Arcadia Gardens Retirement Hotel

Allegation investigated: Resident sustained an injury due to staff neglect or physical abuse.

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on 07/27/2026 to deliver findings regarding the above allegation. LPA was greeted by Executive Director Pamela Parsons and facility staff. LPA explained the purpose of the visit. During the investigation, LPA reviewed and obtained copies of the Resident Roster, Staff Roster, R1's Face Sheet, Physician's Report, Admission Agreement, Care Plan, Resident Assessment, skin assessment records, physician's orders, nurse charting, medication prescriptions, and a copy of the in-service training provided to caregivers regarding resident dementia care. LPA also conducted a tour of the facility, observed the resident's condition and care environment, and interviewed five (5) staff members (S1–S5), nine (9) residents (R1–R9), and one (1) witness (W1). (continued on 9099C) Unsubstantiated Allegation: Resident sustained an injury due to staff neglect or physical abuse. It is alleged that R1 sustained an injury due to staff neglect or physical abuse. During staff interviews, staff consistently reported that R1 has fragile, thin skin and is prone to developing bruising or discoloration due to their advanced age and medical condition. Staff stated that R1 frequently resists personal care, including bathing, repositioning, and incontinent care, requiring two caregivers to assist. According to staff, care is provided to R1 by explaining each step of the process, offering reassurance, and returning later if R1 refuses assistance. Staff denied using excessive force, restraining R1, or physically abusing them. Staff further reported that the facility requested protective arm sleeves (geri sleeves) through R1's physician to help prevent additional skin injuries due to their fragile skin. During resident interviews, most residents reported that staff treat them with dignity and respect and provide assistance when needed. Although some residents reported occasional delays in staff response, they indicated their needs were ultimately met and expressed overall satisfaction with the care provided. None of the interviewed residents reported concerns regarding staff neglect, physical abuse, or inappropriate treatment of residents. During R1's interview, R1 was alert, communicative, and able to respond appropriately to interview questions. R1 stated they enjoy living at the facility, like the staff, and reported that staff treat them with dignity and respect. R1 did not disclose concerns regarding neglect or physical abuse. During the witness interview, W1 reported being aware of the discoloration observed on R1's arms and stated the concern had been discussed with the facility Administrator. W1 reported believing the discoloration was consistent with R1's fragile skin, advanced age, and prolonged bed bound status rather than abuse or neglect. W1 further reported visiting R1 approximately twice weekly, expressed no concerns regarding the care being provided, and stated that R1 reported being treated appropriately by staff. During observations, LPA toured the facility and observed resident rooms to be clean, well maintained, and free of objectionable odors. Residents appeared clean, appropriately groomed, and receiving care consistent with their needs. R1 was observed finishing lunch, appeared frail but well groomed, was in good spirits, and did not exhibit signs of distress. R1's room was clean and organized. No observations were made during the visit that were consistent with staff neglect or physical abuse. Based on the investigation conducted, which included interviews with staff , witness and resident, as well as a review of relevant records, there was insufficient evidence to support the reported allegation. 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 was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 28-AS-20260108125252

Allegation investigated: Staff mismanaged residents' medications.

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegation. LPA met with Administrator Pamela Parsons and explained the reason for the visit. The initial visit was conducted on1/08/26 and included the following: LPA requested copies of staff/resident roster. LPA reviewed file for Resident (R1) and received copies of identification and emergency sheet, admission agreement, and physician’s report. LPA interviewed Director of Nursing Suzana Zadourian and Staff S1 telephonically. Documentation named Narrative Charting was also submitted for 12/27/25 -12/30/25. Medication List for Resident R1 was submitted for 12/10/25- 01/09/26. At today's visit 6/6/26 interviews were conducted with Administrator Pamela Parsons, and Staff S2 - Staff Staff S5. Interviews were conducted with Resident's R1- R15. In regards to the allegation Staff mismanaged residents' medications, based on interviews conducted and information gathered Director of Nursing Suzana Zadourian confirmed that there was a medication error Substantiated in which Resident R1 was administered medication by a nurse after mistakenly being identified as Resident R2. Stated that R1's identify was not verified and was thus given R2's medication. Afterwards staff reviewed the medications that were administered to R1 and they were not serious medications in being stomach medications and that R1 would have to wait a number of hours to take the medications that are always prescribed to R1. Staff S1 confirmed that there was a mismanagement of R1's medication and that it was corrected the same evening. Staff S2 stated that there was a mix up in which Resident R1 was given in error Resident R2's medication. Staff S3 stated that she had mistakenly mixed up Resident R1 and R2 and that R1 by error was given R2's Medication. Administrator revealed that the staff did communicate that R1 was given R2's medication, but R1 was given the correct meds the same evening. Interview with R1 who stated that there was 1 time that they administered medication incorrectly and had given him R2's medication by mistake. Stated he did get his prescribed medication shortly thereafter. Interviews were conducted with Resident's R2- R15 who stated that they had received their medication and that they were never given incorrect medication belonging to another resident. Document Narrative Charting lists 12/17/25 notes regarding a medication error involving R1 mistakenly being administered medication that was prescribed to R2. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies are being cited according to California Code of Regulations, Title 22. Resident R1 stated that his prescribed medications were given to him shortly after the incorrect medication was given. R2 stated that staff pick up his meds and also give him his meds. Said 1 thing he doesn't have to worry about is medication because staff does a great job. Also said that staff has never missed giving him his doses of medication each day. 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. An exit interview was conducted and a copy of this report was discussed and provided to facility Executive Director Pamela Parsons.the state’s words, verbatim · CDSS document, Jun 6, 2026 · control 28-AS-20251229105321

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 7, 2026

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by Resident R1 being administered incorrectly R2's medication which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 6, 2026

Plan of correction: The licensee shall conduct medication training regarding medication administration and how to ensure medications are dispensed to the correct resident at all times. Training date to be submitted by POC due date and a signed log of those who attended once completed. Training was conducted on 12/29/25 Proper Medication Administration 1/3/26 Communication and Confidentiality and Proper Procedures. Deficiency cleared.

Allegation investigated: Staff is refusing to provide the residents' family with residents' facility file.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent unannounced complaint investigation visit regarding above allegations. LPA met with Executive Director Pamela Parson and explained the reason for the visit. The investigation consisted of the following: During the initial visit conducted on 02/05/2026 LPA requested a copy of resident roster and staff roster. LPA interviewed staff 1-2 (S1-S2). LPA requested documents for R1 to be emailed or mailed as soon as possible. On 02/11/2026 LPA interviewed Executive Director over telephone. On today’s visit LPA interviewed witness #1 (W1), obtained emails between POA and facility, along with a copy of face sheet for R1.LPA also delivered findings. See 9099C Unsubstantiated In regard to the allegation “Staff is refusing to provide the residents' family with residents' facility file”, it is alleged that facility will not release file records to R1’s family. During interviews with Executive Director and staff all three stated they do not remember R1. R2 stated that he/she received email correspondence and was looking for file for R1 but could not find them. Executive Director informed LPA that there were able to find a handwritten face sheet for R1 with emergency contact information. Executive Director contacted the POA and was told that R1 resided at facility in 2018 for no more than 6 months. LPA was able to confirm dates of R1’s stay with W1. LPA obtained a copy of face sheet dated 09/13/2018. Per section 87506(e) Resident Records Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Pamela Parsons.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 28-AS-20260203154746

