Atria Park of Pacific Palisades

Type of visit: Required - 1 Year

On 06/02/23, Licensing Program Analysts (LPAs) Antonine Richard and Mario Leon conducted an unannounced annual required, using the full CARE Inspection Tool. LPAs met with Executive Director Remon Pegels and explained the purpose of today’s visit. The facility is an RCFE licensed for sixty (60) non-ambulatory and also includes a hospice waiver for (10) ten. Currently, there are thirty eight (38) non-ambulatory residents residing in the facility, all are over the age of 59. The facility is a three-story structure located in a residential neighborhood. It consists of the following: 40 (40) resident rooms with attached bathrooms, dining area, kitchen, garage, lounge, activity room and roof top, with shaded areas featuring table and chairs. LPA and executive director toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage area for cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. The water temperature was measured at 126.8 F in the industrial kitchen, which was not properly identified. Smoke detectors were observed in client rooms and are connected to the fire system. LPA reviewed Medication Administration Record (MAR) and observed it to be maintained in order and accurate. See LIC809C LPAs observed sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Two deficiencies were cited during this inspection visit, see LIC809D. An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director, Remon Pagels.the state’s words, verbatim · CDSS document, Jun 2, 2023

Allegation investigated: Residents are not provided adequate supervision. Resident's dietary needs are not being followed. Facility has pests. Hazardous cord hanging from window.

On 5/17/2023 Licensing Program Analyst (LPA Martessa Brown conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Raymond Pagels. LPA explained the purposed of the visit was to deliver findings regarding the allegations listed above and was grated entry. The investigation consisted of the following: On 5/6/22 LPA toured the facility and interviewed Executive Director Reymond Pagels. LPA obtained LPA reviewed documents in association with the allegations. On 5/6/22 LPA Brown interviewed staff S1-S3 (S1-S3). On 5/17/23, LPA toured the facility and interviewed staff (S4-S5) and Residents (R2-R4). Continued on 9099-C The investigation revealed the following: Unsubstantiated Regarding the allegation: residents are not provided adequate supervision. It was alleged that there is not adequate supervision for residents in the facility. LPA toured the facility on 5/6/22 and 5/17/23. LPA observed 3 Residents Service Assistance in memory care unit (RSA). LPA observed kitchen area located adjacent to the dining room section off. LPA did not observed resident without adequate supervision. LPA conducted interviews on 5/17/23 with 2-R4 and all residents stated they have no concern with the supervisor at the facility and have not heard any complaints. Interviews conducted on 5/6/22 and 5/17/23, Administrator and staff S1-S5 stated there is 3 RSA in memory care unit and did not hear of any concern with no supervisor. Above allegation is unsubstantiated. Regarding the allegation: Resident's dietary needs are not being followed. It was alleged that dietary needs are not being followed. LPA toured the facility on 5/6/22 and 5/17/23. LPA observed face sheet/ dietary board and binder for residents located in the main kitchen. LPA also observed face sheet/Dietary binder for residents in mc unit. Interviews conducted on 5/6/22 and 5/17/23, staff S1-S5 stated residents dietary needs are followed and checked before they are served. LPA Interview Administrator LPA R1 request bacon was given a piece of bacon but did not consume it. Interview R2-R4 stated they had no diet restrictions. LPA reviewed R1 physician report and indicated R1 was a vegetarian. Factsheet indicated resident was on a regular diet. Information from W1 stated R1 was a pescatarian. Based on records review and documents it was unclear on R1 dietary needs the above allegation is unsubstantiated. Regarding the allegation: Facility has pests. It was alleged the facility has roaches. LPA toured the facility on 5/6/22 and 5/17/23. LPA did not observe any pest in the facility. LPA conducted interviews on 5/17/23 with 2-R4 and all residents stated they have not seen any roaches in the facilty and had no concern. Interviews conducted on 5/6/22 and 5/17/23, Administrator and staff S1-S5 stated they have not seen any roaches in the facility and pest control comes once a month. The above allegation is unsubstantiated. Regarding the allegation: Hazardous cord hanging from the window. It was alleged the facility has a hazard chocking cord. LPA toured the facility on 5/6/22 and 5/17/23. LPA did not observe any hazard choaking cord hanging from the window. LPA conducted interviews on 5/17/23 with R2-R4 and all residents stated they haven’t heard any concerns with any item being hazardous. Interviews conducted on 5/6/22 and 5/17/23, Administrator and staff S1-S5 stated there is no hazard cord hanging from the window and did not have concerns. The above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit report conducted and report was provided to Remon Paglethe state’s words, verbatim · CDSS document, May 17, 2023 · control 11-AS-20220527135834

