Atria El Camino Gardens

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection. LPAs met with Senior Executive Director (ED), Kim Hagen , and explained the purpose of the visit. Facility is licensed for 325 non-ambulatory residents, hospice waiver of 20. Facility currently has 192 residents, 11 on hospice services. LPAs and ED conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: eleven (11) rooms in Memory Care/ Life Guidance unit, nine (9) rooms in Assisted Living, three (3) laundry rooms, two dining rooms, Salon, Movie Theater, Library, kitchen, mini Grab & Go Grille, Learning Center, Employee Lounge, and the courtyard. LPAs observed the facility to have the mandated posters posted in a conspicuous space. LPAs observed Administrator Certificate for ED to be expired. ED informed LPAs her certificate has been renewed but did not receive the copy. LPAs confirmed on CCLD website, Administrator Certificate #6050074740 is current with expiration date of 12/07/2024. LPAs informed ED LPA Yang will contact Admin Cert unit for a copy of ED's certificate. In areas toured, LPAs did not observed any violation of health, safety and personal rights. LPAs completed the CARE tool and found the facility to be in compliance at this time. No deficiencies observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Legal/Non-compliance

On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived at the facility unannounced to conduct a required quarterly case management visit in accordance with the Stipulation and Order, effective date 06/01/2022 to 05/31/2024. LPAs met with the Executive Director (ED), Kimberly Hagen, and explained the purpose of the visit. During today's visit, LPAs observed the Stipulation and Waiver and Order to be posted in a conspicuous space in facility hallway. LPAs observed the facility to be clean, safe, sanitary and in good repair. LPAs reviewed facility's Stipulation binder and reviewed the orders of the stipulation. LPAs observed the facility to conduct daily audits of emergency call response. LPAs observed documentation of facility's monthly staff training. LPAs observed records of resident care task audit, staff numbers and observed sufficient staff per resident care needs. Additionally, LPAs observed incident reports submitted to LPA Yang for emergency call responses which exceeds 10 minutes. As a result of today's visit, LPAs observed the facility to be in compliance to Stipulation and Waiver and Order. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Incident

On 10/20/2023, Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced to conduct a case management visit regarding the incidents reports the Department received on Tuesday October 17, 2023. LPAs met with Executive Director (ED), Kim Hagen, and explained the purpose of the visit. LPAs and ED discussed the serious/unusual incident report (SIR) submitted for an incident occurring on 9/10/2023 regarding R1’s emotional distress. LPAs discussed the importance of submitting SIRs in a timely manner as Title 22 mandates written reports to be submitting within seven days of occurrence. ED explained the dated of occurrence was inputted incorrectly as the incident occurred on 10/15/2023 not 9/10/2023. Additionally, LPAs and ED discussed the SIR submitted for an incident occurring on 10/16/2023 regarding the incident with medications in R2’s room. LPAs discussed the importance of informing family members that medications are to be locked and secured if resident is able to store own medications. ED informed LPAs R2 is a new resident in care, and is in the Med Program, meaning facility assist with medication administration. ED stated the medications found in the room where over the counter medications which was removed during time of observation. ED informed LPAs the facility notified family members immediately to remind them of facility's protocols. ED also stated primary care physician was notified as all medications need a doctor's order. LPAs and ED then discussed the LIC 624A Death Report received for R3. ED informed LPAs R3 was hospitalized beginning of the month due to a concern home health nurse observed. ED stated R3 was then discharged to a skilled nursing facility and then hospitalized again for the original concerns when R3 was at the facility. ED stated cause of death is unknown as R3 has not been at the facility for a few weeks. Please continue on LIC 809-C... LIC 809-C... At this time, LPAs requested a copy of R3's LIC 602, Emergency Contact, Needs and Assessment, all 2023 Incident Reports, list of meds, and Power of Attorney documents. LPAs informed ED to submit a copy of R3's Death Certificate once received by the family. This incident will be under review until further notice by the Department. During this visit, no deficiencies cited. Exit interview conducted and a copy of the report was provided to ED.the state’s words, verbatim · CDSS document, Oct 20, 2023

Allegation investigated: Facility is unsanitary. Staff do not ensure that the facility is free from pests.

On 08/11/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver the findings of the allegations cited above. LPA met with Executive Director, Kimberly Hagen, and explained the purpose of the visit. During the investigation, LPA conducted interviews and inspection of the facility. LPA is unable to find and or meet the preponderance, per policy. The results of the investigation are as follows: ** Report continued on 9099-C ** Unfounded Allegation: Facility is unsanitary. The Department conducted interviews to investigate this allegation. During interview conducted with S1 on 02/08/2023, S1 informed LPA the bistro is cleaned after each shift and trash are thrown out daily. Based on LPA’s observation on 02/08/2023 and 05/04/2023, LPA observed the bistro to be clean and sanitary. Allegation: Staff do not ensure that the facility is free from pests. The Department conducted interviews to investigate this allegation. During interview conducted with S1 and S2 on 02/08/2023, LPA was informed there is no concerns of cockroach and/or pest in the kitchen. LPA was informed by S1 that during the duration of S1’s employment, S1 has not seen any cockroaches presence in the bistro kitchen. On 2/8/2023 and 5/4/2023, LPA inspected the kitchen space in areas included but not limited to: under the refrigerator, freezer, fryer, and inside storage room, LPA did not observe presence of pests. During this investigation, LPA conducted records review and extensive interviews. LPA found the facility to be compliance with Title 22. Based on interviews conducted, the preponderance of evidence standards have not been met. Based on information obtained during the investigation, LPA finds the allegations to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Executive Director and a copy of this report and appeal rights was provided to Executive Director. Allegation: Staff serve residents moldy food. The Department conducted interviews to investigate this allegation. During interview conducted with S1 and S2 on 02/08/2023, LPA was informed that all food are labeled and discarded after the third day. LPA was informed that some sauce are made of herbs, that residents have mistaken it to be green mold. During interview conducted on 05/04/2023 with ED, LPA was informed a resident had complained about her cheese. LPA was informed by ED that the cheese served was blue cheese. Facility staff do not follow proper hand washing procedures. The Department conducted interviews to investigate this allegation. During interview conducted with S1 and S2 on 02/08/2023, S1 and S2 both informed LPA that the kitchen protocol is to wash hands prior to putting on gloves for prepping. During interviews, LPA was informed there are handwashing signs posted in the kitchen and restrooms for staff to follow. Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Executive Director and a copy of this report and appeal rights was provided to Executive Director.the state’s words, verbatim · CDSS document, Aug 11, 2023 · control 25-AS-20230131141449

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding of the allegation cited above. LPA met with Executive Director, Kim Hagen, and explained the purpose of the visit. During this investigation, LPA conducted records review and extensive interviews. LPA found the facility to be compliance with Title 22, 87224 Eviction Procedures. Based on interviews conducted, the preponderance of evidence standards have not been met. Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Please continue on LIC 9099-C. Unfounded Continued from LIC 9099... Allegation Staff handled resident in a rough manner. The Department conducted records review interviews to investigate this allegation. During interview conducted on 02/08/2023, LPA was informed that R1 had a change of health condition and has been violating House Rules as R1 continued to be disrespectful to facility staff. During records review conducted, LPA observed the 30 day eviction to list the occurrence of when R1 violated the House Rules, effective date and referral services for alternative housing. Additionally during records review, LPA observed R1's LIC 624 Unusual Incident/Injury Report to stated on 01/20/2023 and 01/21/2023, R1 was observed to be yelling and disrespectful to others. During an interview conducted on 02/07/2023 with R1, R1 admitted to telling facility staff to "fuck off" and "go to hell". Therefore, the allegation is UNFOUNDED. Exit interview was conducted with Executive Director and a copy of this report and appeal rights was provided to Executive Director. The signature of the Executive Director on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, May 4, 2023 · control 25-AS-20230207101842

Allegation investigated: Facility is interfering with residents packages/mail.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed above. LPA met with Executive Director, Kim Hagen, and explained the purpose of the visit. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. During the investigation, LPA conducted interviews and records review for the allegation cited above. The results of the investigation are as follows: Please continue report on LIC 9099-C... Unfounded LIC 9099-C... Allegation: Facility is interfering with residents packages/mail. The Department conducted records review and interviews to investigate this allegation. During interview conducted on 03/17/2023 with ED indicated that R1 has signed a Mailed Medication Waiver and Authorization, which authorized facility to "open such packages and store any such medication on my [resident's] behalf". ED informed LPA that in the packages retrieved obtained vitamin supplements. Record review indicated R1 did sign the waiver on 10/27/2022. Additionally on 3/17/2023, LPA interviewed R1 who confirmed to LPA he had ordered vitamins on Amazon although he was informed by facility staff that all supplements need a doctor's order. Interview indicated R1 was unaware he had signed the waiver as R1 implied the Admission Agreement packet was over 100 pages. Therefore, the allegation is UNFOUNDED. During this investigation, LPA conducted records review and extensive interviews. LPA found the facility to be compliance with Title 22. Based on interviews conducted, the preponderance of evidence standards have not been met. Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of the report and appeal right was provided. LIC 9099-C1... Allegation: Facility financially abused resident. The Department conducted records review interviews to investigate this allegation. During interview conducted on 03/17/2023 with ED indicated the money removed from R1's account was from an auto payment that R1 had signed up for during his admission. During interview conducted with R1 indicated facility being dishonest as he had requested a stop on auto payment but facility has failed to complied. Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of the report and appeal right was provided.the state’s words, verbatim · CDSS document, May 4, 2023 · control 59-AS-20230307161915

Allegation investigated: Facility tampered with resident's records.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed above. LPA met with Executive Director, Kim Hagen, and explained the purpose of the visit. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. During the investigation of this complaint, the Department conducted interviews and record review for the allegations cited above. Please continue report on LIC 9099-C... Unsubstantiated Continued from LIC 9099... Allegation: Facility tampered with resident's records. The Department conducted record review and interviews to investigate this allegation. Interview conducted with R1 indicated that R1 believed facility intentionally altered R1's LIC 602 in order to increase R1's rent. During interview conducted on 03/17/2023 with ED indicate a new LIC 602 was faxed in by R1's primary care physician (PCP) after ED and SW addressed concerns to R1's PCP regarding R1's medication. Record review indicate that R1 signed an Authorization To Release Health Information form which permits facility to contact R1's PCP for medical purposes. Record review indicate that R1 has five (5) LIC 602 since October 2022. LPA observed first LIC 602 to be dated 10/9/2022, second LIC 602 dated 11/29/2022, third LIC 602 dated 12/7/2022, fourth LIC 602 dated 12/9/2022, and the fifth LIC 602 dated 01/10/2023. Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 4, 2023 · control 59-AS-20230309130818