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Director of Nursing Suzana Zadourian. Nursing director assisted LPA with the visit and facility tour. Administrator, Pamela Parsons, arrived shortly after and assisted with the facility tour. The facility is licensed and has Fire clearance approval to serve for a capacity of 175 non- ambulatory residents including 25 bedridden residents, ages 60 and above. The facility has an approved Hospice Waiver on file for twenty-three (23) residents. Eighteen (18) residents currently on Hospice. Facility has an approved Dementia Care Plan in their plan of operation and accept residents with dementia. Facility does not handle residents’ monies. During the visit, a tour of the facility, review records and interviews with staff and residents’ consisted of the following: 1. Infection Control: Infection control practices were observed. Infection control plan is on file. 2. Physical Plant/Environment Safety: The facility is in a residential neighborhood, consists of three floors and has 189 resident bedrooms and 189 resident bathrooms. Level 1 has resident bedrooms, memory care unit, recreation/activity rooms, beauty shop, storage rooms, employee lounge, library, and laundry rooms. 2nd level is memory care, reception/lounge area, resident bedrooms, dining room, kitchen, multiple offices, recreation/activity rooms and laundry rooms. 3rd level consists of resident bedrooms, nurse's office, medication room, penthouse, recreation/activity rooms and laundry rooms. CONTINUED ON 809C.................. A physical tour was conducted. LPA randomly toured resident rooms on each floor in building sections A, B, C, D, E and F. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 105.0 – 120.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. The resident rooms are equipped with a signal system located in each restroom and facility phones to call the front desk. Facility had central air and heating accommodations in the common areas. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable at the memory care unit at the lower level. Interior and exterior space is available to permit residents to walk in safe and comfortable environments. 3. Operational Requirements: The Program Design was reviewed. Fire clearance approved for 175 non- ambulatory residents, 25 bedridden residents, ages 60 and over. Floor of bldg. F & second floor of bldg. F cleared for dementia wings/ with delayed egress. Each dementia unit consisting of 11 rooms. May retain twenty-three (23) Hospice residents. Eighteen (18) residents currently on Hospice. Care and supervision to meet the residents’ needs was observed. Liability insurance expires 02/28/2026. 4. Staffing: One hundred and two (102) full-time staff and twenty nine (29) part-time staff members provide care and supervision to the residents. 5. Personnel Records/Staff Training: Five (5) staff files were reviewed for criminal background clearance and training. All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR training that are active. Administrator certificate is current and expires on 07/31/2026. 6. Incident Medical and Dental: All residents have an Appraisal/Needs and Services Plan on file. Staff training was on file. CONTINUED ON 809C...................... 7. Resident Rights/Information: Physician orders were reviewed for five six (6) resident files. Medications were also reviewed for six (6) residents. Medications are centrally stored and locked in the nurse's office on the third floor. First aid kit is fully stocked. Mandated documents and signages are posted in common areas. Resident records are stored in a locked cabinet and inaccessible to residents. 8. Resident Records/Incident Reports: Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Resident records are stored in a locked cabinet and inaccessible to residents. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Staff is adhering to residents' meal plans as per physicians orders for mechanical/ diabetic diets Sufficient food supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Food is stored in covered containers at the appropriate temperatures. Pesticides or poisons are not stored in the food areas, stored in separate closet inaccessible to residents. Freezer and refrigerator has required temperatures, which was within Title 22 Regulation guidelines. 10. Disaster Preparedness: Emergency and Disaster Plan (LIC610E) was found in the facility. The last Fire/Emergency Drill are conducted quarterly on by third-party company on 11/08/25 PM and NOC shift. 11/10/2025 AM shift safety drills were conducted. Smoke and carbon monoxide detectors are operable and in compliance. Fire extinguishers were last serviced on 02/06/26 are fully charged and in compliance. 11. Planned Activities: Sufficient Space is provided to accommodate both indoor and outdoor activities. Sufficient equipment and supplies are provided to meet the requirements of the activity program. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. Outside grounds were toured and pool/spa area with self-latching fenced gate was observed. The outdoor activity area has a shaded patio with ample seating. 12. Residents with Special Health Care Needs: Eighteen (18) residents are receiving hospice services. There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview was held with Administrator and a copy of annual facility inspection report was provided.the state’s words, verbatim · CDSS document, Feb 10, 2026

Allegation investigated: Licensee did not issue a timely refund of advance fees as required.

The census of 233 indicated on the report is not correct the correct census is 133. Licensing Program Analysts (LPAs) Vaid and Mallett conducted 10-day unannounced complaint visit, was met by Administrator Pamela Parsons and the purpose of the visit was discussed. Toured the facility interviewed staff/residents. Did not observe any health and safety concerns. The investigation consisted of the following: LPA Vaid requested, obtained and reviewed the staff/ residents’ roster, resident inquiry sheet, admissions agreement. Regarding the allegation: Licensee did not issue a timely refund of advance fees as required. It is alleged that the facility failed to provide resident timely refund for deposit paid in advance. Five (5) out of five (5) staff interviewed deny this allegation. Three(3) out of Five (5) staff acknowledge the refund was valid. According to staff interviewed the refund was delay due to incomplete correspondence between the admissions and accounting departments. Staff have admitted to the oversight made of not refunding fees within fifteen (15) days of written notification. CONTINUED ON 9099C.............. Substantiated Review of the admissions agreement: Appendix C, 4. Timing of Refund/Credit- Any refund due under Section 3 above shall be paid to you within fifteen (15) days of issuing the notice of termination. Facility was notified by residents’ family on 07/05/25, in writing due to facility not being able to provide the level of care needed for the resident. Correspondence between residents’ family and admissions manager, agree higher level of service needed and facility not able to provide. Seven (7) out of eight (8) residents interviewed could not corroborate this allegation, residents did not have issues with refunds from the facility. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies are being cited according to California Code of Regulations, Title 22. Citation was issued, exit interview was conducted with Pamela Parsons-Administrator. A copy of this report 9099, 9099C and 9099D were given. Copy of Appeals rights given.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 28-AS-20250805142616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(E)(1)(a) · Plan of correction due date: Aug 5, 2025

87507-Admissions agreement. (E) Preadmission fees shall be refunded according to the following conditions: 1. A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: a.The applicant decides not to enter the facility prior to the facility completing a preadmission appraisal as defined in Section 87457. This requirement was not met by: the facility failed to refund advanced deposit to resident within fifteen days as wriiten in the admission agreement.the state’s words, verbatim · CDSS document, Aug 12, 2025