Allegation investigated: Licensee did not bring changes in resident condition to the attention of the residents’ physician in a timely manner. Questionable death.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (Amy Berggreen, Community Business Director) and was later met by Administrator (A2: Remon Pagels). The purpose of this visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. A virtual 10-Day visit was conducted by (former) LPA Jennifer Jones on 07/06/20 (via telephone) with (then) Executive Director/Administrator (A1: Brian Larios) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. During the televisit, LPA requested pertinent documents: Staff and Residents' rosters, Physician’s Report, Admissions Agreement, Identification and Emergency Information, Re-appraisals, and Medical Records for Resident #1. A separate investigation was conducted by the Department of Social Service Investigator (IB: Edward Hector) which included a review of medical, hospital, home health, and hospice records for Resident #1 including: interviews with facility staff, medical services staff, and witnesses. LPA/RA Ceniceros spoke to S1 to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. Unsubstantiated Regarding Allegation #1: this investigation revealed that Resident #1’s medical records from the hospital, home health agency, hospice care, and facility showed all three (3) agencies in communication with one another about Resident #1’s condition. Various medical records from six (6) different agencies [(three (3) home care services, two (2) offices of assigned doctors, and one (1) hospital)], listed the constant communication with Resident #1’s family (Daughter/Power of Attorney), facility staff, and assigned primary care physician. IB Investigator Edward Hector noted that medical records documented that Resident #1 had developed three (3) non-pressure wounds on the left, lower leg and received daily wound care by home health nurses. Prior to receiving care for the left leg wounds, Resident #1 had recently been discharged from home health services for a healed wound on the resident's right leg. Resident #1 was admitted to the hospital on 05/14/20 for poor circulation that caused open wounds. While the resident was in the hospital, the resident's physician warned the resident's family (Daughter/Power of Attorney) that amputation of the wounded leg was necessary or else sepsis would develop; however, the family (Daughter/Power of Attorney) opted for comfort and declined amputation. Resident #1 was discharged from the hospital on 05/18/20; and, the family agreed to Resident #1 returning to the facility on hospice - despite the doctor's recommendation of amputation. Medical records documented that Resident #1 had been under consistent care of registered nurses or hospital staff and all changes in the resident's condition were thoroughly communicated as well as to the resident's family (Daughter/Power of Attorney). Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Licensee did not bring changes in resident condition to the attention of the resident’s physician in a timely manner is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed that Resident #1 was admitted to the facility on 12/26/17. A small sore was noticed on the resident’s leg on 04/16/20. Daily wound care by home health nurses began on 04/25/20 thru 05/06/20. During that time, the resident developed three (3) non-pressure wounds on the left, lower leg due to poor circulation. Resident #1 was admitted to the hospital on 05/14/20 because of poor circulation, which caused the wounds to open. Resident #1 had a skin integrity diagnosis before the sore developed; thus, it was not out of the ordinary for this resident to develop this wound. Resident #1's physician warned the family (Daughter/Power of Attorney) about sepsis without utilizing amputation; however, the resident’s family opted for comfortable measures instead. Medical records indicated that the family (Daughter/Power of Attorney) refused amputation and were advised of a potential result of a terminal illness. Resident #1 was discharged from the hospital on 05/18/20 and placed on hospice care and returned to the facility with the family's (Daughter/Power of Attorney) approval. Resident #1 passed away on 06/04/20 with a primary diagnosis of sepsis and a secondary diagnosis of non-pressure ulcer with necrosis of muscle. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Questionable Death is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Executive Director/Administrator, Remon Pagels.the state’s words, verbatim · CDSS document, Nov 16, 2022 · control 11-AS-20200703090616