Allegation investigated: Facility is overcharging a resident in care

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kimberly Hagen, to deliver findings into the complaint allegation listed above. During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility is overcharging a resident in care ** Report continued on 9099-C ** Unsubstantiated Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents. Relevant party indicated that a resident in care was being charged more than the agreed amount listed on their admission agreement. LPA observed resident (R8’s) admission agreement signed 10/27/2022 and invoices itemizing charges from October 2022 to March 2023. LPA observed that charges for level of care services and pre-admission fees were included in R8’s signed admission agreement. LPA observed that invoice for January 2023 showed a charge for $530 for medication services when, according to interviews with staff members S1, S2, and ED, as well as a review of R1’s Physician’s Report for RCFE LIC 602A dated 12/9/2022 (faxed to the facility on 12/13/2022), R8 was not receiving medication services. LPA observed that $530 were credited back to R8 on invoice for February 2023. LPA observed a charge for $4012.50 for “Private Duty Personnel” for R8’s March 2023 invoice. Interview with ED indicated that service was provided due to an incident in which R8 attempted suicide on 1/1/2023. R8’s updated LIC 602A dated 1/10/2023, which was completed during hospital visit following incident that occurred on 1/1/2023, indicated R8 as not exhibiting suicidal/self-abuse behaviors and not experiencing depression. A comment on the last page of R8’s LIC 602A dated 1/10/2023 indicates that R8 had a “suicide attempt by overdose” but also states that R8 “is not acutely a suicidal or homicidal.” Interview with ED indicated that R8 did not agree to private duty personnel services and implementation of services for R8 was decided by facility. Interview with ED indicated that a meeting with R8 and the facility was attempted to address service implementation, but R8 refused to participate in meeting with facility. R8’s admission agreement signed on 10/27/2022 states “If you become a safety risk to yourself or to others during your residency, we have the right in our sole determination to obtain, at your expense, private duty personnel to provide supervision or assistance until you move from the Community or your safety is no longer at risk.” Due to Incident that occurred on 1/1/2023, the facility began providing additional supervision for R8 to ensure their safety. Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, S9, and ED indicated that there have been no incidents witnessed in which the facility charged a resident fees not indicated in their admission agreement. ** Report continued on 9099-C **the state’s words, verbatim · CDSS document, Mar 24, 2023 · control 25-AS-20221209100006

Allegation investigated: Facility did not issue a refund to resident.

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kimberly Hagen, to deliver findings into the complaint allegation listed above. During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Facility did not issue a refund to resident. ** Report continued on 9099-C ** Unfounded Interview conducted with relevant party indicated that resident (R8) was not issued a refund for unnecessary charges. LPA observed R8’s admission agreement signed 10/27/2022 and invoices itemizing charges from October 2022 to March 2023. LPA observed that charges for level of care services and pre-admission fees were included in R8’s signed admission agreement. LPA observed that invoice for January 2023 showed a charge for $530 for medication services when, according to interviews with staff members S1, S2, and ED, as well as a review of R1’s Physician’s Report for RCFE LIC 602A dated 12/9/2022 (faxed to the facility on 12/13/2022), R8 was not receiving medication services. LPA observed that $530 were credited back to R8 on invoice for February 2023. In review of California Code of Regulations, Title 22, Division 6, Chapter 8, there are no regulations to address allegation of facility not issuing a refund to resident for the scenario given regarding complaint. Based on records reviewed, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with ED and a copy of this report was provided to the facility. The signature of ED on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 24, 2023 · control 25-AS-20221216115606

Allegation investigated: Facility is mismanaging residents' medications

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Kimberly Hagen, to deliver findings into the complaint allegation listed above. During the investigation, LPA conducted interviews, reviewed documentation pertinent to the investigation, and conducted a medication count. The results of the investigation are as follows: Allegation: Facility is mismanaging residents' medications ** Report continued on 9099-C ** Substantiated Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and ED indicated that there have been no incidents witnessed in which a resident was threatened by facility staff. Allegation: Facility is not releasing records to residents Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and ED indicated that there have been no incidents witnessed in which a resident requested for copies of their records from the facility and did not receive them. Allegation: Facility is not treating residents with dignity Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and ED indicated that there have been no incidents witnessed in which a resident was not treated with dignity by facility staff. Allegation: Facility did not give proper documentation to resident's physician Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and ED indicated that there have been no incidents witnessed in which emergency medical services did not receive the necessary documents needed when a resident was transferred from the facility to the hospital Allegation: False claims Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and ED indicated that there have been no incidents witnessed in which the facility presented false claims regarding services the facility provides or services the residents receive. ** Report continued on 9099-C ** Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents. During inspection conducted on 1/31/2023, LPA conducted a medication count for residents R8, R9, and R10, comparing each resident’s Centrally Stored Medication Form (CSM) with medications centrally stored for the resident. LPA observed that every medication counted for R8 was off count in relation to what was documented, including both under and over the amount documented. 1 medication for R8 had more tabs in the bottle than the quantity documented. No missed or refused medications were documented to account for the medication errors for R8. Medications for R9 and R10 did not demonstrate any medication errors. Based on interviews conducted by the department, records reviewed, and medication count, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. ED's signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 24, 2023 · control 25-AS-20230112112030

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 25, 2023

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count, the facility did not ensure that R8 was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Facility will conduct an in-service training with all Med-Techs on medication administration. Facility will also conduct a medication audit to address current errors. Facility will submit to LPA information regarding in-service training and medication audit, including time and date of in-service and training material, by POC due date of 3/25/2023.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood met with Executive Director (ED), Kimberly Hagen, to conduct a case management visit. During inspection conducted on 3/24/2023, it was discovered that a written notice regarding change in level of care regarding private duty personnel was not issued to resident (R1) within 2 days after the implementation of new services due to a change of level of care. LPA requested the 2 day written notice for the private duty personnel implemented during today's visit and facility was unable to supply requested document. Per Health and Safety Code §1569.657(a), a deficiency is being cited on the attached 809-D. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. The ED’s signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 24, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.657(a) · Plan of correction due date: Apr 8, 2023

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that R1 received a 2-day notice of new private duty personnel services implemented, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2023

Plan of correction: Facility will complete a statement of understanding regarding H&S Code 1569.657. Facility will submit statement of understanding to LPA by POC due date of 4/8/2023.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 3/24/2023 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 6/1/2022-5/31/2024. A copy of the Stipulation and Order is available for review upon request. LPA met with the Executive Director, Kimberly Hagen. During today's visit, LPA reviewed the following stipulations of the order: 1. Facility shall be clean and in good repair -During inspection, LPA observed facility to be clean and in good repair 2. Alert button logs -LPA observed documentation regarding alert button logs and observed that alert buttons were being responded to timely -Facility is reporting regularly to LPA regarding response times for alert buttons 3. Audit of resident care tasks and staff numbers - LPA observed records of resident care task audit and staff numbers and observed sufficient staff per resident care needs 4. Staff training -Facility is conducting monthly training and LPA observed staff training material and attendance sheets No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Mar 24, 2023

Allegation investigated: Staff are not taking precautions for COVID-19

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director, Kimberly Hagen, to deliver findings into the allegation listed above. LPA wore a surgical mask. Facility staff wore masks while on the premises. During the investigation, LPA conducted interviews. The results of the investigation are as follows: Allegation: Staff are not taking precautions for COVID-19 ** Report continued on 9099-C ** Unsubstantiated Relevant party indicated that staff are not wearing masks while on the premises, that visitors are entering the facility from entrances that are not the one central entry point for COVID-19 screening, and 1 resident who was COVID-19 positive was not staying in isolation and entered the lobby area with other residents when they were supposed to be in isolation. Interviews conducted with residents R1, R2, R3, R4, R5, R6, and R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and Executive Director (ED) indicated that staff wear masks while inside the facility. LPA observed staff wearing masks while inside the facility during visits conducted on 11/17/2022, 12/14/2022, 12/22/2022, 1/18/2023, 1/31/2023, 2/2/2023, 2/9/2023, 2/23/2023, and 3/2/2023. Interviews with residents R2, R3, R4, staff members S5, S6, S7, S8, and S9, and ED indicated that they have witnessed 1 resident who was COVID-19 positive leave their isolation room, but all witnesses indicated that resident was redirected back to their room once noticed by facility staff to be out of isolation. Interviews with resident R4, staff members S6, S7, S8, and ED indicated that visitors have been witnessed entering the facility from entrances that are not the one central entry point for COVID-19 screening. However, all witnesses indicated that visitors are redirected to central entry point for COVID-19 screening when noticed by facility staff. Interviews with residents R1, R2, R3, R4, R5, R6, R7 indicated that they have no concerns regarding the COVID-19 protocols of the facility. Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents. Interviews with residents R1, R2, R3, R4, R5, R6, R7, staff members S1, S2, S3, S4, S5, S6, S7, S8, and S9, and ED indicated that themselves and others at the facility have participated in response testing for COVID-19 when there has been a COVID-19 outbreak on the premises. LPA received documentation regarding COVID-19 testing at the facility. LPA contacted a Sacramento County Public Health representative, who confirmed that the facility reported their most recent COVID-19 outbreak and has been reporting results from response testing. Based on interviews conducted by LPA and documentation, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 25-AS-20221110111555

Allegation investigated: Staff inappropriately interfered with resident’s sleep

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director, Kimberly Hagen, to deliver findings into the allegation listed above. LPA wore a surgical mask. Facility staff wore masks while on the premises. During the investigation, LPA conducted interviews. The results of the investigation are as follows: Allegation: Staff inappropriately interfered with resident’s sleep ** Report continued on 9099-C ** Unsubstantiated Interview with relevant party indicated that a resident's sleep as been disturbed at the facility. Interviews with residents R5 and R7 indicated that they have had their sleep interrupted by staff in the past. However, R5 and R7 indicated that, after communicating their sleeping preferences with staff, their sleep was no longer interrupted. No other resident interviews indicated that they have experienced their sleep be disturbed at the facility. Interviews with staff members S1, S5, S6, S7, S8, and S9 indicated that, if they are aware of a resident's sleeping schedule, they will work around that resident's schedule to provide services. No other staff interviews indicated that they were aware of any residents' sleep being disturbed by facility staff. Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Executive Director and a copy of this report was provided to the facility. The signature of the Executive Director on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 25-AS-20221215101621

Allegation investigated: Facility is interfering with residents receiving mail. Food is not served in a safe or healthful manner.

