revealed R1’s family had been notified of R1’s exit-attempting behavior. Interviews conducted Please continue to 9099-C, Pg 2. Substantiated and records reviewed revealed that when R1’s family member arrived at the facility at around 3:05 pm, R1 was not in their room; the staff began to search the property but R1 could not be found. R1’s family member contacted others at the family home approximately 1.6 miles away at which time it was discovered that R1 had arrived at the private residence on foot and alone. Interviews conducted revealed staff did not recall R1’s elopement however, record review revealed written documentation to verify staff was notified in writing of R1’s elopement. Interviews conducted revealed staff try to redirect residents who cannot leave unassisted; Residents’ pendants alert staff if they go off the property, and available caregivers will try to locate the resident. It is unclear if R1 was wearing their pendant or if the pendant alerted staff when R1 left the property. Record review revealed R1’s Physician’s Report (LIC 602) states R1 has a diagnosis of Aphasia and cannot leave the facility unassisted; and, R1’s Physician was informed of the elopement. Interviews conducted and records reviewed revealed staff could not determine how R1 eloped from the facility. Since the incident, Staff have implemented additional safety checks for R1. Based on records reviewed and interviews conducted, the allegation that Resident eloped from the facility due to lack of staff supervision 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 California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 29-AS-20260218172426

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 4, 2026

87468.2(a)(4)… residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above when Resident 1 (R1) eloped from the facility alone and without supervision which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator agrees to provide written plan as to safety measures that will ensure Residents do not leave the facility without supervision.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a case management visit to address a deficiency discovered during the investigation of Complaint #29-AS-20260218172426. LPA met with Executive Associate Director and Administrator Mitch Leichter on 2/25/2026 from approximately 12:20 pm to 4:15 pm. Long Term Care Ombudsman (LTCO) Diane See accompanied LPA during the visit. LPA conducted interviews with staff and obtained documents pertaining to the investigation. During the complaint investigation, it was determined that Resident 1 (R1) had eloped from the facility without supervision and the incident was not reported to Community Care Licensing Division (CCLD) as an unusual incident/injury report as required per California Code of Regulations (CCR). The following deficiency was observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 4, 2026

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events…(D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above when a resident eloped from the facility and it was not reported to CCLD within seven (7) days of the occurrence which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator agrees to submit LIC624 Unusual Incident/Injury Report with an explanation for the late reporting. Administrator agrees to submit written acknowledgement of 87211 in its entirety.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Jackie Barron, Assisted Living Coordinator. LPA explained the purpose of the visit. Administrator Mitch Leichter and Business Director Dalia Gutierrez were unavailable at the time of the inspection. At the time of arrival, there were three care staff on duty with twenty-three (23) residents in care. Entrance interview conducted. The facility is a one-story Residential Care Facility for the Elderly (RCFE) licensed for 36 non-ambulatory of which ten can be bedridden. The facility has a hospice waiver for twenty (20) residents. Currently, there are five (5) residents on hospice. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. The facility was seen to be in good repair inside and outside. There are four fire extinguishers, inspection was current as of 11/3/2025. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kits were observed to be complete. Please continue to 809-C, Pg 2. Residents participate independently in holiday and birthday celebrations, live entertainment, local volunteer group participation, Cycling Without Age, local university and community college activities, physical exercise and activities, and outings to parks, restaurants, and other local attractions. The front entry consists of a sidewalk and concrete ramp entering the facility into the reception area. The facility consists of two wings and an additional building for resident occupancy adjacent from the main building. The main building is a horseshoe shaped building with approximately eighteen residents’ rooms. The adjacent building has seven resident rooms. The facility maintains a comfortable temperature. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). Medications are administered per Physician’s orders. Review of staff records reviewed revealed Staff 1 (S1) and Staff 2 (S2) have received a criminal background clearance, however have not been properly associated to the facility. Additionally, staff records reviewed revealed a clerical error occurred during the processing of Staff 3’s (S3’s) hiring process and (S3) must undergo a new criminal background clearance in order to be cleared and associated to the facility prior to working in the facility. From approximately 12:57 pm to 1:47 pm, LPA confirmed with Community Care Licensing Division, Woodland Hills Regional Office that S1 and S2 were not properly associated to the facility and a clerical error occurred during the processing of S3’s application. Due to time restraints, LPA will return at a later date to continue the inspection. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalties issued. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.the state’s words, verbatim · CDSS document, Nov 7, 2025