Allegation investigated: Illegal eviction

On 05/02/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Executive Director, Remon Pagels, and Community Business Director, Amy Berggreen. LPA explained the purpose of today's inspection visit and to collect information regarding the allegation mentoned above. The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1, #2, and #4 (R1-R4) service records and other pertinent documents associated with this complaint.. Interviews with staff #1-#5 (S1-S5), residents #1-#4 (R1-R4), and witness #1-#2 (W1-W2) A tour of the entire facility was inspected. Evaluation Report continues on LIC 9099-C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Illegal eviction. The details of the complaint state resident #1 (R1) was served with a 30-Day Notice to Terminate. The complainant contacted the Department and claims that (R1) is not treated fairly and that the staff does not like (R1). The complainant states (R1) is accused of having a physical altercation with another resident and that is the reason for the illegal eviction. An interview with (R1) states she was served with an eviction notice, and this is not the first time. (R1) states a prior 30-Day Notice to Terminate was issued in October 2021. An interview with staff #1-#5 (S1-S5) all confirmed that a 30-Day Notice to Terminate was served to (R1) on 03/15/22. The 30-Day Notice to Terminate, Proof of Service of 30-Day Notice to Pay or Quit were sent to (R1), (R1's) family representative, Long Term Ombudsman, and Community Care Licensing (CCLD). The documents were sent by facsimile to (CCLD) on 03/16/22 with an incorrect fax number. The El Segundo Regional (CCLD) did not receive these documents. The facility failed to follow up with (CCLD) for approval as written in Title 22 Regulations Section 87224 Eviction Procedures. The Department contacted the facility on 04/28/22 and spoke with the acting Executive Director and was informed that a Notice to Terminate was issued to (R1) on 03/16/22. It was determined the notice is not valid. Based on interviews and record reviews, there is sufficient evidence to support the allegation mentioned above. Based on interviews and record review conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), The Department observed the following deficiency and issued a citation. An exit interview was conducted with Remon Pagels, and a hard copy was provided with signature and Appeal Rights. INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident sustained an injury while in care. It is alleged resident #1 (R1) sustained an injury while in care. The complainant claims (R1) sustained injuries on her left ankle. The complainant can not recall the date and time when it happened. The complainant was not present when the incident took place between (R1) and another female resident. An interview with (R1) claims it happened several years back in the Parlor room. (R1) is uncertain of the date and time. (R1) confirms she suffered injuries to her left ankle. (R1) claims there were no witnesses and the other female resident is no longer at the facility. Interviews with residents #2 and #3 (R2-R3) state they were made aware of the incident that had happened but did not have the privilege of any of the information. Interviews with staff #2-#5 (S2-S5) all verified that an incident between (R1) and another female resident had