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to open a complaint the Department received. This is a joint visit with Long Term Care Ombudsman (LTCO), Ron Carerra. LPA and LTCO met with Executive Director, Kimberly Hagen, and explained the purpose of the visit. Prior to initiating the visit, LPA interviewed reporting party (RP) regarding the allegations cited aove. RP stated the allegation is "nothing having to do with nothing". LPA then was no longer able to obtain further information from RP as RP did not want to talk about it during the phone call. When LPA interviewed Executive Director who informed LPA all residents have a mailbox for their mails and letters. Executive Director informed LPA that all packages are delivered to the front desk and will be given to residents. Executive Director informed LPA packages are never opened by staff. When asked how would the facility know if medications are inside the packages, Executive Director responded "I guess we won't know unless we see it in the room since we don't open their packages." Continue on LIC 9099-C... Unfounded LIC 9099-C ... Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Executive Director, and a copy and appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 8, 2023 · control 25-AS-20230130101737

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/29/2022 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 6/1/2022-5/31/2024. A copy of the Stipulation and Order is available for review upon request. LPA met with the Senior Executive Director, Kimberly Hagen. During today's visit, LPA reviewed the following stipulations of the order: 1. Facility shall be clean and in good repair -During inspection, LPA observed facility to be clean and in good repair 2. Alert button logs -LPA observed documentation regarding alert button logs and observed that alert buttons were being responded to timely -Facility is reporting regularly to LPA regarding response times for alert buttons 3. Audit of resident care tasks and staff numbers - LPA observed records of resident care task audit and staff numbers and observed sufficient staff per resident care needs 4. Staff training -Facility is conducting monthly training and LPA observed staff training material and attendance sheet No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 29, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 10/29/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Senior Executive Director, Kimberly Hagen, and explained the purpose of the visit. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: buildings A, B, C, and memory care, common areas, dining rooms, activity rooms, kitchen, outdoor area, main restrooms, and PPE storage room. Fire extinguishers are ready for emergency use and all stairwells have evacuation chairs. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Senior Executive Director completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 29, 2022

Allegation investigated: Resident visitation rights are violated.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver complaint findings for a complaint received on 4/26/2022. LPA met with Deborah Ahrens, BOD and Ingrid Weber, Memory Care Director . Kimberly Hagen, Administrator joined by phone. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and confirmed there are currently multiple positive Covid cases at the community. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. During the course of the investigation, LPA interviewed the Administrator, Business Office Director, Memory Care Director, resident (R1), resident's POA, and another individual who knows R1. LPA reviewed documentation pertaining to R1 including, but not limited to: Physician's report, pre-assessment, initial care plan and care plan due to change in condition, General Durable Power of Attorney and Power of Attorney for Health Care for R1, emails from an individual who has visited with R1 and a text message sent from one individual to a second individual, who both had visited R1, describing a follow up phone call received on/around 4/22/2022 from the facility about their recent visitation. The results of the investigation are as follows: cont on 9099C(1)... Substantiated Allegation: Resident visitation rights are violated. The complaint alleges that when (2) visitors asked the facility if resident (R1) could join them for a lunch outing, with their mom, another resident, off site,. they were told by the Memory Care Director she would need to check with (R1's) family. The Memory Care Director followed up and sent a text to one of the visitors stating that they could no longer visit with (R1) due to Covid and they would have to wear a mask for outdoor visitation. LPA reviewed several emails received from an individual who had visited with R1 in the Memory Care Unit on multiple occasions. The individual stated on 4/26/22, that she had visited with R1 the Friday before (4/22/22) and following the visit she received a text from another individual who had also visited with her that day, stating that they would not be able to visit again if they did not wear a mask both indoors and outdoors. The visitor stated that she has not always been diligent about wearing a mask inside due to another friend being hard of hearing that she also visited with. LPA reviewed a subsequent email from the same visitor, dated 4/29/22, noting that she and another visitor were denied visitation with resident (R1) due to resident's family not granting permission and they were also not allowed to enter the Memory Care Unit to visit another resident (R2), who also resides in the Memory Care Unit, but had to visit outdoors where the facility staff brought R2 to meet them. LPA reviewed a third email received on 5/7/22 where the same visitor states that she was again denied visitation inside the facility on 5/6/22 and was only permitted to visit outside the building with resident (R2). The email states that the visitor inquired with facility staff why she/they could not visit with R1 on the inside Memory Care patio and the staff did not provide an answer. The Memory Care Director stated that she communicated with the daughter of R2 that since the (2) ladies visiting R1 "are always removing their masks", they would need to conduct any future visits outdoors. LPA reviewed a copy of a text message sent from the family member of resident (R2) to one of the visitors who had visited resident (R1) on 4/22/22. The text message states that it is a summary of the phone call made by a facility director to the family member of R2 with the following requests made: 1) Masks need to be worn at all times; 2) Indoor visits no longer allowed; 3) Outdoor visits still allowed but masks still need to be worn at all times; 4) Visiting with other residents is unfortunately not allowed due to not only Covid safety but for privacy as well; 5) if the (2) visitors wishing to visit with R1 are unmasked again, they will no longer be able to visit. cont on 9099C(2).. 9099C(2)...R1's physician's report, dated 1/13/22, notes that resident has a diagnosis of Alzheimer's Dementia with behavioral disturbance and cannot leave the facility unassisted and also indicates that resident does not have any motor impairment that would require use of an assistive devise. Resident's initial assessment and care plans (2) note that resident is not a fall risk, does not require assistance with transferring and does not use an assistive/adaptive device. POA stated that R1 is a social person and he is happy for her to have visitors, but he would like to know who his mother is visiting with due to a past history of people trying to take from her financially. Resident stated to LPA that there are some "wonderful ladies that always ask for me when they visit because they know I like to read." One email from one of the visitors describes how R1 likes to read and how she brings her new books. Memory Care Director also stated that she has to notify and get authorization from R1's POA before allowing anyone to visit R1. Both the Memory Care Director and R1's POA confirmed that there is not a restraining order for visitation, preventing anyone from visiting or a conservatorship for R1 currently in place. The Department issued Provider Information Notice (PIN) 21-48- ASC on 11/17/2021 entitled "Authority of Conservators and Agents under Powers of Attorney related to Resident Rights". The PIN states under "Residents' Rights to Visitors, Telephone Calls and Personal Mail": POAs typically do not address issues concerning visitation, telephone calls, or personal mail and therefore, agents are not authorized to restrict these rights. However, a POA agent can regulate visitation, telephone calls or personal mail only if: 1) the resident explicitly gave the agent the authority to regulate these issues in the POA and 2) the principal does not disagree with the choices the agent is making. Principals, even those with a cognitive impairment, retain the legal authority to control their health care and other personal decisions unless a court has taken that authority away. The Department reviewed the General Durable Power of Attorney of (R1) provided during the complaint investigation. While the document does grant power to resident's POA regarding mail receipt and services, it does not address visitation or telephone calls. Based on information obtained during the investigation, the allegation is found to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 9099-D page. Exit interview. Copy of report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2022 · control 25-AS-20220426122233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Sep 6, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11) To have their visitors, including ombudspersons 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 interviews conducted and documentation reviewed, the Licensee did not ensure that resident's (R1) was able to visit with visitors who requested to visit with her on 4/29/2022 and on 5/6/2022, which posed a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2022

Plan of correction: Licensee/Administrator agree to conduct a training with department managers to discuss POA's and visitation rights in general for residents. Documentation of agenda/attendees to be provided to CCLD by 9/30/22.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced at the facility to deliver complaint findings and also issue a citation for a deficiency discovered during the course of a recent complaint investigation. LPA met with Kimberly Hagen, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and confirmed there are currently multiple positive Covid cases at the community. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. During the investigation of complaint #25-AS-20220426122233, the Department reviewed documentation entitled "Secured Environment Addendum" for resident (R1) and observed it to be signed by resident's Power of Attorney on 2/25/2022. LPA discussed the document with facility Administrator, Memory Care Director and POA during a phone conference on 4/29/22 and that it does not include resident's signature. Resident's POA stated that resident clearly knew she was moving into a facility with a secured environment and was rejected for Assisted Living. The facility was previously cited on 2/23/2018, for the same deficiency, under Health and Safety Code §1569.698(f) which reads: Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 809-D page. Exit interview. Copy of report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.698(f) · Plan of correction due date: Aug 25, 2022

§1569.698 Building standards; adoption; locked and secured perimeters in residential care facilities; persons with dementia (f) Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. This requirement is not met as evidenced by: Based on documentation reviewed, the Licensee did not ensure that resident (R1) signed the "Secured Environment Addendum" dated 2/25/22. The document was signed by resident's POA instead which posed a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2022

Plan of correction: LIcensee/Administrator agree to conduct a review of all resident files in the Memory Care Unit to ensure that each resident has signed the Addendum and have agreed to live in the secured environment. Facility to provide copies of all signed Addendums to CCLD by 9/30/2022.

Allegation investigated: Facility is not allowing resident to manage own medications

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint the department received on 3/14/2022. LPA met with Kimberly Hagen, Administrator, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and confirmed the number of positive cases currently at the facility. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. During the investigation, LPA interviewed Administrator, (2) Regional Nurses, resident (R1), resident's representative. LPA reviewed the following documentation pertaining to resident (R1) including, but not limited to: physician's reports, care plan, medications lists, copy of faciliy medication policy and admission agreement. Additionally, LPA consulted with a Department Clinician. Cont on 9099C(1).. Unfounded Allegation states that resident has had the facility manage his medications for 2 years and has concerns about staff turnover and lack of supervision of the medication staff and has requested to manage his own medications. The facility is denying his request and has told him this is not possible. Resident states he is aware of all the medications he needs to take and the times he is required to take them. Resident has been reassessed and his physician has indicated resident can manage their own medications. The results of the investigation are as follows: Regional Nurse, Alisa Salluce, indicated on 3/22/22 that Regional Nurse, Cindy Barnes, consulted with her prior to assessing resident the first time to determine if resident could identify the medications he takes, and the reason and side effects of each one. Both regional nurses stated that several opportunities were given to resident who was not able to identify the majority of the medications being taken, or the reason or side effects of each one. Additionally, both regional nurses stated that Regional Nurse Barnes reached out to resident's Physician's Assistant to come in to the facility to assess resident with her, but it was not agreed upon. Following the phone call, resident's Physician's Assisted then immediately rescinded, on 3/14/22, her prior authorization, noted on the physician's report, allowing resident to mange his own medications. LPA observed fax documentation showing the authorization was rescinded from 'Yes" to "No" for resident to manage his own medications. LPA observed that resident's physician's Assistant wrote an order, effective 3/30/22, for resident to manage his own medication with the assistance of his daughter. Regional Nurse Barnes stated that she provided resident with two different opportunities in March 2022 to identify his meds and explain what each medication is for and the side effects and resident was not able to identify all of the meds he takes, and stated "he needs to be able to identify and know what meds he takes". They would also still need to provide supervision to ensure that resident is taking them per doctor's orders. Administrator, Kimberly Hagen, stated she spoke with resident on 4/15/22 and explained that if staff is supervising him while he takes medications that are prepared by resident's family member, they are still supervising him, and resident must be enrolled in the medication program. On 5/13/2022, LPA had a virtual meeting with resident, resident's representative, Administrator, and Regional Nurse Barnes to discuss the matter of resident managing his own medications further. Resident's representative explained that resident's physician and she and resident agreed that resident will have a check-list of what meds to take at which time to be able to manage his own medications. prescription. cont on 9099C(2)... Regional Nurse Barnes stated that resident needs to be able to identify his medications and he takes a lot of them, explaining that resident is currently managing his PRN meds in his room and the doctor keeps giving him more and some are prescription. Administrator stated on 5/13/22 that resident refused to discuss what medications any further with staff. LPA explained that the Department's nurse also reviewed the request for resident to manage his own medications and the facility would need to "develop a care plan that addresses his needs, restricted health condition and medications" and the care plan should indicate how to meet all of these requirements. Resident and resident's representative stated during the meeting on 5/13/22 that resident does not have to show the facility he can identify each medication he takes to be allowed to manage his own medications. LPA reviewed documentation of "Medication Policy" signed on 12/17/2019 by resident which says residents "can keep medicine in their apartments only if you manage all of your medications". Regional Nurse Barnes stated that they have Title 22 regulations to follow with the state as well as their own policy and cannot allow resident to manage his own medications if he cannot identify them and express his understanding of the reason for the medication and the side effects of usage. Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 25-AS-20220314163537