Plan of correction: Facility to provide LPA with proof of refund. Administrator to provide a signed statement understanding of the company refund policy. Send to LPA by 8/19/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual inspection visit. LPA met with Administrator, Pamela Parsons, and Director of Nursing Suzana Zadourian. Nursing director assisted LPA with the visit. The facility is licensed to serve for a capacity of 175 non- ambulatory residents including 25 bedridden residents, ages 60 and above. The facility has an approved Hospice Waiver on file for twenty-three (23) residents. Twenty -two (22) residents currently on Hospice. Facility has an approved Dementia Care Plan in their plan of operation and accept residents with dementia. Facility does not handle residents’ monies. Administrator certificate is current and expires on 07/31/2026. During the visit, a tour of the facility was conducted, food supply and medications were reviewed. The facility is located in a residential neighborhood, consists of three floors and has 186 resident bedrooms and bathrooms. Level 1 has resident bedrooms, memory care unit, recreation/activity rooms, beauty shop, storage rooms, employee lounge, library, and laundry rooms. 2nd level is memory care, reception/lounge area, resident bedrooms, dining room, kitchen, multiple offices, recreation/activity rooms and laundry rooms. 3rd level consists of resident bedrooms, nurse's office, penthouse, recreation/activity rooms and laundry rooms. A physical tour was conducted. LPA randomly toured resident rooms on each floor in building sections A, B, C, D, E and F. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 105.0 – 120.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. The resident rooms are equipped with a signal system located in each restroom and facility phones to call the front desk. The signal system was tested in various resident's room on each level and are operable. Average time for caregivers to assist residents is 2-4 minutes. (-continued in LIC 809 C-) Facility had central air and heating accommodations in the common areas. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits are operable at the memory care unit at the lower level. Interior and exterior space is available to permit residents to walk in safe and comfortable environment. Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Food is stored in covered containers at the appropriate temperatures. No pesticides or poisons are stored in the food areas. The last Fire/Emergency Drill is conducted on 02/10/2025 and 02/11/2025, PM shift and NOC shift. Smoke and carbon monoxide detectors are operable and in compliance. Fire extinguishers were last serviced on 02/06/25 are fully charged and in compliance. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. Outside grounds were toured and pool/spa area with self-latching fenced gate was observed. The outdoor activity area has a shaded patio with ample seating. Medications are centrally stored and locked in the nurse's office on the third floor. First aid kit is fully stocked. Mandated documents and signages are posted in common areas. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. No deficiencies were observed as per California Code of Regulations, Title 22. Exit interview was conducted and copy of this report was provided to facility Administrator, Pamela Parsons.the state’s words, verbatim · CDSS document, Feb 27, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced case management visit regarding an incident on the relocation of 1 resident from Con Carino Braeburn (Woodland Hills South (RO) due to mandatory evacuation orders from the Fire Advisory. LPA met with Administrator, Pamela Parsons, and explained the reason for the visit. During the visit today, LPA Lopez conducted a health and safety check at Arcadia Gardens Retirement Hotel, and no concerns were observed. LPA obtained a copy of the client and staff roster for Arcadia Gardens Retirement Hotel. Per interview with the administrator, there are zero (0) resident(s) that has been relocated from Con Carino Braeburn (Woodland Hills south RO) The resident in question was admitted on 01/06/2025 at Arcadia Gardens Retirement Hotel. Which is before the fires. Facility has sufficient staffing to meet the needs of the residents. Food and hygiene supplies are available to accommodate a total of 162 residents. After further investigation, administrator stated they have one (1) resident placed by licensing due to the fire. Resident was at Pasadena Convention Center. LPA spoke with resident and resident stated resident was at resident's private residence before the fires. LPA asked facility Administrator to send incident report to department if they do receive any residents displaced by fire. An exit interview was held, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Staff are prohibiting resident from having visits.

Licensing Program Analysts (LPAs) Galarza and Mayra Cota conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Executive Director Pamela Parsons. The investigation consisted of: A physical plant tour of the interior common areas and interviews with residents (R1-R11), staff (S1-S3), private caregiver, and family (F1) was completed. A copy of the facility visitation policy, resident roster, staff roster, and file documents pertaining to resident (R1) and former resident (R12) were obtained. *Narrative continues next page. Unsubstantiated Allegation: Staff are prohibiting resident from having visits. The complaint alleges that approximately 4 to 5 weeks ago a person went to the facility to visit resident (R1) and Administrator asked the visitor to wait in the conference room. Administrator then wheeled in the non-ambulatory resident and shortly after the 2 family members entered the conference room. The visitor/former resident (R12) stated they always give advance notice to facility staff of visit plan. It was reported that Administrator allowed R1’s family members to yell and tell the visitor that they are not allowed to visit the resident and was asked to leave the facility. The complaint alleges there is no court order, restraining order, or conservatorship that stipulates resident (R1) shall not be allowed contact with the visitor. A total of three (3) staff were interviewed. Based on interviews conducted, staff stated that the visitor was a previous resident at the facility. Resident (R1's) Power of Attorney's have expressed concern to staff about R1's safety due to cognitive impairment. According to interviews, visitor's conduct i.e. touching of R1's body parts and gift giving is of concern because R1 is cognitively impaired and may be easily influenced by visitor. Staff reported that in the past R1 has stated they feel uncomfortable when they meet with visitor. Staff met with R1 and their POAs on several occasions, which resulted in R1 signing "Resident's Visitor Restriction Forms", that state that they restrict all visits from aforementioned visitor. However, staff reported that due to R1's short and long term memory deficit, sometimes R1 does agree to meet with visitor. The facility visitation hours are from 8AM - 6 PM, with after hour flexibility if needed. Resident (R1) stated that the visitor is a good friend, and is "alright" with the person visiting. The resident stated that staff have not infringed upon their visitation rights. A total of 11 residents were interviewed, none reported visitation issues, and stated their visitors are allowed to visit in the common areas and in their rooms. One (1) family member was interviewed. They stated there are no issues with facility visitation policy and is able to visit anytime. A private caregiver was also interviewed and expressed no concern about facility visitation protocols. Both staff and resident (R1) confirmed visitor is still allowed to visit the resident. Based on record review, the findings indicate R1 requires total care and has cognitive impairment but is able to communicate needs. Former resident (R12)/visitor is also cognitively impaired. There is insufficient evidence to corroborate the allegation. 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. An exit interview was conducted and a copy of this report was discussed and provided to facility Executive Director Pamela Parsons.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 28-AS-20241029140844

Allegation investigated: Staff did not abide to admission agreement

Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit to address the allegation listed above. LPA met with Pamela Parsons, Executive Directof for the facility, and explained the purpose of the visit. The investigation consisted of the following: During the visit, LPA interviewed Staff #1 - 4 (S1 - S4), Residents #2 - 12 (R2 - R12), and also obtained copies of the staff and resident rosters, along with documentation proving that Resident #1's (R1's) community fee had been refunded. LPA attempted to interview R1 during the visit, however they are not a resident of the facility and has since been placed in another facility. Unsubstantiated The investigation revealed the following: In regards to the allegation that "Staff did not abide to admission agreement," it is alleged that R1 had been admitted into Arcadia Gardens Retirement Hotel with acknowledgements from staff, including processing the payment of the community fee and being provided arrangement paperwork for R1's move into the facility, however the family of R1 was later told that Arcadia Gardens Retirement Hotel backed out of the agreement and would not be accepting R1 into the facility. During interviews with the residents, eleven (11) out of eleven (11) did not corroborate the allegation that the facility has not been abiding to the admission agreements that they signed. One resident interviewed stated that all services that are described in the admissions agreement are being provided by the staff members. Another resident interviewed stated that all of their needs are being met, and stated that all services they require are being offered by the facility staff members. During interviews with the staff, four (4) out of four (4) interviewed denied the allegation. One of the staff interviewed stated that they were initially not informed that R1 had a prohibited health condition when they were planning to admit R1, however once this diagnosis was discovered and along with the fact that R1 was not receiving hospice care either, the facility determined that they were not able to admit the resident. Another staff member stated that they had received incomplete information from the Skilled Nursing Facility (SNF) that R1 was residing at, and was not aware that they had a prohibited health condition when they initially considered R1 for admission into the facility the facility, and remained unaware of this until the facility nurse conducted a body check on R1 at the SNF they were residing at, which revealed the prohibited health condition. During record review, LPA determined that the community fee that R1's family had paid was refunded on 10/9/2024 in its full amount. It was also determined that R1 had never signed an admission agreement with the facility. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 28-AS-20241016112841

Allegation investigated: Lack of care resulted in resident requiring medical treatment. Resident was neglected while in care at the facility. Resident's responsible party was not provided resident's document. Resident was not provided services per agreement. Illegal eviction. Facility did not adhere to admission policy. Staff threatened resident.