happened, however, no injuries were sustained. (S4-S5) both who knew the incident state (R1) is not the victim and was the one who instigated the incident. An interview with (S3-S4) claims the facility does not have cameras in common areas. Interviews with (R2-R3) and witness #2 (W2) all verified that (R1) has a history of creating problems with other residents and staff and will often time ignore the facility's house rules. Based on the information collected, there is no evidence to support the allegation mentioned above. Allegation: Resident sustained UTI while in care. It is alleged that resident #1 (R1) sustained UTI while in care at this facility. The complainant states that (R1) went to seek medical attention in March 2022, and it was revealed that (R1) had Urinary Tract Infection and it is caused by neglect of (R1's) care. However, the complainant contradicts her accusation, when she states that she has no issues with the care staff at this facility and praises them for their services. An interview with (R1) reveals it is common for elderly people to have UTIs. (R1) states she had a history of UTI about 50 years back and did not see it as a problem. A review of a current (R1's) physician's report dated 03/07/22 indicates (R1) can provide self-care. (R1) does not need assistance with toileting and does not wear adult diapers. Interviews with (S1-S5) all verify (R1) is cared for seven (7) days a week by a third-party home care services between 6 am - 2 pm paid by (R1's) family. An interview with staff #3 (S3) states it was under recommendation for the family member to have (R1) examined for UTI as she now exudes some behavior changes in condition. Witness #1 (W1) and (S3) confirmed (R1) did not have prior health issues that are the main causes of UTI. Interviews with (R2-R3) and (R1-R3) all claim that the care has never been an issue and that caregivers are attentive and responsive. Based on the information collected, there is no evidence to support the allegation mentioned above. Allegation: Staff failed to meet residents’ needs. The details of the complaint state staff failed to meet the resident's needs. According to the complainant, it is not the care that is the issue, (R1) is not granted dignity and respect at this facility. Interviews with (R1-R3) reported the staff is kind and respectful to all the residents. Interviews with (S1-S5) dispute this claim and state staff have mandated training on how to address residents' needs. (S1-S5) all verified that it is (R1) who is critical and will often cause attention to oneself with other residents. An interview with (R1) did not have comments to add and stated that the management staff has been unkind. (R1) did not have specific dates, times, and a witness who could collaborate on her statement. An interview with (W2) states she has observed the staff at this facility grants(R1) dignity and respect. Based on the information collected, there is no evidence to support the allegation mentioned above. Based on information gathered, an inspection of the facility, observation, analysis of service records, and interviews conducted, the Department found no evidence to support the allegations listed on this complaint report. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Remon Pagels and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 2, 2022 · control 11-AS-20220427164524