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection following the recent receipt of several incident reports (LIC624) for multiple residents. LPA met with Kimberly Hagen, Administrator, Sharika Montenegro, Resident Services Coordinator, and Ingrid Weber, Memory Care Director. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols, completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and confirmed the number of positive cases currently at the facility. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. The following incidents were discussed for each resident as follows: Resident (R1) is an ILU resident who was sent out on 6/9/22 (4:35 pm) following the discovery of skin breakdown on lower shin and buttocks. Resident fell twice on 6/8/22, in the morning and evening- both falls were related to slipping from the wheelchair. On 6/9/22, (7:45 am) resident slipped off her bed. Resident refused medical transport following each fall but was sent out later that day. Resident is currently rehabilitating at a skilled nursing facility and will be re-valuated upon return for Assisted Living. Resident (R2) fell on 6/9/22 at 4:50 pm when trying to get up from the toilet. Resident was sent out due to complaints of right hip pain. Resident returned from the ER the same day with no injuries or changes in medications. Resident reminded to push pendant if needs help. Remains at level 0. cont on 812C(1).. Resident (R3) fell on 6/8/22 at 2:40 pm after slipping from the recliner chair. Resident was sent out to the ER due to high blood pressure and returned the same day. Resident was also recovering from Covid and has been placed on hospice as of 6/15/22. Resident (R4) resides in ALU and was sent out on 6/9/22 for an evaluation due to erratic behavior observed. Resident has a diagnosis of Bi-Polar and has started to decline. Resident was given a change in medications and the family has been staying with resident more. Additionally, a private companion has been hired to stay with resident 2 hours during the evening time. Administrator stated she will continue to work with the family and staff will continue to redirect resident, pending the effectiveness of the recent medication changes. There are no deficiencies cited during today's inspection. Exit interview. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Jun 16, 2022

Type of visit: Case Management - Legal/Non-compliance

*Note: This document has been amended to add the additional information below, please see Line 23* An office meeting was held on 06/08/2022 at 9:00 AM on a Microsoft Teams Meeting video conferencing system review the stipulation adopted on 6/1/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following were in attendance: Regional Manager Alycia Berryman, Licensing Program Manager Maribeth Senty, Licensing Program Analyst Cassie Yang, Representatives of WG El Camino Gardens SH LP; Atria Management CO, Administrators of WG El Camino Gardens SH LP; Atria Management CO: Jason Thomas, Danny McCoy, Jen Johnson, Dana Stanel and Kimberly Hagen. Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with Representatives, Administrators, and Licensees who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License-Stayed with Probation · Limitations and conditions · Monitoring Penalty-Rescinded · Future Application for License, Registration, Certification or Approval · Licensure, Certification or Approval; Application Denial, Tolling of Probationary Period · Completion of Probation *Discussed the licensee’s ability to seek an early termination of probation after one year*x · Violation of Stipulation Term · Monitoring Fee · Department's Authority · Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims · Severable terms · Public Records · Signatures · Counterparts · Effective Date: (6/1/2022 – 6/1/2024) · No Oral Modification · Representations RE. Corporate Licensee The Licensees/Respondents/Representatives stated they would abide by the following: · Abide by the contents/terms of the Stipulation (submit all documents timely) · Operate the facility in substantial compliance with the regulations and statues governing the operation of a residential care facility for the elderly. CCLD will do the following: · Increase monitoring Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. COMMENTS-LICENSE PROBATION PERIOD 06/01/2022 TO 06/01/2024 FACILITY LICENSED FOR 325 NON-AMBULATORY RESIDENTS, 20 OF WHOM MAY RECEIVE HOSPICE SERVICES.the state’s words, verbatim · CDSS document, Jun 8, 2022

Allegation investigated: Staff are not assisting residents with showering as often as needed. Staff are not assisting residents with ambulating to the restroom in a timely manner.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 1/7/2022. LPA met with Kimberly Hagen, Administrator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. During the investigation, LPA interviewed Senior Executive Director (SED), (3) Med-Techs, (3) resident and reviewed documentation including pendant response times and shower schedules. The results of the investigation are as follows: Allegation: Staff are not assisting residents with showering as often as needed. cont on 9099C(1).. Unsubstantiated Allegation is that facility is short staffed (one staff per building) and residents' needs are not being met in a timely manner. Specifically, staff are not able to assist residents with showering as often as needed. Three Med-Techs were interviewed on 2/24/22. One Med-Tech stated that staffing has been okay so far and there are 2 outside agencies providing staff- 2 staff are placed in Building B and in Building C and 1 staff is placed in Building A. The same Med-Tech stated that from 4-6 pm, staff are the busiest, and there are 2 caregivers that work 12 hours and 1 "floater" caregiver that works in building B and C but can go to building A if needed. A second Med-Tech stated the facility uses agencies if needed so there are 3 Med-Techs on each shift, one for each building, A, B and C. This Med-Tech stated that she will assist with showers, if needed, and the average time is 5-10 minutes, residents don't usually have to wait long and the mornings are the busiest. This Med-Tech stated that sometimes staff doesn't clear the pendant button so the response time can appear longer than it actually is and sometimes residents can refuse a shower. A third Med-Tech stated that the facility is using agencies currently with Covid cases and the staff from agencies "don't respond to radios and don't communicate well" and many work 12 hour shifts. This Med-Tech stated staff has communicated to management that additional caregivers are needed from 6 am- 9 am and from 4 pm- 7 pm but 1 Med-Tech is always sufficient at any time. Three residents were interviewed on 2/24/22. One resident confirmed he does not use the pendant to request assistance and staff will attend to him in 5 minutes or less. A second resident stated she receives standby shower assistance and there are no issues with using the call pendant. A third resident indicated she receives a shower twice/weekly and there is a helper that helps her- and showers are given as scheduled and are "always on the right day". The same resident stated she has never had a pendant and always receives assistance when it's needed. LPA reviewed shower schedules, printed on 3/3/22, for Assisted Living residents. Schedule showers are scheduled from once weekly to daily and notes are added as to the amount of assistance resident needs. Based on information obtained through interviews and documentation reviewed, LPA finds the above allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099C(2)... 9099C(2).. Allegation: Staff are not assisting residents with ambulating to the restroom in a timely manner. Allegation is that staff are not able to assist residents with walking to the restroom in a timely manner, which has resulted in residents having poor hygiene and having "accidents" that could have been avoided or having to "hold it' while waiting for staff to assist. One resident said she does not need any assistance with toileting, and there are no issues with using the call pendant. A second resident said he does not use the pendant to request assistance and staff will attend to him in 5 minutes or less. A third resident said she has never had a pendant. One Med-Tech stated that average time is 5-10 minutes, residents don't usually have to wait long, the mornings are the busiest, and sometimes staff doesn't clear the pendant button. A second Med-Tech stated "Sometimes it's a problem- we help as needed and work as caregivers if someone needs shower help. On Hall A, there is 1 male caregiver and sometimes there is a delay if a female resident needs a shower and prefers a female caregiver. On Hall B, 1 -2 caregivers is usually okay since the residents are more independent. "Hall B and C are the busiest and there are a lot of pendant pushes for escorts, toileting and showers". The pendant calls go to staff's pagers. Residents are asking for more help on Hall B and C. The same Med-Tech stated that staff has communicated to management that from 6 am- 9 am and from 4 pm- 7 pm and during this time, 3 caregivers are needed. This Med-Tech stated the biggest concern is "the Med-Tech is supposed to be on the floor at the same time they are passing meds- Maybe we need another floater or more staff from the outside agency". LPA reviewed pendant reporting for period 12/21/21 - 1/31/22. SED stated "Our average (mean) response time for the attached pendant reporting period is 13.1 minutes; the median response time is 10.67 minutes. Our policy goal is a 15-minute response time, so we are compliant with our policy". LPA observed several repose times to be significantly longer than 15 minutes. SED provided several reasons why a response time may be greater than 15 minutes, as follows: "The log records a “response” when the pendant is cleared—not when a staff member arrives...Staff do not clear the pendant until the resident’s needs have been met.... Also, staff sometimes forget to clear the pendant immediately after providing service to the resident. Finally, in some instances, residents simply refuse to allow us to clear the pendant or there is a malfunction with a pendant that will not allow us to clear it." cont on 9099C(3).. 9099C(3).. SED provided an update during the investigation, on 3/7/22, stating the facility has dedicated many resources over the past few months to improving pendant response times- "The most significant issue was residents using the pendants as a “concierge” button—in other words, non-emergencies. We have re-educated residents on the proper use of the pendant and greatly reduced the number of pendant calls. In addition, the vast majority of pendant calls were coming from a very small number of residents, some of whom would press their pendants 10-20 times per day. These residents were evaluated on their ability to understand the proper use of the pendant and, if appropriate, moved to a higher level of care (e.g., memory care). While we had made significant improvement in response times in December and January, I am pleased to report that the average response time for February was 8.99 minutes, and the average response times for the past seven days has dropped below five minutes." SED provided LPA with pendant response documentation times for April 2022 and May 2022. For April 2022, the average response time is 3.43 minutes and for May, the call average is 1.51 minutes for May 2022. Based on information obtained through interviews and documentation reviewed, LPA finds the above allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, May 17, 2022 · control 25-AS-20220107160441