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to the facility. LPA met with Administrator, Pamela Parsons and explained the purpose of today’s visit of the above-mentioned allegations. LPA Tao conducted the initial complaint investigation visit on 10/12/23 and a subsequent complaint visit on 06/07/24. LPA obtained resident/staff rosters, interviewed staff/residents/visitor, conducted physical plant, and obtained resident #1’s (R1)’s facility records and related documents. The investigation consisted of the following: resident interviews from resident #2 (R2) to resident #10 (R10); attempted but unable to interview resident#1 (R1) due to resident had deceased; staff interviews from staff#1 (S1) to staff#4 (S4); interview of visitor #1 (V1); conducted physical plant; and review of facility records. (-continued in LIC 9099 C-) Unsubstantiated The investigation revealed the following: In regard to the allegation, lack of care resulted in resident requiring medical treatment, it was alleged staff did not provide care to resident which resulted resident was transferred to a hospital for medical care. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that facility staff had provided care to residents timely which did not lead residents to seek medical treatments. All four (4) out of four (4) staff denied the allegation. Staff interviews revealed that staff would assist residents to meet residents’ care needs. Mostly, residents’ needs for seeking medical treatment were due to residents’ physical conditions. Per LPA’s observation, staff provided care to residents timely as residents called for assistance using the signal systems and when residents requested assistance from the caregivers in person. Therefore, facility staff assisted residents timely to meet residents care needs. In regard to the allegation, resident was neglected while in care at the facility, it was alleged staff failed to check on resident until after resident missed two meals. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that facility staff would check on residents if they did not come to the dining rooms for meals or declined food tray services. All four (4) staff denied the allegation. Staff interviews revealed that staff had to do round in each shift to check on residents, assist residents to meet residents’ care needs and observe residents’ physical conditions. When staff doing round, staff would knock on residents’ room doors, call out residents’ names, wait for residents’ responses if they were in their rooms, and check on residents even if residents declined staff going into their rooms. Per record review, there was an incident report, dated 08/24/23, indicated resident was observed to be weak and need medical attentions while staff was checking on resident. Per LPA’s observation, staff did round to check on residents, responded to residents’ call signals, and asked residents if they needed helps. Thus, facility staff did not neglect residents while in care. In regard to the allegation, resident's responsible party was not provided resident's document, it was alleged the administrator did not provide a signed copy of the resident’s admission agreement to resident’s responsible party upon admission. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that residents and/or responsible parties received a copy of the residents’ admission agreements after admissions. (-continued in LIC 9099 C-) All four (4) staff denied the allegation. Administrator’s interviews revealed that the administrator had to go over the admission agreements with residents and/or responsible parties upon admission. The copies of the admission agreements were provided to them accordingly. Residents who claimed the facility did not provide them copies could had been misplaced or lost the copies instead not provided. Per record review, it revealed the residents’ admission agreements had multiple signature pages (signed and dated) to show residents/responsible parties had received a copy of the admission agreements and records. Thus, facility staff did not fail to provide resident’s admission agreements. In regard to the allegation, resident was not provided services per agreement, it was alleged that staff did not assist resident with the second shower of the week and did not change resident’s clothes. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff assisted residents with bathing as scheduled and as needed. Staff would change residents’ clothes after showers and as needed. All four (4) staff denied the allegation. Staff interviews revealed that staff assisted residents with bathing as scheduled; however, residents had rights to decline of being bathed/changed clothes. Staff could not force residents to take baths and/or change clothes if they did not want to. Per LPA’s observation, residents’ clothes looked clean with no foul odor. Thus, facility staff did not fail to provide services per agreement. In regard to the allegation, illegal eviction, it was alleged that the facility’s 30-day notice policy was provided to resident#1 (R1) while resident was in the hospital and may not be able to return within 30 days. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that residents were not aware of any evictions happening at the facility. All four (4) staff denied the allegation. Staff interviews revealed that no eviction notices had even issued and sent to R1. Resident deceased, therefore, no eviction could happen. Thus, facility did not illegally evict resident. In regard to the allegation, facility did not adhere to admission policy, it was alleged that administrator charged resident#1 (R1) for services not received and billed resident for $3,000 more on R1’s final rent statement. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that residents did not observe services charged but not provided on their rent statements. All four (4) staff denied the allegation. Staff interviews revealed that administrator had adjusted the remaining unpaid balance down to $0 upon resident#1’s discharge due to death. The alleged $3,000 service charge was never paid by the resident / responsible party. (-continued in LIC 9099 C-) Per visitor interview, resident#1 (R1)'s final rent statement was adjusted down to $0 and no payment was required. Per record review, resident#1’s final bill, dated 09/19/23, all remaining balance was wrote-off to $0 and the book was closed. Therefore, facility did not fail to adhere to admission policy. In regard to the allegation, staff threatened resident, it was alleged that staff scolded and threatened the resident severely while in care. Per resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. Resident interviews revealed that staff did not scold or threaten residents. Since residents may had hearing problems, residents would ask the staff to speak louder, therefore, residents could hear the staff. All four (4) staff denied the allegation. Staff interviews revealed that the facility policy did not allow staff scold or threaten residents. Staff had in-service training on resident’s rights and proper care. Per observation, LPA did not observe staff had talk down, disrespect or threaten residents in care. Therefore, staff did not threaten residents. 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. An exit interview was conducted with Administrator. A hard copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 28-AS-20231006122743

Allegation investigated: Resident sustained multiple severe pressure injuries while in care. Staff did not seek medical attention for resident in a timely manner. Staff did not notify resident's authorized representative of change in resident's condition