Type of visit: Required - 1 Year

On 11/12/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unannounced evaluation visit. When the LPA arrived, they were greeted by Associate Executive Director Dalia Gutierrez. LPA informed facility representatives of the reason for the visit upon entry. The LPA 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. This is a Residential Care Facility for the Elderly (RCFE). This facility is approved for a maximum capacity of thirty-six (36) residents. All residents are licensed for non-ambulatory status, of which ten (10) may be bedridden. The facility has an approved hospice care waiver with the licensing agency for twenty (20) residents. The LPA inspected the food service areas in the facility and observed that items which could constitute a danger to residents are kept inaccessible to residents in the kitchen area. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. LPA observed an appropriate/adequate amount of perishable and non-perishable food items maintained in the facility. Furniture is room/resident appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, common areas, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each resident has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each resident has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always ensure clean linens for residents. Equipment and supplies for resident personal hygiene is available and on site. Continued on 809-C Activity supplies are available for residents. As the facility has an approved fire clearance for a maximum thirty-six (36) residents, a signal system was observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per CCL regulations. Food storage and preparation areas are clean and appropriate for food preparation. The food service areas are clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. Central storage of resident medications was observed by LPA, inaccessible to residents. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Fire extinguishers and smoke detectors operate properly. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed. Vehicles used to transport residents are in safe operating condition with appropriate insurance information. At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. This is a 2-story facility with residents only accessible to the 1st floor. The 2nd floor of the facility constitutes the administrative offices/Staff areas. There is a main dining room, living room, storage room, kitchen, and laundry area/game room constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use, only ramps. There is a fireplace on the premises, which is covered and inaccessible to residents. Carbon monoxide detectors were operational at the time of the visit. The fire extinguisher was fully charged and serviced annually. The facility maintained a comfortable temperature in all areas inspected. LPA did not observe any noticeable outdoor hazards. Outdoor activity spaces in the facility are shaded and equipped with furniture for resident use. The facility has adequate storage of additional supplies/emergency supplies. The designated laundry area in the facility has appropriate storage of cleaning products. Emergency food and water in storage were observed to be in good condition by the LPA. Cleaning supplies, disinfectants, and other items that could pose a danger are kept in areas inaccessible to residents. Continued on 809-C The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by residents in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per residents in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped residents who need such items. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each resident bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assisting device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. The facility has provisioned to each resident of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. An emergency exiting plan and emergency phone numbers are posted in an appropriate place. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and resident records are maintained at the facility and available for review by the LPA as employees are hired and residents accepted into the facility. The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each resident and/or their authorized representative. Resident records are maintained on the facility premises in a secured area. Centrally stored medications are locked inaccessible to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The facility administrator meets the qualifications as specified in Title 22 regulations with an active RCFE administrator certificate that expires on 02/20/2025. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. Exit interview conducted by LPA. Copy of this report provided to the facility.the state’s words, verbatim · CDSS document, Nov 12, 2024

Allegation investigated: Staff do not answer resident's call button in a timely manner.