Allegation investigated: Resident left facility and staff didn't know

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 10/20/2021. LPA met with Kimberly Hagen, Administrator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. During the investigation, the Department interviewed Senior Executive Director (SED), Kimberly Hagen, prior Assistant Executive Director (AED), Barbara Fleck, Business Office Director (BOD), Deborah Ahrens, the Ombudsman and (1) family member of resident (R1). The Department reviewed documents pertaining to Resident (R1) including, but not limited to: resident charting notes, care plans, physician’s report, Ombudsman report, Unusual Incident/Injury Report (LIC624), Resident Agreement, video surveillance, text messages between facility and resident's family member and local law enforcement reports. The results of the investigation are as follows: report cont on 9099C(1).. Substantiated 9099C(1).. Allegation: Resident left facility and staff didn't know. Resident (R1) moved to the facility in April 2021 with a diagnosis of Mild Cognitive Impairment (MCI), occasional confusion, history of alcohol abuse, uses a walker/cane at times due to leg weakness, and Resident's physician's report dated, 4/16/2021, also states that resident is to avoid alcohol due to medications being taken. Resident's Functional Needs assessment, or care plan, was updated on 8/30/2021 as part of a quarterly update, and again on 9/24/2021 for a "Change in Condition". Both assessments note that resident is non-ambulatory and is not able to leave the community unassisted. The assessment conducted on 9/24/2021 notes the only change is that resident has a diagnosis of Vascular Dementia, and now requires status checks, 10 times daily. Executive Directors stated on 10/27/2021 that resident went missing on October 16, 2021 and returned on their own on October 17, 2021, around 10:04 am. LIC624 says “resident signed out of the community with a friend, at approximately 1:15 pm on 10/16/2021”. Local law enforcement report for the incident says that "(resident) temporarily checked himself out for the day.... then left the facility with an unknown woman... and (resident's) family member was later contacted by the assisted living facility when staff was unable to locate (resident)..." On 10/16/2021 at 9:35 pm, law enforcement contacted Business Office Director (BOD) by telephone who stated that between 12:30 pm- 2:00 pm, on 10/16/2021, an unknown woman, carrying a grocery bag, attempted to visit resident but did not have proof of a Covid-19 vaccination. LIC624 states "resident and friend informed the community they would be leaving together". One video surveillance provided to the Department shows the visitor walking into the facility, on 10/16/2021 at 12:58 pm, with a bag, was given a mask to wear by facility staff, and then exited the facility, waiting outside near the entrance. A second video surveillance provided by the facility shows resident (R1) to be exiting the facility on 10/16/021 at 1:05 pm, walking from the lobby reception area outside the front entrance. The law enforcement report notes that BOD stated that residents are allowed to check themselves out of the facility if accompanied by a coherent adult, living outside of the community, and residents are not given a curfew but are instructed to notify the facility if they will be away longer than 24 hours. Additionally, law enforcement confirmed that the facility check out logs do not document or identify who residents leave with, but only note the resident's name and time resident leaves/returns. The report indicates that facility staff stated that resident (R1) has been known to temporarily check out of the facility for several hours, but has always returned. Resident's family member stated she was not aware that resident ever left. cont on 9099C(2).. 9099C(2)..Resident’s family member stated in an interview to LPA that a facility Med-Tech (S1) called her on 10/16/2021, around 7:30 pm, and left a message that she was looking for the resident to administer his evening medications. Resident’s family member stated that when she returned the call, she was instructed to speak to the Business Office Director (BOD) who advised her that resident “had signed himself out earlier in the day”. Facility provided a sign out sheet, dated 10/16/2021, showing that BOD signed resident out at 1:00 pm and wrote the note "Care staff notified" in the column, "Time In" and additional notes "advised care staff of no return" with no time reference. Resident's notes were reviewed that were entered by several staff members regarding the incident on 10/16/2021. On 10/18/2021 (7:49 pm), staff (S3) documented that resident missed 5 pm and 8/9 pm medications scheduled on 10/16/2021 and that resident left the facility without letting facility staff know. There were no resident notes entered on 10/17/2021. On 10/18/2021 (8:23 pm), SED entered notes that multiple texts and messages had been left for resident’s family members (2) and on 10/18/2021 a message was left for resident’s Power of Attorney that resident purchased alcohol on a grocery outing. On 10/18/2021 (10:58 pm), staff (S2) entered notes that facility staff met with resident to discuss the recent incident and how it poses a safety hazard to resident and to the community. These same notes indicate that resident’s friend signed resident out for a visit off-site before resident left with the visitor and that resident returned to the community in possession of a lot of alcohol. Review of the Ombudsman’s report notes that on 10/21/2021, the Ombudsman and Assistant Executive Director met and discussed the “check-out/check-in system used” at the facility and AED indicated that they “now have a formal system” in place since resident left the facility with an unknown woman and was gone for an extended period of time. LPA discussed with SED and BOD who stated there is not a specific letter on file from resident's doctor stating that resident can only leave with a family member or with the facility on a group outing. BOD stated that it was her understanding that resident was able to leave the facility if accompanied by another individual/escort. Based on information obtained during the investigation, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is cited on the 9099D page. Exit interview. Copy of report provided to Executive Director. 9099C(1).. LPA reviewed the Resident's Functional Needs assessment, or care plan, was updated on 8/30/2021 as part of a quarterly update, and again on 9/24/2021 for a "Change in Condition". Both assessments note that resident is non-ambulatory and is not able to leave the community unassisted. The assessment conducted on 9/24/2021 notes the only changes is that resident has a diagnosis of Vascular Dementia, and now requires status checks, 10 times daily, and shows all care needs to be (210 points) related to status checks. EDs stated that R1’s rate had increased due to the change in diagnosis and that R1’s family was notified of the rate change. In the same interview, AED stated that the rate increases when a resident has Dementia because staff have to increase monitoring, to every 2 hours, and that it's the facility's policy that anyone in Assisted Living with Dementia is required to be checked on regularly, due to behaviors. Both SED and AED stated that resident's rate had increased due to the change in diagnosis and that resident's family was notified of the rate change. LPA was provided with a copy of a "Change in Assisted Living Services" letter, dated 9/27/2021, sent to resident (R1) advising of a change in supportive services. In the same notification, resident is listed as his own "Responsible Person". BOD stated that resident informed her of his change in diagnosis to Vascular Dementia, a few weeks following his appointment on 8/13/2021, and the medical documentation was forwarded to the AED or care department, who then completed an updated assessment on 9/24/2021. Ombudsman report states that the updated Functional Needs Assessment was discussed with AED on 10/21/2021, who stated that the reassessment is done annually on all residents with a diagnosis of Dementia living in all facilities. Family member stated they did not believe status checks were necessary every two hours as resident’s condition had not changed since April 2021 when resident moved in and resident was previously taking medications prescribed for a Dementia diagnosis when resident lived out of state. Physician’s Report, dated 4/16/2021, notes that resident has a diagnosis of Mild Cognitive Impairment (MCI) and cannot leave the facility unattended but can attend shuttle shopping trips with a group at the facility. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. cont on 9099C2)... Allegation: Staff didn't notify family when resident was not in facility. LIC624 for incident states “resident signed out of the community with a friend, at approximately 1:15 pm on 10/16/2021” and .... “When resident did not return as expected, community called family. Community and family were unable to reach resident or friend via phone. Law enforcement was called. Resident failed to return for his evening and following morning doses of medications." Resident’s family member stated she was first informed about resident leaving the facility when a facility Med-Tech called her on 10/16/2021, around 7:30 pm, and left a message telling her that she was looking for resident to administer his evening medications. SED and AED stated on 10/27/2021 in a Department interview that resident's son is the emergency contact, and one of resident's daughter will step in when resident's son is unavailable. Text messages provided to the Department document a discussion with resident's son and SED on 10/17/2021 at 9:49 am regarding who the female visitor was, as shown in the video surveillance. BOD stated on 5/17/2022 that the facility front desk closes at 7:30 pm and around 6:30-7:00 pm, while staff is preparing to close, they will check the sign-out log and see if there are any residents who haven't returned yet. BOD stated that it was "not unusual for (R1) to come back late" after leaving and resident's family was contacted shortly after resident had not returned. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff didn't call emergency services when resident left per their agreement. LIC624 submitted for incident on 10/16/2021 reads, in part, “When resident did not return as expected, community called family. Community and family were unable to reach resident or friend via phone. Law enforcement was called...." BOD stated she contacted law enforcement when resident didn't return around 6:30-7:30 pm and spoke with law enforcement on 10/16/2021, again at 2 subsequent times, to provide additional information. BOD stated she is not clear if she called 9-1-1- or non-emergency line. SED provided police number to resident's other family member, on 10/17/2021, who requested it. The family stated they would follow up and file a "Missing Person's" report. SED stated in a text message, on 5/5/2022, that resident's daughter made the police report after the facility notified her that resident had left the facility. Resident's family member stated to LPA, on 3/11/2022, that she called law enforcement immediately after being informed that resident was not found in the facility. Law enforcement report, dated 10/16/2021, identifies the reporting party (RP) as resident's family member. Based on information obtained during the investigation, LPA finds the allegation to be UNSUBSTANTIATED-meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, May 17, 2022 · control 25-AS-20211020154446

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: May 19, 2022

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on interviews conducted and documentation reviewed, the Licensee did not ensure that resident (R1) did not leave the facility, on 10/16/2021, accompanied in a group, as directed by resident's physician, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 17, 2022

Plan of correction: Administrator updated sign-out logs to include additional contact information for resident and visitor. Administrator agrees to review all Assisted Living resident files with a dementia diagnosis and update the list kept at reception regarding residents who can leave unassisted Training plan discussed during today's exit interview- training to be conducted by 6/3/2022. Agenda/attendees to be provided to the Department by 6/30/2022.

From the deficiency page

There is no second citation issued on this page.the state’s words, verbatim · CDSS document, May 17, 2022

Allegation investigated: Facility does not have adequate supervision. Staff did not provide adequate food service to residents.