***This report serves as an amendment and supersedes the original complaint investigation report created on 12/15/23. The purpose of this amended Licensing report is to issue additional citations. The findings remained as substantiated. *** Today 06/07/24, Licensing Program Analyst (LPA) Tao conducted a subsequent complaint visit of the above allegations. LPA met and explained the purpose of today's visit with Administrator, Pamela Parsons. On 12/15/23, Licensing Program Analyst (LPA) V. Maldonado conducted a subsequent complaint visit to continue the complaint investigation and deliver findings. LPA Maldonado met with administrator, Pamela, and explained the purpose for the visit. On 03/03/21, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegation listed above. (- Continued on LIC9099-C-) Substantiated ***This report serves as an amendment and supersedes the original complaint investigation report created on 12/15/23. The purpose of this amended Licensing report is to issue additional citations. The findings remained as substantiated. *** Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted via tele-conferencing with Administrator, Pamela Parsons. During that virtual visit, LPA Tao conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA Tao virtually toured the facility via Facetime with Administrator and observed that the facility was clean and in good repair. LPA observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Tao observed wash basins, showers/bathtubs and toilets were operable and did not observe any immediate health and safety concerns. On 03/05/21, a subsequent tele-visit was conducted by Investigator Jose Santana, during the visit, Investigator Santana interviewed staff from staff#1 (S1) to staff #21 (S21) which included Administrator Pamela Parsons; interviewed resident’s representative (RR); interviewed social worker (SW); obtained records from staff#9 (S9) and staff#20 (S20) to staff#23 (S23); and obtained records from police department (PD), hospital’s social worker (SW) and fire department (FD). IB reviewed resident#1 (R1)’s facility file and related documentation. Department was unable to interview resident#1 (R1) because R1 was passed away on 03/15/21. Regarding the allegation, resident sustained multiple severe pressure injuries while in care, it was alleged that a resident had multiple pressure injuries from resident’s leg, back and buttock area while in care. During the investigation, the department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from outside providers. Per staff interviews, R1’s home health representative indicated they were not aware of R1 pressure injuries, were not notified by the facility of R1’s pressure injuries and did not receive any orders to treat R1’s pressure injuries. Home health staff were notified by the facility of R's pressure injuries on 02/25/21. (- Continued on LIC9099-C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 12/15/23. The purpose of this amended Licensing report is to issue additional citations. The findings remained as substantiated. *** Interviews with staff revealed that not all staff were not made aware of R1’s pressure injuries and administrator failed to communicate R1’s pressure injuries to facility staff and with R1’s home health agencies. Per file reviews, on 02/10/21, R1 had redness on buttocks. On 02/18/21, S4 and S6 were aware of R1’s pressure injuries on resident’s back/buttock area. The facility did not address or document R1’s pressure injuries on R1’s care plan and did not notify R1’s family or responsible party of R1’s declining health and pressure injuries. On 02/25/21, S4 reported the resident had skin breakdown on resident’s hip and then notified R1’s home health care. On 02/26/21, the home health nurse came to assess R1 for pressure injuries and reported R1’s had unstageable pressure injuries on the resident’s back/buttock area and left heel. Although the facility contacted home health on 02/19/21, a home health assessment of R1’s pressure injuries was not obtained until 02/25/21. Thus, R1 developed multiple severe pressure injuries, an unstageable pressure injury to the back, buttock area and left heel, due to staff failing to address R1 pressure injuries in R1’s care plan and did not obtain home health for R1s pressure injuries upon first knowledge of R1s pressure injuries on 02/18/21. Regarding the allegation, staff did not seek medical attention for resident in a timely manner, it was alleged that facility staff failed to provide timely medical care to resident who had several pressure injuries, including unstageable pressure injuries. The department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from third party providers. Staff, S4 and S6, observed R1 had pressure injuries on 02/18/21. Per administrator, staff had been performing medical treatment to resident’s wound care on the pressure injuries since the wounds were first observed on 02/18/21. Per R1’s records review, there were no documents or written orders to reflect the facility obtained medical treatment for R1. (- Continued on LIC9099-C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 12/15/23. The purpose of this amended Licensing report is to issue additional citations. The findings remained as substantiated. *** Administrator reported R1 was under a full medical care from R1’s home health nurses for wound care to breast and back. However, interviews with R1’s home health staff reported they provided care for R1’s existing medical condition to resident’s leg and breast, and did not provide home health services for R1’s pressure injuries to back and buttock area. Home health did not have written orders to treat R1’s pressure injuries on R1’s back and buttock area. On 02/25/21, facility staff notified R1’s home health care to evaluate resident’s back and buttock area for R1’s skin breakdown. On 02/26/21, home health reported the resident had unstageable pressure injuries on the R1’s buttock area. Therefore, as a result of staff failing to obtain timely medical attention for R1 pressure injuries, R1 physically declined and developed several pressure injuries, resulting in R1 being sent to the hospital on 02/26/21 and admitted to hospice care on 02/27/21. Regarding the allegation, staff did not notify resident's authorized representative of change in resident's condition, it was alleged that staff did not inform resident’s family/authorized representative about the resident’s pressure injuries, ongoing physical decline, and the tremendous weight loss. Per staff interviews, staff were aware of R1 had pressure injuries on 02/18/21 which were reported to staff internally and on 02/25/21, R1 had skin breakdown which staff reported to home health. On 02/26/21, R1’s authorized representative was notified by R1’s home health representative that R1 had unstageable pressure injuries and the ongoing physical decline. Per staff interview, S6 admitted to knowledge of R1 having a change of condition on 02/18/21; however, staff did not inform R1’s representative about R1’s change in condition. During LPA Tao’s 12/08/23 telephone interview with administrator, the administrator admitted that facility only reported R1s change in condition internally within the facility and did not notify R1’s family or representative. Thus, staff failed to inform resident’s authorized representative regarding R1s change of condition. (- Continued on LIC9099-C-) ***This report serves as an amendment and supersedes the original complaint investigation report created on 12/15/23. The purpose of this amended Licensing report is to issue additional citations. The findings remained as substantiated. *** Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC9099-D. An immediate $500 civil penalty is being issued during today's visit due to the lack of care and supervision resulting in resident sustaining multiple pressure injuries. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). An exit interview was conducted and a copy of the licensing report, along with appeal rights were provided to administrator, Pamela Parsons.the state’s words, verbatim · CDSS document, Jun 7, 2024 · control 28-AS-20210302095454

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Jun 10, 2024

Reappraisals (a)(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement was not met by evidence of: Based on record review & staff interviews, the licensee did not (1) comply with the section cited above; (2) document or update resident#1's Plan of Care; (3) provide care by medical professional to resident#1 who had unstageable pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87463 and resident care plan. Licensee agrees to submit a written statement of how this deficiency will be corrected by 06/10/24. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 06/10/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 10, 2024

Incidental Medical and Dental Care (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met by evidence of: Based on interviews and record reviews, Administrator failed to seek timely medical attention for resident#1 when resident sustained pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87465, provide proper medical care which includes pressure injuries for residents as required. Licensee agrees to submit a written statement of how this deficiency will be corrected by 06/10/24. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 06/10/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 14, 2024

Additional Personal Rights of Residents in Privately Operated Facilities(a)(4) 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 was not met by evidence of: Based on interviews and record reviews, Administrator failed to provide proper care, supervisions and services to meet resident#1’s care needs who had pressure injuries and changed in condition, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Licensee/ Administrator agrees to submit a written plan on how this deficiency will be corrected by 06/14/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jun 14, 2024

Personal Rights of Residents in All Facilities (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met by evidence of: Based on interviews and record reviews, Administrator failed to inform and notify resident#1's authorized representative of change in condition, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Licensee/ Administrator agrees to conduct in service training to staff on regulation 87468.1 and how to properly inform residents and their authorized representatives of residents' change in condition. Licensee agrees to submit a written statement on how this deficiency will be corrected by 06/14/24. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 06/14/24.