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b) · Plan of correction due date: May 11, 2022

87224(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety... mental and/or physical health or safety of others in the facility. This requirement is not met as evidenced by:Based on interviews and record reviews. The facility failed to properly inform CCLD of the 30-Day Notice to Terminate on 03/15/22. The notice is not valid unless CCLD approves. This violation posed a potential health risks to residents in care.the state’s words, verbatim · CDSS document, May 2, 2022

Plan of correction: Executive Director is to review Title 22 Regulaiton Section 87244, and resubmit a 30-Day Notice to Terminate for RO approval by POC 05/11/22. This violation is corrected on visit 05/02/22. The facility resubmitted a new 30-Day Notice to Terminate. A hard copy was given to LPA and original was faxed on 04/29/22.

Allegation investigated: Resident developed a pressure injury while in care.

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the above facility. . LPA spoke with staff via telephone prior to entering the facility to conduct risk assessment and was informed that facility has no COVID-19 cases nor do any of the clients have symptoms. LPA arrived at facility and explained the purposed of the visit is to deliver findings on the allegations listed above and was allowed entry to the facility. The investigation consisted of the following: On 2/20/2020 LPA conducted initial visit and met with Administrator. LPA reviewed and requested copies of facility records. LPA did a health and safety check and toured the entire facility with administrator. LPA received the following records: staff roster, client roster, time sheet from 2/1/2020 to 2/15/2020, Physicians reports, admissions agreements, hospice/home health notes, medication logs, emergency and ID information. medication administration records, hospice care info for five residents. LPA also requested resumes and staff training for staff 1-staff 5, administrator certificate, daily shift notes for January 2020 and February 2020, house rules and activity schedules. LPA conducted a review of the Investigation Branch’s findings. Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident Developed a pressure injury while in care. It is alleged that resident developed pressure injuries while in facilities care due to staff neglect. IB Investigator Jose Santana conducted an investigation into the allegations which consisted of both records review and interviews. On 1/8/2020 Resident 1 (R1) was discharged from hospital on 1/8/2020 with notes stating resident had blanchable redness to coccyx and inner gluteal region. R1 entered facility on 1/8/2020. An initial assessment was conducted of their care needs and it was noted by facility staff on 1/9/2020 that resident did not require any skin care. On 1/10/2020 Doctors Choice home health visited R1 at facility to conduct an assessment and noted a stage 2 pressure injury on right buttock. Physician gave Doctors Choice home health a wound care order for treatment. Facility noted R1’s visit with Doctors Choice home health but did not have a report. It was stated during interview by S1 that facility would follow-up with Comfort choice home health, but a review or facility records does not show any documentation regarding follow-up. On 1/10/2022 R1 was admitted to St. John’s Health Center for another diagnosis and home health treatment stopped. R1 returned to facility on 1/16/2020 and home health services with Doctor’s Choice were not resumed. On 2/3/2020 a “blood blister” was found by facility staff on R1’s sacrum and Doctors Choice Home health was contacted. Doctors Choice home health resumed their treatment of R1 on 2/3/2020 and on 2/4/2020 it was noted that R1 had a stage 2 pressure injury on their mid-lower back/sacrum with a recommended wound treatment and a note to turn resident every two hours and not have them sit for too long. On 2/10/2020 the “blood blister” started to break open and Doctors Choice home health had not visited R1 since 2/4/2020. Another home health service was requested and after their assessment of an unstageable pressure injury on R1’s sacrum, primary care physician for R1 was contacted and recommended R1 be sent to hospital. R1 entered hospital on 2/12/2020 and was diagnosed with three pressure injuries, redness to heals, one pressure injury on right hip and unstageable pressure injury on right sacrum. Based on observations, interviews, and record review(s), the preponderance of evidence standard has been met. On 2/12/2020 R1 was admitted to St. Johns Health Center and present during admission were three pressure injuries: redness to heels, one pressure injury on right hip and unstageable pressure injury on right sacrum. Records and interviews indicate that there was a break in home health coverage from 1/16/2020 when R1 returned from hospital to 2/3/2020 when “blood blister” was found by facility staff. Therefore, the allegation, is found to be SUBSTANTIATED. California Code of Regulations, Title 22 are being cited on the attached LIC9099-D. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1) Exit interview conducted, appeal rights were discussed, and a copy of this report and appeal rights was provided to Business Director Amy Burgreen.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 11-AS-20200220112554

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.49(c)(1) · Plan of correction due date: Apr 21, 2022

Civil Penalty: Any violation that the department determines resulted in the injury or illness of a resident. It was observed through records review and interview that on 2/12/2021 Resident 1 was admitted to hospital with pressure injuries. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2022

Plan of correction: Licensee will submit written plan detailing how to ensure residents are provided with required services via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 11, 2022

Personal Rights of Residents in all Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodation, furnishings and equipment. This requirement was not met as evidenced by: It was observed through records review and interview that on 2/12/2021 Resident 1 was admitted to hospital with pressure injuries. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 20, 2022

Plan of correction: Licensee will complete a staff training on observation, documention, reporting and seeking medical/Home Health services in a timely manner. Submit in writting plan for training and sign in sheet as verification via fax by POC due date,

Allegation investigated: Facility did not permit the formation of a resident council