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 1/18/2022. LPA met with Kimberly Hagen, Administrator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. During the investigation, LPA interviewed Senior Executive Director (SED), Kimberly Hagen, Business Office Director (BOD), Culinary Director, (1) Culinary staff, (3) Med-Techs, and (3) residents and reviewed documentation including: facility dining menus for January 2022, staffing levels and an Unusual Incident/Injury report (LIC624). The results of the investigation are as follows: cont on 9099C(1)... Unsubstantiated Allegation: Facility does not have adequate supervision. Complaint discusses three specific concerns as follows: Due to insufficient staffing the staff do not turn in required paperwork for long-term care insurance and the insurance company has attempted to decline her claim. Business Office Director confirmed she processes long-term care paperwork and each department submits specific paperwork to her which is forwarded to the respective insurance company before the end of each month. BOD stated it is "a very tedious" process as she has to fax paperwork and then email it to the insurance company and then send it by USPS also and has 5 days to do so. BOD stated that if the paperwork is late on her end, she will adjust the billing so resident only pays what they would have paid or will pay after the reimbursement. BOD stated she hired an assistant in February 2022 to help with the paperwork. Many residents are not receiving their showers and not being provided with the care they are paying for. Med-Techs (3) were interviewed on 2/24/2022. One Med-Tech stated sometimes there are 2-4 showers scheduled on a shift and we will try to accommodate them". A second Med-Tech stated "Sometimes it's a problem- we help as needed and work as caregivers if someone needs shower help. On Hall A, there is 1 male caregiver and sometimes there is a delay if a female resident needs a shower and prefers a female caregiver. On Hall B, 1 -2 caregivers is usually okay since the residents are more independent. "Hall B and C are the busiest and there are a lot of pendant pushes for escorts, toileting and showers". Residents are asking for more help on Hall B and C. Staff has communicated to management that from 6 am- 9 am and from 4 pm- 7 pm, 3 caregivers are needed. 1 Med-Tech is always sufficient at any time." A third Med-Tech stated the facility uses agencies, if needed, so there are 3 Med-Techs on each shift, one for each building, A, B and C, and the average wait time is 5-10 minutes, and the mornings are the busiest. This Med-Tech stated that sometimes staff doesn't clear the pendant button, and sometimes residents refuse their scheduled shower. cont on 9099C(2)... 9099C(2)..LPA interviewed (3) residents. One resident stated that she receives a shower twice weekly and there is a helper that helps her, showers are given as scheduled and are "always on the right day". A second resident stated she receives shower standby assistance, and a third resident- indicated he does not use the pendant to request assistance and staff will attend to him in 5 minutes or less if assistance is requested. Resident stated one day she found resident (R1) laying in the hallway alone, after falling, and it took staff 15-20 minutes to respond. LPA discussed LIC624 submitted to the Department for resident (R1)- who fell on 11/18/2021 near Building C mailboxes. The LIC624 notes that emergency medical technician's arrived and assessed resident who was then sent to the Emergency Room. LPA discussed additional information with SED who stated resident became a two-person assist and needed a higher level of care. Two Med-Techs were interviewed about the allegation. The Med-Tech referenced in LIC624 stated he was off the day R1 fell and stated, "it's not likely she would be laying in the hallway for 15-20- minutes and was not seen". This Med-Tech stated R1's balance was not the best and so staff did status checks on her and staff still have to call 911 for every unwitnessed fall. A second Med-Tech stated she was unsure of reasons why resident may have been waiting on the floor for 15-20 minutes after falling and did not have any additional information. Based on information obtained through interviews and documentation reviewed, LPA finds the above allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not provide adequate food service to residents. Allegation has two parts. Allegation asserts that at breakfast on 1/18/2022, there was no chef and all the food was pre-made and reheated which causes the food to be of very poor quality. Residents complain the food is served cold and due to insufficient kitchen staff residents wait a long period of time before food is served. cont on 9099C(3)... 9099C(3)...Culinary Director stated, when asked about staffing shortages in the kitchen, "All of our staffing in the kitchen/dining is from an agency except for (1) staff from Atria." Culinary Director was asked about food being pre-made and reheated and stated, "We have a special #1 and #2 which can be served quicker.... and "everything is made fresh- only dessert is served the next day and no more than 3 days after it's made. We don't reheat to serve- the food quality has stayed the same- nothing has changed". A lead server stated , "We have a few Atria staff and a few temporary staff from the agency and there has never been a time when there are no staff in the dining room to serve". The lead server stated, when asked about resident complaints, "We tell the chef. Every month, we host a Food for Thought meeting- residents can voice their concerns." The Culinary Director also stated, "Food for Thought" meeting isheld in the main dining room on the first Thursday of the month so residents can voice their opinions/concerns about food service." LPA interviewed (3) random residents who were sitting in the dining room on 2/24/2022. The first resident stated the food is good, the servers provide timely service, and the food is fresh. A second resident stated the has no complaints about the food service. A third resident- "for the most part it is good" and "yes, we have to wait sometimes- it's hard for the contract people to know what to do" and "once in a while it's not hot". SED and BOD confirmed, while looking through electronic personnel files, that 1/18/22 was a Tuesday and provided names of (5) staff who began their shift on that morning in the kitchen. Allegation asserts the facility is not serving many vegetables to the residents, and the main chef refuses to serve them V8 juice even though they have the juice in storage. Culinary Director stated in an interview, “We substitute with a similar product if we can't get the juice. I couldn't get V8 juice”. Nothing has changed with the food served. We order all our vegetables and 90% of other food from (the same outside company). The quantity never changed."LPA reviewed (2) facility dining menus- on menu features always available items for breakfast, lunch and dinner and dessert, and the second menu features “Daily Specials” which offer a variety of foods to choose from, including a different soup, salad, entrée, dessert/fruit/fruit juice. Also offered at lunch and dinner are a “Restaurant’s Favorite” which feature an entrée, side and vegetable. Based on information obtained through interviews and documentation reviewed, LPA finds the above allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report provided to facility.the state’s words, verbatim · CDSS document, May 17, 2022 · control 25-AS-20220118151104

Allegation investigated: Facility is not abiding to admission agreement

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to commence a complaint investigation. LPA met with Kimberly Hagen, Administrator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. During today's inspection, LPA discussed allegation with Kimberly Hagen, Administrator, Ingrid Weber, Memory Care Director and Deborah Ahrens, Business Office Director and reviewed pertinent documentation pertaining to resident (R1),including: care plan, Residency Agreement, and Room Change Addendum to the Residency Agreement. The results of the investigation are as follows: cont on 9099C.. Unfounded Interview with Executive Director confirmed that resident (R1) moved from Assisted Living to Memory Care on 1/27/2020 and the monthly costs were increased only at that point, due to resident's increase need for care/supervision. Executive Director reviewed monthly electronic billing statements with LPA which showed a cost of care increase effective 1/27/2020 when resident moved from Assisted Living to Memory Care. LPA reviewed resident's Residency Agreement which states that when there is a change in the level of care, resident will be consulted with at the time of the change in the level of care. Agreement notes that the resident's responsible person will also be informed of any changes. Residency Agreement also explains how the assessment level is determined for a resident in memory care and denotes it as "Alz 1" or "Alz 2 and lists the additional charge for each level. Resident signed the Residency Agreement on 4/24/2019 as resident's own responsible person. Interview with Memory Care Director revealed that resident remained at Level 1 the entire time while residing in Memory Care and resident was "still physically able to move around with a walker and needed minimal assistance with care" and had many lucid moments. Resident's care plan, dated 11/17/2021, shows a care point that was for Level 1. LPA reviewed documentation entitled " Room Change Addendum to El Camino Gardens Residency Agreement" , signed on 1/23/2020 by resident, noting that resident will be charged for Alz 1 Level of Care and Basic Services upon moving to the new apartment on 1/23/2020. Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. Copy of report provided to Executive Director.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 25-AS-20220412100354

Allegation investigated: Facility not in good repair

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation and deliver findings. LPA met with Kimberly Hagen, Administrator. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: KN95 mask. During the investigation, LPA's Calzada and Yang interviewed the Divisional Maintenance Director, Maintenance Specialist, Executive Director, Assistant Executive Director, and (2) residents. LPA's reviewed the following documentation: history of work orders for apartment, contractor's invoice. The results of the investigation are as follows: cont on 9099C. Unsubstantiated Resident (R1) stated she has lived at the facility since September 2017 and was told by the prior occupant that the apartment leaks every time it rains and the carpet gets wet near the heater/AC unit where the water comes in, and the carpet gets really soaked during a big storm. Resident informed LPA's that maintenance had vacuumed the water from her carpet and placed a board on her AC unit to prevent further leaks. Facility work orders reviewed for resident's apartment, from 2013 forward, show that on 9/21/2013, a work order was entered for "water issues... needed asap" and on 11/1/2015 "water was leaking into the apartment- radio's maintenance who are responding immediately". Divisional Maintenance Director stated on 12/31/2021 that the leaking was reported on 12/23/2021 at 8:39 am, housekeeping staff immediately confirmed the leak, and the Maintenance Specialist followed up and investigated the exterior of the building by cleaning the gutters and resealing the ptac unit to prevent further leaks. Division Maintenance Director added that after the recent big storm, he reviewed prior work invoices for the cleaning of the gutters, and determined that the outside cleaning company failed to complete the job, asserting "it's not a roofing issue, it’s a gutter issue". Maintenance Specialist explained on 12/31/2021 that upon learning of the leak due to the recent rain, he immediately cleared out the gutter and closed the down spout pipe to prevent future leaks and temporarily placed a blocker board on top of the ptac unit until the re-routing of the overflow is fixed. LPA's observed on 12/31/2021 that a board had been placed at an angle on top of the unit outside so any rain/moisture would run away from the unit and not on the unit, leaking potentially to the inside. An outside contractor's invoice, dated 1/1/2022, notes that an "emergency call" was made on Sunday, 12/26/2021, to the facility to address water entering resident's apartment via the A/C unit. The invoice documents that the gutter outside/above the unit was cleared of leaves that were causing the gutter to be clogged, causing the water to pour out at the overflow onto the A/C unit. Additionally, during this maintenance call, the overflow was sealed to prevent water from flowing onto the unit and into the building. Administrator stated in an email to the Department "The community promptly addressed the issue through internal remediation and cleaning and also called out an vendor to address the issue from occurring again." cont on 9099C(2)... 9099C(2)..Both the resident and facility staff stated that the facility offered another apartment unit to resident, but the resident didn't want to move due to the location of the apartment and the summer sunlight. Based on information obtained, the Department finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. A Technical Advisory Note was issued to schedule regular gutter maintenance. Exit interview. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 25-AS-20211223103421

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced to conduct a case management inspection as a follow up on a incident report received on 3/9/22 of a medication incident on 3/4/22. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA's was screened per Covid-19 precautionary measures upon entering the community. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. LPA was accompanied by Administrator and Regional Care Specialist to the med cart and medication tech (S1) who had misinterpreted R1 medication order on 3/4/22. Though S1 mistakenly prepared two vials of a medication instead of the prescribed one vial, R1 refused that medication on 3/4/22 so the medication was not given. Licensee will clarify medication dose language with all med techs and consult with the pharmacy that prepares MARS to record commonly used language. There are no deficiencies being cited from this case management. Exit interview. Copy of report left at facility.the state’s words, verbatim · CDSS document, Mar 11, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPA's) Sabrina Calzada and Talwinder Bains arrived unannounced to conduct a case management inspection as a follow up to receiving a SOC 341 on 2/22/2022. LPA's met with Kimberly Hagen, Administrator, Allison Perkes, Asst. Executive Director, and Deborah Ahrens, Senior Community Business Director. Prior to initiating today's inspection, LPA's completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA's was screened per Covid-19 precautionary measures upon entering the community. LPA's ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA's discussed SOC341 regarding resident (R1), with Deborah Ahrens, Senior Community Business Director. The facility has made appropriate follow ups and confirmed that R1 still resides at the facility. There are no deficiencies being cited from this case management. Exit interview. Copy of report left at facility.the state’s words, verbatim · CDSS document, Feb 24, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Mknelly and Regional Manager (RM) Alycia Berryman, arrived at the facility unannounced on 11/23/2021 for a case management visit.. LPA met with Executive Director (ED) and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. LPA and RM ensured they used hand sanitizer just after entering the facility and the following Personal Protective Equipment (PPE) was worn. Additionally, LPA and RM were screened by receptionist. The purpose for the visit was to discuss a recent eviction notification received by Community Care Licensing (CCL) for R1 and a recent fall by R2. R1 has had a change of condition in their ability to manage a restricted health condition. ED informed LPA that they are successfully working with the resident, responsible parties, physician and home health to integrate measures to allow R1 to remain at the facility. LPA asked that the facility rescind the eviction order and copy CCL when the notice is sent. R2 had a fall with injuries on 11/18/21 which was reported to CCL on 11/20/21. R2 has returned to the community and their care plan is being updated to meet R2's physical, cognitive and supervision needs. LPA and RM were given a tour of the facility. ED will email LPA a copy of staff schedules for 11/21/21- 11/27/21 As a result of this visit, there are no deficiencies cited. Report was reviewed and copy providedthe state’s words, verbatim · CDSS document, Nov 23, 2021