Allegation investigated: Facillity failed to provide resident's records to attorney

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit at the facility regarding the above allegation. LPA met with Araceli Dimaguila and explained the reason for the visit. Administrator arrived 10 minutes later. The investigation consisted of the following: LPA requested copies of staff/resident roster. LPA reviewed file for resident #1(R1) and requested copies of identification and emergency sheet, admission agreement, physician’s report, power of attorney, release of information letter request dated 5/21/24, and authorization for the release of medical information letter. LPA interviewed administrator. LPA contacted R1’s power of attorney over the phone and contacted law firm representative. The investigation revealed the following: Regarding allegation: Facility failed to provide resident's records to attorney. It is alleged that on 05/21/2024 law office requests the facility to produce R1’s records and have not been received. (CONTINUED ON LIC 9099C) Unsubstantiated Interview with administrator revealed that letter request for records was received by their accounting department on 5/24/24. Administrator was out of the facility from 5/24/24-5/27/24 and received the letter on 5/28/24. Upon returning administrator reviewed the letter and requested medical records staff to pull records from storage and put the records together to comply with the request. Due to the large amount of documents facility was not able to provide records by due date of 5/29/24. Based on documents reviewed, law firm letter - release of information dated 5/21/24 is stamped 5/24/24 which is when it was received by the facility. Per Health and Safety Code (HSC) facility is to provide records upon requested not exceeding two business days. Due to the holiday weekend facility was to provide records by 5/29/24. During my visit, R1’s records were available for review. However, older records are currently on storage and need to be pulled out. LPA contacted law firm and informed that facility’s administrator will provide records by 5/30/24 end of day. Administrator spoke with a law firm representative, who accorded that mailing the documents by end of day 5/30/24 was acceptable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Pamela Parsons and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240524113755

Allegation investigated: Staff are prohibiting resident from having visits.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Executive Director Pamela Parsons and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Resident and Staff rosters, Copies of documents within R1's file, interviews with 4 Staff and 9 Residents were conducted during todays visit. (Continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are prohibiting resident from having visits. It is alleged that staff are prohibiting R1 from having visits with a friend who has previously been able to visit and is now restricted from doing so. LPA reviewed R1's file and observed a Resident's Visitor Restriction form in which R1 has on occasions signed that they do not wish to have visits with this friend. LPA interviewed 4 staff and 4 out of 4 staff deny the above allegation and stated that residents are allowed visitation and are given privacy during visits. Staff interviewed also stated that R1 is given the option when asked if they would like to visit and if R1 says yes R1 will then ask where their visitor is and asks for staff to take them to their visitor. Staff stated that they do not stay present while R1 is having a visit with their friend and allow them to visit with privacy. LPA interviewed R1 and R1 stated that they are able to have visits and mentioned that their friend visited them last week. Interview (via phone) with R1's friend, they stated that they visited R1 last week and have not been back since to visit, they stated they feel that staff will not allow visitation and when LPA asked if they have ever been denied a visit with R1 the friend stated that they have never been denied visitation with R1 by staff. LPA interviewed 8 additional residents and 8 out of 8 residents denied the above allegation and stated that they are able to have visits with friends/family and are given privacy during their visits. Based on statements and interviews conducted with staff and residents, and review of R1 files, there was not enough supportive evidence to concur with the reported allegations. 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 held, and a copy of this report was provided to Pamela Parsons - Executive Director.the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 28-AS-20240410122524

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tao conducted an unannounced site inspection for the expansion of dementia unit on the 2nd floor at the facility. LPA met with Administrator, Pamela Parsons, and Chief operations officer, David Chirikian. The capacity remained the same as 200 residents which included 175 non-ambulatory and 25 bedridden, ages 60 and above. The facility had approved twenty-three (23) Hospice Waivers and approved dementia wing on the first floor which has delayed egress that consisted of 11 rooms. Facility has an approved Dementia Care Plan in their plan of operation to accept residents with dementia. Fire clearance: Fire clearance is granted for 200 residents which included 175 non-ambulatory and 25 bedridden on 03/20/24. Structure: The facility is located in a residential neighborhood, consists of three floors/levels and has 186 resident bedrooms and bathrooms. Resident bedrooms, memory care unit, recreation/activity rooms, beauty shop, storage rooms, employee lounge, library and laundry rooms are located at the lower level. Reception/lounge area, resident bedrooms, dining room, kitchen, multiple offices, recreation/activity rooms and laundry room are located at main level. Upper level consists of resident bedrooms, nurse's office, penthouse, recreation/activity rooms and laundry room. Today’s visit is regarding the new expansion of the dementia unit on the 2nd floor. This unit included 11 residents’ rooms and one dining room with delayed egress. (- continued LIC 809 C -) Bedrooms and Bathrooms for residents: Bedrooms are spacious, accommodated for residents and in compliance with regulation. Bathrooms have grab bars maintained for each toilet, bathtub and shower. Linens & Hygiene Supplies: Sufficient linen/supplies which include pillowcases, mattress pads, blanket and bedspreads are available. Adequate supply of linen, wash clothes and towels are observed. Smoke Detectors/Signal system: Smoke /carbon monoxide detectors are tested and operable which are located in hallways and each bedroom. Signal system is tested and operational. Residents & Staff Files: Locked cabinets for records of staff and residents are installed and available. No resident is currently residing at this new unit. Water Temperature: Water was measured at a range of 110.6 to 112.9 degrees Fahrenheit which was in compliance with Reg Title 22. Fire extinguishers/ delayed egress: Fire extinguisher was fully charged, and last fire inspection was on 3/20/24. Delayed egress was operational. Finding: No issue was observed during today’s visit. Exit conference was conducted with administrator. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 22, 2024

Allegation investigated: Facility staff is overcharging resident in care. Facility staff threatened to evict resident in care.

Licensing Program Analyst (LPA) Tao conducted a subsequent visit today. The initial unannounced 10-day complaint visit was conducted on 04/13/23. On today’s visit, LPA met with Administrator, Pamela Parsons upon arriving at the facility. LPA explained the purpose of today’s visit which to investigate the above-mentioned allegations. The investigation consisted of interviews of residents from resident#1 (R1) to resident#8 (R8), attempted but failed to interview resident#9 (R9), interviews of staff from staff#1 (S1) to staff#6 (S6), conducted a facility tour, and review of facility records. LPA Tao spoke with Administrator and obtained resident roster, staff roster, and Resident #1’s (R1)’s facility files. The investigation revealed the following: (-continued in LIC 9099C-) Unsubstantiated In regard to the allegation: facility staff is overcharging resident in care, it was alleged that the facility was charging resident#1 (R1) an additional monthly rent of $2000 for care and services in year 2023. Eight (8) out of eight (8) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that facility did not over charge them on additional rent. All six (6) staff who were interviewed denied the allegation. Staff interviews revealed that residents' rent was adjusted based on the care and services provided. Per record review, resident#1's monthly rent was increased by $150 as compared Jan 2023 to Jan 2024. No additional charges on care and services. Therefore, facility staff did not overcharge resident in care. In regard to the allegation facility staff threatened to evict resident in care, it was alleged that resident was threatened to be evicted. Eight (8) out of eight (8) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that facility did not threaten them of eviction. All six (6) staff who were interviewed denied the allegation. Staff interviews revealed that staff did not threaten resident for eviction in any form. Per record review, resident#1 (R1) did not have any eviction notice. Per observation, LPA interviewed resident#1 (R1) at the facility which resident was still residing at the facility. Therefore, the facility staff did not threaten resident for eviction. 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. An exit interview was conducted with Administrator. A hard copy of the reports were provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 28-AS-20230404151230

Allegation investigated: Staff did not respond to resident in a timely manner. Staff are not providing resident with privacy. Staff did not safeguard resident's personal belongings. Staff did not provide a comfortable environment for resident.