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings for the complaint allegation above. LPA met with Dalia Gutierrez, Business Office Manager and explained the purpose of the visit. During the investigation, LPA reviewed relevant documents and conducted staff interviews on 7/16/2021, and interviews with witnesses on 7/15/2021. On the allegation: Staff do not answer resident's call button in a timely manner. It was alleged staff did not respond to Resident 1's (R1’s) call button in a timely manner. Staff stated call buttons were addressed in the resident council meeting held 7/16/2021. Staff stated the caregiver or med tech always respond to the call but may not reset the button. Other times, there could be a short delay when a caregiver is with another resident. Staff stated ten minutes response time is normal, and 20 minutes is the maximum. Staff stated they always see other caregivers check their pagers, and the batteries are checked often. Staff also stated Please continue to 9099-C, Pg 2. Substantiated sometimes residents think they used their call button but they did not actually press it hard or long enough to call for staff. Staff stated they also have alarms in their rooms or bathrooms they can pull. Staff also stated on occasion it can take them a while to answer the door if everyone is busy helping residents with care. LPA reviewed call button logs for 5/28/2021 through 7/16/2021. LPA observed numerous calls buttons that were responded to after 20 minutes. LPA reviewed the call button logs for R1 for a two-week period from 6/1/2021 to 6/15/2021 and observed that R1 frequently used their call button, up to several times per day. LPA observed for the two-week period, there were 20 calls between 21-30 minutes response time, 10 calls between 31-40 minute response time, 4 calls with a 41-50 minute response time, 1 call with a 51-60 minute response time, and 2 calls over 60 minutes response time. Based on the information obtained, the allegation is deemed Substantiated at this time. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and 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 issued at the time of the visit. and care is always prioritized. Staff stated R1 had a slip and fall during a shower on the morning shift. Ever since then, R1 was a “little more afraid” or “guarded” when it came to showers. LPA reviewed shift notes on 6/16/2021 that indicate R1 showered, fell, and the fire department responded but R1 was ok. LPA reviewed shift notes on 6/19/2021 that indicated R1 refused to shower due to the fall. LPA reviewed shift notes that indicate R1 fell in the shower on 6/23/2021. R1’s physical therapist trained all shifts on how to assist R1 but staff stated R1 was still afraid to shower. This was confirmed by notes from home health occupational therapist (OT) dated 6/24/2021, the OT discussed safe transfers and the notes recommended toilet aid for toileting hygiene, and stated on the next visit they would train facility staff on showers using the shower chair. Notes from home health OT on 7/1/2021 indicate they trained caregivers and a family member on the resident using a commode. Notes from home health OT on 7/7/2021 indicates they tried a shower chair, but R1 felt the shower chair was not safe and states to continue with commode or bed bath. Staff stated though some residents require 1 person transfer assist, they had no residents at the time who were solely 2-person transfer assists. Staff stated R1 would confuse staff and call them by the wrong names. LPA observed staff schedules for June and July 2021. LPA observed one med tech and two caregivers on the AM shift, one med tech and two caregivers on the PM shift, and one med tech and one caregiver on the NOC shift. LPA observed edits made in pen to the schedule, including adding agency staff as needed. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. On the allegation: Staff handle resident in a rough manner. It was alleged that one staff handled residents roughly when assisting residents. Staff interviews stated they had not witnessed any rough handling or heard of it. Staff also stated they had not heard of it from any families/visitors. Staff stated they never heard R1 complain about staff handling them roughly or treating them without dignity. During LPA’s visits to the facility on 7/16/2021 between 12:10 pm and 5:40 pm, on 9/29/2021 between 11:20 am and 1:20 pm, on 10/20/2022 between 2:00 pm and 3:30 pm, and on 11/20/2023 between 9:30 am and 3:30 pm, LPA did not observe any staff handle residents roughly or act inappropriately. LPA interviewed Administrator about staff performance in 2021, and no staff were subject to disciplinary action based on rough handling or inappropriate interactions with residents. LPA interviewed residents who indicated there were no concerns with the care provided by facility staff. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. Please continue to 9099-C, Pg 3. On the allegation: Resident is not accorded dignity in relationships with staff. It was alleged that facility staff made a resident who was not incontinent wear diapers because they could not respond fast enough to assist them to the restroom due to a lack of staffing. It was also alleged that on one occasion a staff refused to help a resident to the restroom. R1’s physician’s report dated 5/17/2021 does not indicate any bladder or bowel impairment. However, R1’s preadmission appraisal dated 6/2/2021 indicates R1 needs prompting to toilet regularly and is “usually” not incontinent. R1’s appraisal, needs and services plan indicates R1 needs assistance toileting and needs assistance with products such as briefs and pulls ups. Staff interviewed stated they were not aware of any incidents where residents’ personal rights were violated. Multiple staff indicated if they witnessed something inappropriate, they would not hesitate to call the other staff out or escalate the issue. Staff indicated Resident 1 (R1) was incontinent for the most part, and therefore it was appropriate that R1 to wear diapers. Staff indicated R1 always wore a pull up in case they had an accident, but often wore briefs due to their needs. R1’s admission agreement has an addendum indicating incontinent services and supplies were added to their fee starting 7/1/2021. Staff stated R1 improved due to physical therapy. Staff stated they never heard R1 complain about staff not treating them with dignity. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. On the allegation: Facility failed to safeguard belongings. It was alleged that the remote control to a resident’s mechanical bed was missing, and reporting party believed it could have been stolen by a staff. Staff stated residents have the inventory form for their personal belongings. Staff stated sometimes residents have lost hearing aids in the past. Staff stated the family is notified as soon as they find out something is missing. Families are told up front to limit expensive items brought into the facility. The facility has replaced missing items before, such as pajamas or pants, and have been offered reimbursement or credit on their fees. LPA reviewed R1’s Resident Personal Property and Valuables form signed by R1’s responsible party. The form is crossed out and “N/A” is written in the area to list personal property/valuables entrusted to the facility. Based on the information obtained, the allegations are deemed Unsubstantiated at this time. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 29-AS-20210709080012