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the facility today to conduct a case management visit regarding an incident report received by CCLD on 10/22/21. The facility currently does not have any COVID positive cases. Staff wore masks in the facility and LPAs wore N95 masks. Additionally, LPAs were screened upon entry at the facility. On 10/22/21, CCLD received an incident report indicating that on 10/16/21 resident (R1) signed out of the community and left with a friend intending on returning to the facility the same day. R1's Physician's Report LIC602A indicates that R1 is unable to leave the facility unassisted. R1 does not have a conservator. The incident report indicates that R1 did not return the evening of 10/16/21. The facility contacted R1's family and the family contacted law enforcement. Law enforcement arrived at the facility on 10/16/21 and spoke with the Senior Business Community Director regarding R1. R1 returned to the facility the following day, 10/17/21, and the facility reported there were no adverse reactions to R1 missing doses of medication while away. Facility contacted family, law enforcement, and physician to report R1's return to the community. Senior Executive Director, Assistant Executive Director, and staff (S1) spoke with R1 regarding the house rules which state to "notify the Front Desk if you are planning to be away overnight and inform us of your expected date of return, so we know when to expect you. In the event of an emergency, please also provide us with a telephone number where you can be reached while you are away". Moving forward, the facility will obtain a contact phone number for residents in all scenarios where residents leave with an escort/visitor. No deficiencies are being cited during today's visit. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 4, 2021

Type of visit: Office

***This report was amended*** On October 29, 2021, a Non-Compliance Conference was conducted on this day in the Sacramento North Regional Office via Microsoft Teams, due to COVID 19 precautions. The purpose of this Non-Compliance Conference meeting was to discuss the history of citations that have been issued in the last year, related citations since 2016, complaints substantiated on August 6, 2021 and on April 8, 2020 and a civil penalty issued on August 30, 2021 in the amount of $15,000 dollars. Present in the meeting was Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Maribeth Senty, Licensing Program Analyst (LPA) Angela Hood, Licensing Program Analyst (LPA) Kevin Mknelly, Senior Executive Director/ Administrator, Kimberly Hagen, Assistant Executive Director, Barbara Fleck, Facility Representative, Michael Mejia, Lori C. Ferguson, Jen Johnson and Aron Alexander, and Legal Counsel, Jay Thomas and Joel Goldman. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process. Issues discussed during the meeting were: · Summary of Complaint filed against this facility · Summary of substantiated complaints filed since 2016 to present · Personnel Requirement violations · Criminal Clearance violation · Personal Rights of Residents in Privately Operated Facilities · Personal Rights violations · Administrator Qualifications and Duties/Accountability Report continued... ***This report was amended*** ·Total overall A citations issued since 2016 to present: 8 · Total overall B citations issued since 2016 to present: 15 · Total overall citations issued during the 2021 year period noted include the following: Type A violations 1 Type B violations 3 The facility has stated they will do the following to achieve continued and substantial compliance: Staffing is maintained with trained and competent staff sufficient to meet the identified needs of residents in care. CCLD will do the following: · Increase Monitoring The Department would like the facility to submit the following by: November 5, 2021 It was agreed that the licensee will submit a compliance plan to the department by November 5, 2021. The plan will address resident care and staffing issues. Included in the plan will be a detailed description of oversight and quality assurance measures proposed for or in place at the facility that specifically review staff training and competency, call response times, resident tasks completion and resident care plans accuracy. Additionally, ensure the report includes data from December 2019 to present and information on the I-POD caretaker system. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. An exit interview was conducted with Aron Alexander. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. Administrator/board member will sign the document and send signed copy to LPA, Kevin Mknelly at kevin.mknelly@dss.ca.govthe state’s words, verbatim · CDSS document, Oct 29, 2021

Allegation investigated: -Unlawful eviction

Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with the Senior Executive Director, Kimberly Hagen, to deliver findings into the allegation of unlawful eviction. LPAs wore N95 masks and were screened upon entry in the care home. All staff wore masks in the care home. There are no COVID positive cases at the facility. Unlawful eviction: On 9/3/21, the facility issued, via certified mail, a 30-day notice to terminate resident (R1) and also mailed a copy to R1’s responsible person. The notice indicates termination of R1’s residency beginning 10/4/21 due to R1 failing to comply with the general policies of the community. R1 and their responsible person signed the facility’s Admission Agreement on 1/26/21. The Admission Agreement’s sections pertaining to their Motorized Cart Policy and their House Rules indicate that residents shall operate their motorized carts in a “safe manner, taking special precautions near doorways, at corners, when approaching pedestrians, backing up, and in other situations that present an additional risk of injury”. ************************************************Continued on LIC9099-C************************************************** Unfounded According to interviews with staff (S1, S2, and S3), R1 has had several occasions of not operating their motorized scooter in accordance with the facility’s policy. The facility provided LPA with a written statement from S2 for an incident on 8/25/21 were R1 was operating their motorized cart at a fast speed, which is also indicated in the 30-day notice to terminate sent to R1. Interviews with S1 and S3 indicated that, on 9/1/21, R1 was intoxicated and not operating their motorized scooter in a safe manner. Interview with S1 indicated that R1 was operating their scooter at a high speed and almost hit S1. Interview with S3 indicated that R1 was operating their scooter at a high speed almost hitting another resident and ended up running into a bench. Both S1 and S3 stated that they had a conversation with R1 regarding their motorized scooter speed. A written statement from staff (S4) indicates that, on 9/1/21, R1 was intoxicated and operating their motorized cart in an unsafe manner, running into the walls and almost running into another resident. Notes provided by the facility indicate that conversations were made with R1 and/or responsible person on 8/26/21 and 9/1/21. The House Rules in the Admission Agreement indicate that “residents may choose to drink alcoholic beverages in their apartments provided that their conduct does not disturb other residents or pose a health and safety risk to themselves or others”. Title 22, Division 6, Chapter 8, Section 87224(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). (3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. Based on records reviewed and interviews conducted, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted.the state’s words, verbatim · CDSS document, Oct 27, 2021 · control 25-AS-20210909134608

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with the Assistant Executive Director, Barbara Fleck, to conduct a case management visit. LPAs wore an N95 masks and were screened upon entry in the care home. All staff wore masks and there are no COVID positive cases at the facility. During a file review and interview previously conducted, it was discovered that a 30-day written notice to terminate issued to resident (R1) was not provided to CCLD. Facility staff were unable to locate any documentation indicating that the 30-day written notice to terminate was submitted to CCLD. LPA reviewed the Department's internal databases and could not locate the 30-day written notice to terminate that was issued to R1. Due to the information above, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 809-D page. Exit interview was conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 27, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: Nov 10, 2021

87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on records reviewed and interview conducted, the facility did not ensure they submitted the 30-day written notice to terminate R1 to CCLD, which poses a potential health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2021

Plan of correction: Facility shall submit a statement of understanding to LPA by the POC due date of 11/10/21.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the facility unannounced on 10/27/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPAs met with Barbara Fleck, Assistant Executive Director, and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility and completed a facility risk assessment. LPAs ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. LPAs toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: buildings A, B, C, and memory care, common areas, dining rooms, activity rooms, kitchen, outdoor area, main restrooms, and PPE storage room. Fire extinguishers are ready for emergency use and all stairwells have evacuation chairs. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Assistant Executive Director completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 27, 2021

Allegation investigated: Residents were not treated with dignity and respect. Employee showered residents in cold water and verbally abused residents in care.

Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/06/2021 to open a complaint the Department received on 08/05/2021. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; upon entry completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA was screened by staff, Vanessa Jones, upon entering the facility. LPA met with Business Director (BD), Deborah Ahrens and Administrator (AD), Alicia Rist. LPA requested the following documentation for review: documentation of the investigation and termination of staff, Carmencita Phelps (S1). LPA interviewed BD, AD and Life Guidance Director, Ingrid Weber. BD, AD and LG stated the abuse did occur and S1 admitted to abusing residents (R1, R2, and R3) by giving them cold showers and verbally threatening the residents. A deficiency is being cited due to the information stated above on LIC9099-D, per California code of regulation, title 22. Exit interview conducted, copy of report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2021 · control 25-AS-20210805163237

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Aug 7, 2021

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse... This requirement was not met as evidenced by: S1 admitted to giving residents (R1, R2, and R3) cold showers and verbally threatening residents in care. This posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 6, 2021

Plan of correction: Licensee terminated staff (S1) on 8/4/2021 as a corrective action. Licensee stated they held an in-service training on elder abuse for all employees. Licensee agrees to provide documentation of all the staff in attendance for the in-service training conducted on 08/05/2021 by POC date. Documenation includes all employees' signatures who were in attendance.

Allegation investigated: Staff did not shower resident Staff did not allow resident to smoke Staff did not supervise resident when smoking