Licensing Program Analyst (LPA) Tao conducted a subsequent visit today. The initial unannounced 10-day complaint visit was conducted on 04/13/23 and a subsequent visit was conducted on 03/15/24 with LPAs Tao and Reyes. On today’s visit, LPA met with Administrator, Pamela Parsons upon arriving at the facility. LPA explained the purpose of today’s visit which to investigate the above-mentioned allegations. The investigation consisted of interviews of residents from resident#1 (R1) to resident#11 (R11), interviews of staff from staff#1 (S1) to staff#5 (S5), and interviews with visitors. LPA Tao conducted a facility tour, and review of facility records. LPA Tao spoke with Administrator and obtained resident roster, staff roster, and Resident #1’s (R1)’s facility files. (-continued in LIC 9099C-) Unsubstantiated The investigation revealed the following: In regard to the allegation: staff did not respond to resident in a timely manner, it was alleged that staff did not provide assistance to resident timely after resident fell. Ten (10) out of eleven (11) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that facility staff would provide timely care if residents called on the signal button for help. All five (5) staff who were interviewed denied the allegation. Staff interviews revealed that staff would assist residents timely if residents when residents called for help. LPA tested and called the signal button. Staff responded to LPA’s calls in about 2 minutes and staff attended to residents’ rooms to provide care in range of from 3 minutes to 10 minutes. Therefore, there was not preponderance evidence to show staff failed to respond to resident in a timely manner. In regard to the allegation staff are not providing resident with privacy, it was alleged that staff did not provide privacy to residents and visitors during visits and did not allow visitor to go to resident’s room during the visit. Ten (10) out of eleven (11) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that staff provided privacy to residents during visitation and residents could choose where the visitation took place. All five (5) staff who were interviewed denied the allegation. Staff interviews revealed that staff honored residents’ privacy and offered it to residents for visitations. Per record review, residents had personal rights for privacy and visitation. Therefore, the facility staff provided residents and visitors with privacy during visits. In regard to the allegation staff did not safeguard resident's personal belongings, it was alleged that resident’s cell phone was missing while in care. Ten (10) out of eleven (11) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that when their cell phones or personal items were claimed missing, staff would assist to find them and one (1) of eleven (11) residents did not report missing a cell phone. Their items were misplaced and found in the next day. Residents were not aware of any personal items being stolen. All five (5) staff who were interviewed denied the allegation. Staff interviews revealed that staff would search for the missing items and return them to residents when found. Staff stated the claimed missing items were misplaced, not missing. Therefore, the investigation did not reveal facility fail to safeguard residents’ belongings. (-continued in LIC 9099C-) In regard to the allegation staff did not provide a comfortable environment for resident, it was alleged that resident was left in a shivering cold room in the cold day. Ten (10) out of eleven (11) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that residents had never left in a cold room shivering. The staff would check on them and assist as needed. All five (5) staff who were interviewed denied the allegation. Staff would do rounds and respond to call buttons to assist resident if rooms were cold or hot. Per LPA’s observation, resident’s rooms’ temperature were in the range of 70- 75 degree Fahrenheit which was in compliance with Title 22. Therefore, the residents’ rooms had comfortable temperature. 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. An exit interview was conducted with Administrator. A hard copy of the reports were provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 28-AS-20230407113436

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Pamela Parsons. The facility is licensed to serve for a capacity of 200 residents including 175 non-ambulatory and 25 bedridden residents, ages 60 and above. The facility is approved for twenty-three (23) hospice residents and has an approved Dementia Care Plan. Annual licensing fees are current. Administrator certificate is current, and the expiration date is 07/31/24. During the visit, the CARE tool was used, a tour of the facility was conducted, food supply was reviewed, staff/residents were interviewed, facility records were reviewed, and medications were reviewed. The facility is located in a residential neighborhood, consists of three floors/levels and has 186 resident bedrooms and bathrooms. Resident bedrooms, memory care unit, recreation/activity rooms, beauty shop, storage rooms, employee lounge, library and laundry rooms are located at the lower level. Reception/lounge area, resident bedrooms, dining room, kitchen, multiple offices, recreation/activity rooms and laundry room are located at main level. Upper level consists of resident bedrooms, nurse's office, penthouse, recreation/activity rooms and laundry room. (-continued in LIC 809 C-) LPA conducted a physical plant. Residents’ rooms were well furnished and in compliance. The bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 106.2 - 110.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. The resident rooms had signal systems. LPA randomly tested the signal system in different resident's room on each level and they were operable. Staff arrived at residents' rooms to respond the calls in a range of 3 to 5 minutes. The facility phones for residents’ use were located at the front desk and operable. Auditory alarm devices to monitor exits were operable at the memory care unit at the lower level. Sufficient supply of perishable and nonperishable foods were observed. The last Fire/Emergency Drill was conducted on 03/12/24. Smoke detectors and carbon monoxide detectors were operable. Outside grounds were toured and pool/spa area with self-latching fenced gate was observed. The outdoor activity area has a shaded patio with ample seating. Medications were centrally stored and locked in the nurse's office on the upper level. Resident records were stored in a locked cabinet and inaccessible to residents. Toxic substances were inaccessible to residents. No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Administrator.the state’s words, verbatim · CDSS document, Mar 12, 2024

Allegation investigated: Resident sustained injuries while in care. Staff are failing to meet resident’s needs Staff leave resident in soiled clothing for extended periods of time. Staff failed to safeguard resident’s personal belongings.

Licensing Program Analyst (LPA) Tao conducted a subsequent visit today. The initial unannounced 10 day complaint visit was conducted on 03/10/22. Upon arriving at the facility, LPA met with Administrator, Pamela Parsons. LPA explained the purpose of today’s visit is to discuss the above-mentioned allegations. The investigation consisted of resident interviews from resident#1 (R1) to resident#10 (R10), staff interviews from staff#1 (S1) to staff#4 (S4), attempted but failed to interview staff#5 (S5) and staff#6 (S6), facility tours, and review of facility records. LPA Tao spoke with Administrator and obtained resident roster, staff roster, and Resident #1’s (R1)’s facility files. The investigation revealed the following: In regard to allegation resident sustained injuries while in care, it was alleged that a resident fell off and injured in the facility. (- continued in LIC 9099C-) Unsubstantiated Ten (10) out of ten (10) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that facility staff would provide timely care if residents fell whether residents were injured or not. Staff would notify residents’ responsible parties if residents fell. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed that staff would assist residents timely if residents fell while in care. Therefore, there was not preponderance evidence to show staff failed to provide care to residents and resident sustained injured. In regard to allegation staff are failing to meet resident’s needs, it was alleged that staff did not provide care to resident on changing diapers and assisting with feeding. Ten (10) out of ten (10) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that staff had provided the care they needed such as grooming, cleaning, changing diaper and assistance with feeding. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed that staff would assist residents per residents’ needs. Per record review, resident was scheduled to have a 2-hour check on reposition / diaper change and assisting with feeding. Therefore, staff provided care to meet resident’s needs. In regard to allegation staff leave resident in soiled clothing for extended periods of time, it was alleged that staff left resident in wet soiled clothing for extended periods of time. Ten (10) out of ten (10) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that they had never left in soiled, wet clothing. Staff changed their clothes timely if got soiled. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed that staff would change residents’ clothes as needed. Per observation, residents were observed to be clean, neat and with no foul odor. Therefore, resident was not left in soiled clothing for extended periods of time. In regard to allegation staff failed to safeguard resident’s personal belongings, it was alleged that resident’s cell phone was missing in the facility. Ten (10) out of ten (10) residents who were interviewed could not corroborate the allegation. Resident interviews revealed that staff would help them to find their missing belongings and most of the time, their missing belonging were found in their rooms. Residents were not aware of any personal items being stolen. Four (4) out of four (4) staff denied the allegation. Staff interviews revealed that staff would assist residents to search for the items and return them to residents. In most cases, resident’s items were misplaced in their room. File review revealed resident #1 did not have the said items under resident’s possession. Therefore, investigation did not reveal staff failed to safeguard resident’s belongings. (- continued in LIC 9099C-) 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. An exit interview was conducted with Administrator. A hard copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20220307133048