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Jan 5, 2024

87303(i)(1) Maintenance and Operation Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall… This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when the signal system went unanswered for an extended period of time, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Business Office Director (BOD) agrees to train staff on call response expectations for the signal system, and will send proof of training to CCL by 1/5/2023. BOD recommended to conduct a call response training to all staff on a quarterly basis.

Type of visit: Required - 1 Year

On 11/20/2023, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an Annual facility Site Inspection Visit. LPA met with Administrator Mitchell Leichter and Marketing Specialist Emma Glazer, and announced the purpose of the visit. The LPA 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. This is a Residential Care Facility for the Elderly (RCFE). This facility has an age range of 60 years and older; approved/licensed for 36 non-ambulatory residents, 10 of which may be bedridden (Rooms 1-7, 9-12, 14-27). There is a Hospice Waiver for 20 residents. KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in locked drawers inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). Additional perishable food items were maintained in storage area in the garage of the facility as well as in extra refrigerator and extra freezer located in the garage of the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to residents are kept inaccessible to residents in the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both in the appropriate temperate Fahrenheit. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. Continued on 809-C COMMON AREAS: At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There is a fireplace in the living room, which is covered and inaccessible. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. This is a 2-story facility with residents only accessible to the first floor. The 2nd floor of the facility constitutes the administrative offices/Staff areas. There is a main dining room, living room, storage room, kitchen, and laundry area/game room constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity supplies and equipment, including activity materials for the residents. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use, only ramps. OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of concrete steps and an open porch with tables and chairs. The front of the facility is contained by a stone/concrete wall with a gate that remains unlocked. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Outdoor activity spaces are completely enclosed by a fence and gates or walls. Outdoor activity spaces in the backyard are equipped with furniture for resident use including a patio with an umbrella for shade. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for residents, and are well-lit. There were no bodies of water noted. The designated laundry area is where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry area is accessible through the common area of the facility as an addendum to the kitchen area. There was emergency food and water in storage area of the garage which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA noted that outside in the back yard is completely enclosed by two gates on either side of the facility and has appropriate furniture for residents as well as shade. LPA did not observe any noticeable outdoor hazards. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Continued on 809-C There are designated individual and shared resident rooms in the facility with storage areas for clean linens, towels, pillows, etc. Each resident bedroom has a single bed(s), nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. RESTROOMS: The facility restrooms were sanitized and in operating condition while the LPA toured the facility. There are multiple resident bathrooms in the facility. All restrooms inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The bathrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees. Nightlights are installed in the hallways outside of the common area restrooms. RECORDS: The facility keeps confidential storage of personnel records and resident records on-site at the facility. Personnel records reviews were reviewed for, but not limited to Personnel records, Health assessments with Tuberculosis (TB) test results, Personnel Action Notice, Job Description with date of employment, Employee Rights, Criminal record Statements/Criminal record clearances, first aid/CPR certification that is not expired, and the appropriate training. All staff member personnel records had the appropriate documentation with no expiration of any training. Resident records were reviewed for Pre-Admission/Placement appraisals, Physicians Reports, Consent Forms, Personal Rights for Residents, Emergency Information, Release of Medical Information, Needs and Services Plan (ANS), Resident Assessments, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. Centrally Stored Medications are in a locked cabinet in a medications room inaccessible/locked to residents. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. Continued on 809-C The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection 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. FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exiting plans with necessary telephone numbers. The facility has copies of the Application for an RCFE, Applicant Information, Designation of Facility Responsibility, Affidavit Regarding Client/Resident Cash Resources, Surety Bond, Personnel Report, Personnel Record, Health Screening Report, Emergency Disaster Plan for Adult Residential Facilities, Residential Infection Control Plan, Facility Sketch, Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Theft & Loss Policy, and Job Description for the Administrator. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 20, 2023