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the investigation and deliver findings to a complaint received on 3/22/2021. LPA met with Alicia Rist, Executive Director, and explained purpose of inspection. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. LPA confirmed there are currently no Covid cases at the community. During the investigation, LPA interviewed the Administrator, Resident Services Coordianator, (1) nurse, (4) caregiver/med-tech staff and resident's representative. LPA reviewed the following documents pertaining to resident (R1) including, but not limited to, physician's report, assessments and care plans, monthly assignment report, incident reports, admission agreement and home health records. The results of the investigation are as follows: cont on 9099C.. Substantiated Resident (R1) moved to facility on/around 1/10/2021 with a physician's diagnosis of Emphysema, age related brain atrophy/mild cognitive impairment, was non-ambulatory and used a motorized power chair for ambulation. Admissions agreement was signed on 12/29/2020. Physician's report dated 11/11/2020 notes that resident had minor confusion, was independent with dressing, feeding, and medications and could transfer independently to/from bed but needed help balancing to be able to shower/bathe. Pre-appraisal dated 12/29/2020 notes that resident is a smoker, used a wheelchair but could get in and out unassisted and needed help with bathing. Resident later received a diagnosis of dementia on 2/26/2021. Allegation: Staff did not shower resident Complaint alleges that facility did not shower resident for 2 weeks and when resident’s representative asked about the showers the facility stated resident was refusing. Resident’s care plan dated 1/10/2021 documents that resident needed “minimal assistance” with showers, scheduled once per week, and staff will stand by and provide assistance with preparing all bathing supplies, and assist with escorting in and out of shower/tub. Care plan was updated on 1/13/2021 and again on 1/22/2021 with no change in shower assistance noted on either assessment. LPA reviewed an e-mail, dated 1/25/2021, from facility responding to resident’s representative about resident not being showered in 2 weeks: E-mail states that care staff reported on 1/24/2021, Sunday, that resident refused a shower, stating he already took one and that a shower would be given that day, 1/25/2021, Monday, even though resident’s scheduled showers are on Sundays. E-mail further states “Staff understand the importance of completing this task as scheduled, we reviewed again today”. Resident Monthly assignment report for January 2021 shows that an entry was made on 1/10/2021, 1/17/2021 and on 1/24/2021 and a shower was only completed on 1/24/2021. Executive Director indicated she cannot say with certainty if resident received a shower or not on 1/10/2021 or on 1/17/2021 based on the documentation on the report. The same report shows that there are were no showers given for February 2021, and the only entry made, on 2/22/2021, notes that resident did not receive a shower due to not being available. Other documentation reviewed confirms that resident was out of the facility starting on 2/8/2021 (pm) and did not return until 3/3/2021 (pm) following a fall and recovery stay at a skilled nursing facility. cont on 9099C(2) On 1/19/2021, Tuesday, resident representative stated resident had an appointment for a TB test and the facility was supposed to take him. LPA reviewed e-mail documentation, dated 1/25/2021, from resident representative to Executive Director, stating, in part, that resident had a doctor’s appointment on Tuesday for a TB test and that facility was advised of resident’s doctor’s appointment. E-mail response sent later in the day on 1/25/2021 states that the facility is not sure how the appointment was missed and that the driver is available to take resident to his next appointment. Executive Director stated the facility has (2) bus drivers that take residents to and from doctor's appointments, and transportation requests need to be made in sufficient advance time and last-minute requests, made the same or prior day, may not be able to be accommodated. Facility uses a bus book to track appointments scheduled in advance. LPA was not able to obtain documentation from the bus book for months January and February 2021. LPA interviewed Resident Services Coordinator (RSC) regarding virtual appointment resident was reported to have on 1/25/2021. RSC stated she recalls resident having a scheduled tele-health appointment on one day but resident was not present at the facility that day and was unsure of the appointment date. RSC stated she doesn’t recall assisting resident on any date and would have entered notes in resident’s electronic file following the appointment. Interview with facility nurse confirmed that RSC or another nurse would have handled the tele-health appointment and normally either resident’s physician and/or family member would need to notify the facility prior to the tele-health appointment and provide an email with the password. Executive Director stated that the facility had adjusted months prior, when the Covid-19 lockdown began, in facilitating virtual appointments with residents and she had not heard of any resident missing a scheduled appointment, stating the facility had purchased multiple I pads to assist residents and families. Resident representative stated the resident had an appointment on 3/19/2021 to take a Covid test prior to moving out, and the facility indicated they did not have their bus available on that day to take resident and an outside bus would be needed. Resident representative stated the outside bus arrived but would then not take resident to the appointment. LPA reviewed several e-mails dated 3/18/2021 and 3/19/2021 between Executive Director and resident representative regarding arranging transportation services for resident’s appointment on 3/19/2021. In summary, e-mails indicate that that the first transportation company was unable to take resident on 3/19/2021 and was requiring facility staff stay with resident since resident has Dementia. 9099C(2)..Additional e-mails explain that a second transportation company was contacted that was available on 3/19/2021 to take resident, stay with him and bring him back and that the facility could cover the cost and that resident representative approved.. LPA reviewed another subsequent email sent on 3/19/2021 (3:14 pm) from facility to resident representative explaining that the transportation service was unable to take resident to the appointment earlier in the day due to resident’s transfer ability out of the vehicle, and no facility staff would be there to help assist. Executive Director stated and e-mail documents that the facility offered to test resident for Covid at the facility the following week; however, resident’s representative worked it out with the new facility to come and test resident at the facility. Resident moved out on 3/24/2021. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Resident charged for services that were not provided Allegation is resident was moved from Level 1 to level 2 on 1/13/2021 and the resident representative was emailed a new assessment that wasn’t agreed to. Also, resident was at the hospital on 2/7/2021 and then rehabilitation on 2/12/2021 and did not return to the facility until 3/2/2021 and was charged for services while out of the facility. LPA reviewed an email dated 1/13/2021 from Executive Director to resident representative which included the revised care plan after discussing with RSD,and requested a signature from resident representative and to advise of any questions or concerns. Executive Director stated that resident representative did not sign the assessment and so put the resident back on Level 1 care and charged separately for laundry services. LPA reviewed email sent on 1/25/2021 from Executive Director to resident representative stating the care plan was reviewed again with RSD and services for housekeeping, bathing and escorts will fall within Level 1 (199 points) and laundry will be charged as an ancillary charge. cont on 9099C(3)... Resident representative stated he signed care plan dated 3/3/2021 where resident was placed at a Level 4 upon returning from skilled nursing. Resident representative stated to LPA that any charges that were inadvertently billed to him were corrected once the long-term care provider was brought into the discussion and he is not owed any funds. Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. There are no deficiencies being cited for these (2) allegations found to be Unsubstantiated. Exit interview. Copy of report and appeal rights provided. 9099C(2)..Interview with one staff indicated that resident did refuse showers when he was "very new", adding that staff tried a "change in face and he still refused'. The same staff stated that if the resident wants a sponge bath staff will give it, stating “Resident (R1) was cold all of the time". A second staff also stated that resident did refuse showers in the beginning, and “ was reluctant when I told him it was time for his shower". Staff stated she was instructed by the Med-Tech to ask resident to sign a refusal form when refusing his shower. Staff stated the next time she told resident it was his shower time, he did allow her to give him a sponge bath once she explained that it was a sponge bath only, stating "He only refused the full shower -he was just uncomfortable with people bathing him". A third staff stated “(R1) was scheduled for a shower one time per week- we had been trying for a couple of weeks and he wouldn't take a shower. Finally staff (S1) was able to get him to shower and it was at an odd time of day.” Additional staff stated she gave resident a shower “only 1 time" and when resident moved in, he said he didn't want any help with showers and could shower himself. Staff stated she told resident that his son wanted him to have a shower and he said "okay" and explained that when she assisted resident, he "couldn't put his foot on the shower- it was difficult for him , transferring- I think he was scared to step as he thinks he will fall". Resident Monthly assignment report for March 2021 shows this staff gave resident a shower on 3/15/2021 and on 3/22/2021. Notes entered on 3/1/2021 and 3/29/2021 correctly reflect that a shower was not given since resident was not available due to being out of the facility. Executive Director stated in an interview that if a resident refuses a shower, staff will try a "change of face and contact resident representative and continue to try showers with different staff on different days and times. Additionally, staff will typically document when a service is refused. Resident likely received a sponge bath based on interviews; however, sponge baths are not typically documented. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(3)... 9099(C)(3)...Allegation: Staff did not allow resident to smoke: Complaint alleges that resident was being combative on/around 3/6/2021, and staff did not allow resident to smoke. LPA reviewed emails dated 3/7/2021 between resident’s representative and Resident Services Director (RSD) discussing how resident was not able to go outside and smoke on 3/6/2021 around 10:00 pm, as requested. Email response from RSD states “I spoke with the staff and clarified to them that your dad has the right to smoke. I assure you it won't happen again.” Interview with (3) staff indicated that resident was denied a smoke break once on their shift. One staff stated that she told resident he couldn't go outside and smoke- “because it was too late at night", around 9-10- pm. Staff stated that resident was "insisting to go out" and smoke and she didn't tell resident "no" but he accepted after a while and this was the only time on her shift this happened. Staff stated this particular night it was a little rainy also. Two staff stated resident was not given a smoke break due to resident not having a lighter available. Staff explained that resident’s cigarettes and lighter were kept in the medication room previously when he returned from skilled nursing and staff "couldn't find it" with another staff stating "we couldn't find a lighter during the shift- we finally found one- a caregiver had one". Staff explained that they were told they took all of his lighters " because he had smoked a couple of times in his room” and that resident kept his cigarettes. Email dated 3/8/2021 (12:36 pm) from Executive Director to resident representative advised that resident needs a new lighter and RSD went to purchase one for resident in the interim. LPA reviewed e-mails dated 3/7/2021 between resident representative and facility stating that he was contacted around 10:00 pm on 3/6/2021 by his father after a staff told him he couldn’t smoke. E-mail response sent by facility later on 3/7/2021 states that facility staff were made aware that resident has the right to smoke and that a similar incident won’t happen again. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(4).. 9099C(4)...Allegation: Staff did not supervise resident when smoking Complaint alleges that resident was left in the rain in the designated smoking section without supervision. Resident care plan dated 1/10/2021 indicates that resident does not require escorting services but resident is a smoker and to encourage resident to use the smoking area. Resident care plans dated 1/13/2021 and 1/22/2021 note that resident requires escorts and assistance to attend meals and/or activities, 3 times/day. It is also noted that resident smokes and to escort resident to the smoking area and stay with resident and allow resident 10 minutes to smoke. LPA reviewed facility internal incident report from 1/20/2021 at approximately 4:30 pm. Report states that resident was found on the ground at the smoking area and staff was made aware when resident pushed his pendant for assistance. Resident did not report any pain or injury and refused medical attention. Staff who reported the incident to the facility stated in an interview that she escorted resident to the outside smoking area, resident then sat on the bench and she stayed with him for a while until she received another call. Staff stated that "(R1) would try to transfer himself and I would tell him to press the button if you need help". LPA reviewed another incident report from 2/8/2021, at approximately 5:50 pm, which notes that resident was found on the floor near the smoking area exit. The same staff stated that resident fell inside and the receptionist saw resident slip from his wheelchair. Resident was sent out for further evaluation following this fall and did not return until 3/3/2021. Another staff stated in an interview that resident must smoke at the bench and there is a slight slope getting to the bench. Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code Code of Regulations, Title 22, Division 6, Chapter 8, the following (3) deficiencies are cited on 9099D pages. Exit interview and copy of report and appeal rights printed and provided.the state’s words, verbatim · CDSS document, Jul 26, 2021 · control 27-AS-20210322151401

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Aug 9, 2021

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews and documentation reviewed, the Licensee did not ensure that resident (R1) was assisted with weekly showers, per care plan dated 1/10/2021, and given a shower on 1/10/2021 and on 1/17/2021, which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 26, 2021

Plan of correction: Licensee/Administrator agree to conduct in-service training with all care staff on how to handle residents who refuse scheduled care. Facility to fax copy of agenda/attendees to CCLD by 8/9/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)6) · Plan of correction due date: Aug 9, 2021

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on interviews and record review, the Licensee did not ensure that resident (R1) was allowed a smoke break on 3/6/2021 at approximately 10:00 pm when requested, which posed a potential personal rights violation to resident in care.the state’s words, verbatim · CDSS document, Jul 26, 2021

Plan of correction: Licensee/Administrator agree to conduct in-service training with all care staff on personal rights. Facility to fax copy of agenda/attendees to CCLD by 8/9/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Aug 9, 2021

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews and record review, the Licensee did not ensure that resident (R1) received supervision from staff, per resident's care plan dated 1/13/2021, during a smoke break on 1/20/2021, which posed a potential health and safety risk to resident in care. Resident fell on the ground during a smoike break and used his pendant to call staff for assistance.the state’s words, verbatim · CDSS document, Jul 26, 2021

Plan of correction: Licensee/Administrator agree to conduct in-service for all care staff on followng care plan instructions. Facility to fax copy of agenda/attendees to CCLD by 8/9/2021.