Allegation investigated: Resident sustained multiple severe pressure injuries while in care. Staff did not seek medical attention for resident in a timely manner. Staff did not notify resident's authorized representative of change in resident's condition

Licensing Program Analyst (LPA) V. Maldonado conducted a subsequent complaint visit to continue the complaint investigation and deliver findings. LPA Maldonado met with (Staff Name & Job Title) and explained the purpose for the visit. On 03/03/21, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted via tele-conferencing with Administrator, Pamela Parsons. During that virtual visit, LPA Tao conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA Tao virtually toured the facility via Facetime with Administrator and observed that the facility was clean and in good repair. LPA observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Tao observed wash basins, showers/bathtubs and toilets were operable and did not observe any immediate health and safety concerns. (Report Continued on LIC9099-C...) Substantiated On 03/05/21, a subsequent tele-visit was conducted by Investigator Jose Santana, during the visit, Investigator Santana interviewed staff from staff#1 (S1) to staff #21 (S21) which included Administrator Pamela Parsons; interviewed resident’s representative (RR); interviewed social worker (SW); obtained records from staff#9 (S9) and staff#20 (S20) to staff#23 (S23); and obtained records from police department (PD), hospital’s social worker (SW) and fire department (FD). IB reviewed resident#1 (R1)’s facility file and related documentation. Department was unable to interview resident#1 (R1) because R1 was passed away on 03/15/21. Regarding allegation: Resident sustained multiple severe pressure injuries while in care. It was alleged that a resident had multiple pressure injuries from resident’s leg, back and buttock area while in care. During the investigation, the department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from outside providers. Per staff interviews, R1’s home health representative indicated they were not aware of R1 pressure injuries, were not notified by the facility of R1’s pressure injuries and did not receive any orders to treat R1’s pressure injuries. Home health staff were notified by the facility of R1s pressure injuries on 02/25/21. Interviews with staff revealed that not all staff were not made aware of R1’s pressure injuries and administrator failed to communicate R1’s pressure injuries to facility staff and with R1’s home health agencies. Per file reviews, on 02/10/21, R1 had redness on buttocks. On 02/18/21, S4 and S6 were aware of R1’s pressure injuries on resident’s back/buttock area. The facility did not address or document R1’s pressure injuries on R1’s care plan and did not notify R1’s family or responsible party of R1’s declining health and pressure injuries. On 02/25/21, S4 reported the resident had skin breakdown on resident’s hip and then notified R1’s home health care. On 02/26/21, the home health nurse came to assess R1 for pressure injuries and reported R1’s had unstageable pressure injuries on the resident’s back/buttock area and left heel. Although the facility contacted home health on 02/19/21, a home health assessment of R1’s pressure injuries was not obtained until 02/25/21. Thus, R1 developed multiple severe pressure injuries, an unstageable pressure injury to the back, buttock area and left heel, due to staff failing to address R1 pressure injuries in R1’s care plan and did not obtain home health for R1s pressure injuries upon first knowledge of R1s pressure injuries on 02/18/21. Regarding allegation: staff did not seek medical attention for resident in a timely manner. It was alleged that facility staff failed to provide timely medical care to resident who had several pressure injuries, including unstageable pressure injuries. The department interviewed staff (S1) through (S21), reviewed R1’s facility file and reviewed documentation from third party providers. (Report Continued on LIC9099-C...) Staff, S4 and S6, observed R1 had pressure injuries on 02/18/21. Per administrator, staff had been performing medical treatment to resident’s wound care on the pressure injuries since the wounds were first observed on 02/18/21. Per R1s records review, there were no documents or written orders to reflect the facility obtained medical treatment for R1. Administrator reported R1 was under a full medical care from R1s home health nurses for wound care to breast and back. However, interviews with R1’s home health staff reported they provided care for R1’s existing medical condition to resident’s leg and breast, and did not provide home health services for R1’s pressure injuries to back and buttock area. Home health did not have written orders to treat R1’s pressure injuries on R1’s back and buttock area. On 02/25/21, facility staff notified R1s home health care to evaluate resident’s back and buttock area for R1’s skin breakdown. On 02/26/21, home health reported the resident had unstageable pressure injuries on the R1’s buttock area. Therefore, as a result of staff failing to obtain timely medical attention for R1 pressure injuries, R1 physically declined and developed several pressure injuries, resulting in R1 being sent to the hospital on 02/26/21 and admitted to hospice care on 02/27/21. Regarding allegation: Staff did not notify resident's authorized representative of change in resident's condition. It was alleged that staff did not inform resident’s family/authorized representative about the resident’s pressure injuries, ongoing physical decline, and the tremendous weight loss. Per staff interviews, staff were aware of R1 had pressure injuries on 02/18/21 which were reported to staff internally and on 02/25/21, R1 had skin breakdown which staff reported to home health. On 02/26/21, R1’s authorized representative was notified by R1’s home health representative that R1 had unstageable pressure injuries and the ongoing physical decline. Per staff interview, S6 admitted to knowledge of R1 having a change of condition on 02/18/21, however, staff did not inform R1’s representative about R1’s change in condition. During LPA Tao’s 12/08/23 telephone interview with administrator, the administrator admitted that facility only reported R1s change in condition internally within the facility and did not notify R1s family or representative. Thus, staff failed to inform resident’s authorized representative regarding R1s change of condition. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC9099-D. (Report continued on LIC9099-C...) An immediate $500 civil penalty is being issued during today's visit due to the lack of care and supervision resulting in resident sustaining multiple pressure injuries. The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). An exit interview was conducted and a copy of the licensing report, along with appeal rights were provided to (Staff Name & Job Title).the state’s words, verbatim · CDSS document, Dec 15, 2023 · control 28-AS-20210302095454

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(a)(3)(B) · Plan of correction due date: Dec 16, 2023

87631 Healing Wounds (a)(3)(B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by: Based on record review & staff interviews, the licensee did not (1) comply comply with the section cited above; (2) document or update resident#1's Plan of Care; (3) provide care by medical professional to resident#1 who had unstageable pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87631 and resident care plan. Licensee agrees to submit a written statement of how this deficiency will be corrected by 12/15/23. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 1/3/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 16, 2023

87465 Incidental Medical and Dental Care (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met by evidence of Based on interviews and record reviews, Administrator failed to seek timely medical attention for resident#1 when resident sustained pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/ Administrator agrees to conduct staff training on regulation 87465, provide proper medical care which includes pressure injuries for residents as required. Licensee agrees to submit a written statement of how this deficiency will be corrected by 12/15/23. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 1/3/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Dec 21, 2023

87468.1 Personal Rights of Residents in All Facilities. (a)(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met by evidence of: Based on interviews and record reviews, Administrator failed to notify resident#1's authorized representative of change in condition, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Licensee/ Administrator agrees to conduct in service training to staff on regulation 87468.1 and how to properly inform residents and their authorized representatives of residents' change in condition. Licensee agrees to submit a written statement on how this deficiency will be corrected by 12/21/23. Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 1/3/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1) · Plan of correction due date: Dec 21, 2023

87405 Administrator - Qualifications and Duties (d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met by evidence of: Based on interviews and record reviews, Administrator failed to provide proper care to resident#1who had pressure injuries and changed in condition, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 15, 2023

Plan of correction: Administrator agrees to submit a written plan on how this deficiency will be corrected by 12/21/23.