On 2/23/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Kirk Brooks. LPA explained the purposed of the visit was to deliver findings regarding the allegations listed above and was granted entry. The investigation consisted of the following: On 2/23/2022 LPA Cifuentes conducted a tour of facility grounds, reviewed facility files and spoke with Executive Director regarding allegations. On 2/3/2022 LPA Cifuentes interviewed staff 1-staff 4 (S1-S4) and residents 1-resident 4 (R1-R4). LPA requested and received a facility roster, staff roster and other documents pertinent to the investigation. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility did not permit the formation of a resident council The complainant alleges that residents’ families had not been made aware of a family council until an email sent out on February 6th, 2022 by the new Executive director. LPA Cifuentes toured facility ground and found a sign at the front reception desk advertising family council meetings. LPA Cifuentes also saw the minutes from the family council meeting posted on a bulletin board in the hall leading to the dining room. LPA also noted that the activities board shows a date, time and place for the resident council. LPA Cifuentes spoke with Kirk Brooks, Executive Director, who stated that the family council formed right before his arrival and that the resident council is on the facilities activity schedule. LPA reviewed resident records and noted that pages 22 to 25 of the admissions agreement are the statements of resident’s personal rights, and outline both the right of the resident to organize and participate in a resident council, but also the rights of resident’s families to organize and participate in a family council. All the documents reviewed by LPA were signed by the resident’s responsible parties. LPA Cifuentes was given copies of the resident activity schedule for December and January, which both show the date time and place of the resident’s council. LPA spoke with residents (R1-R4) regarding the allegation. All four residents stated they were aware facility had a resident council. LPA spoke with staff (S1-S4) regarding allegations. Of the staff questioned, 4 out of 4 stated the facility has a resident’s council, and all four also stated that the facility currently has a family council as well. Based on information gathered, the department did not find sufficient evidence to support allegation the allegation. The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegation: " Facility did not permit the formation of a resident council” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report left with Executive Director Kirk Brooks.the state’s words, verbatim · CDSS document, Feb 23, 2022 · control 11-AS-20220216170056

Allegation investigated: Facility does not have sufficient staff to meet the residents' needs.

On 2/16/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Kirk Brooks. LPA explained the purposed of the visit was to deliver findings regarding the allegations listed above and was grated entry. The investigation consisted of the following: On 1/26/2022 LPA Cifuentes conducted a tour of facility grounds, reviewed facility files and spoke with administrator regarding allegations. On 2/3/2022 LPA Cifuentes interviewed staff 1-staff 5 (S1-S5) and residents 1-resident 5 (R1-R5). On 2/16/2022 LPA toured a portion of the facility to check the staffing. Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility does not have sufficient staff to meet the residents' needs. The complainant alleges that there is insufficient staffing due to the staff not knowing their work schedules. LPA Cifuentes spoke to Resident Services Director Tinatin Darchia, who creates the staff schedules. Per Ms. Darchia, schedules are posted on Thursdays by 3:30pm for the following weeks schedule. Ms. Darchia stated that usually there are three staff in memory care, two staff in assisted living, a medtech who works for both floors. Depending on the day, the Life Guidance Director, the Resident Services Coordinator and the Resident Services Director are available and can substitute if needed to assist with resident care. LPA had previously spoke to Vladimir Kaplun, Executive Director at the time, who stated they had some call offs on January 22, 2022 but they got it covered. Per Ms. Darchin, they had three caregivers that day for the AM shift, the medtech who stepped in to assist with care between passing medications, the Resident Resource Coordinator as well as the Memory Care Director and other staff helping as needed with getting food to the separate floors. LPA spoke with residents (R1-R5) regarding the allegation. All five residents stated they believed the facility had enough staff to meet their need. LPA spoke with staff (S1-S5) regarding allegations. Of the staff questioned, 5 out of 5 stated the facility has sufficient staff to meet the resident’s needs. Based on information gathered, the department did not find sufficient evidence to support allegation the allegation. The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegation: "Facility does not have sufficient staff to meet the residents' needs.”, Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Feb 16, 2022 · control 11-AS-20220124101916

Allegation investigated: Facility is not allowing visitors. Facility mismanaged resident's medication. Facility does not communicate with resident's responsible party.

On 2/3/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Quality Control Stacey Groman. LPA explained the purposed of the visit was to investigate the allegations listed above and was grated entry. The investigation consisted of the following: On 2/3/2022 LPA Cifuentes toured facility grounds, reviewed facility files and interviewed staff 1-staff 5 (S1-S5) and residents 1-resident 5 (R1-R5) Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility is not allowing visitors. The complainant alleges that they were not allowed in to the facility to visit family, despite having all of their vaccinations and a negative Covid-19 test. LPA spoke to facility Nurse Tinatin Darchia, who stated facility went into full building quarantine on 1/2/2022 due to the amount of Covid-19 cases in the community. In a letter sent to residents and families it stated that family visits were restricted to drive-up and terrace visits only, with the exception of end of life situations. This lockdown extended to 1/27/2022 and families were allowed to visit indoors starting 1/28/2022. A letter was sent to families informing them of the change in status. LPA spoke with residents (R1-R5) regarding the allegations. Four of the five residents interviewed stated they were allowed to have visitors, outdoors only during the lock-down. LPA spoke with staff (S1-S5) regarding allegations. Of the staff questioned, 5 out of 5 stated the residents were allowed to have outdoors visits during Covid-10 lockdown, and that there was no baring of visitors when the facility was not in lockdown. Based on information gathered, the department did not find sufficient evidence to support allegation " Facility is not allowing visitors” Allegation: Facility mismanaged resident's medication. The complainant alleges that when R1 left the facility to spend time with family, they did not receive sufficient medications for the time period they would be gone. LPA reviewed facility documents and found a medication release form for R1 detailing the medications and the amount provided to the family. A second medication release form was also found, detailing an additional amount of medication that was provided to R1’s family. LPA interviewed residents regarding allegation and of the residents interviewed 4 out of 5 gave them their medications timely and has not given them the wrong medications. Only 2 of the 5 residents interviewed have traveled out of the community for several days and both of the residents stated they had received sufficient medications. Of the staff interviewed, 5 out of 5 stated the facility gave residents their medications timely and had not given them the wrong medications. 3 out of the 5 staff interviewed mentioned the facility having a tracking system for medication release and 2 of those 3 stated the facility gave families the correct medications for their time out of the facility. Based on information gathered, the department did not find sufficient evidence to support allegation “Facility mismanaged resident's medication.” Continued on 9099-C Allegation: Facility does not communicate with resident's responsible party. The complainant alleges that they got no response when emailing and calling the facility Executive Director. The complainant also alleged that facility staff are not brushing residents’ teeth. LPA received copies of emails/application updates sent to families regarding Covid-19 facility lock down. LPA spoke with residents (R1-R5) regarding the allegations. Of those interviewed 4 out of 5 stated they were not aware of any communication issues between facility and their family. LPA interviewed S1-S5 regarding allegation. 4 out of 5 staff stated that residents families have not mentioned any communication issues. Based on information gathered, the department did not find sufficient evidence to support allegation " Facility does not communicate with resident's responsible party.” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: "Facility is not allowing visitors.”, "Facility mismanaged resident's medication”, “Facility does not communicate with resident's responsible party”, Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Stacey Groman Quality Enhancement Director and a hard copy was provided.the state’s words, verbatim · CDSS document, Feb 3, 2022 · control 11-AS-20220127140129

Allegation investigated: Residents not being changed timely Staff are not following residents dietary requirements Residents hygiene needs are not being met Residents are not being showered timely Facility does not have activities for residents Insufficient staffing Residents are not being fed timely

On 1/12/2022 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA arrived at facility and was greeted by Executive Director Vladimir Kaplam. LPA explained the purposed of the visit was to deliver findings regarding the allegations listed above and was grated entry. The investigation consisted of the following: On 11/3/2021 LPA toured facility grounds and interviewed Executive Director Adrienne Craig Aziz. LPA reviewed documents in association with the allegations. On 12/14/2021 LPA Cifuentes interviewed staff 1-staff 6 (S1-S6), residents 1-resident 6 (R1-R6) and 2 witnesses (W1 and W2). Continued on 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Residents not being changed timely The complainant alleges that R1 has been found several times with soiled briefs and no staff are available to change them. Per Executive Director Adrienne Craig Aziz, residents are checked every two hours. LPA spoke with residents (R1-R6) regarding the allegations. All six residents stated they use the restroom on their own and do not need assistance. Several of the residents spoken to reside in the memory care unit, and due to diagnosis, might have misunderstood the questions. LPA spoke with staff 1-6 regarding allegations. Of the staff questioned, 6 out of 6 stated the residents are changed ever 2 hours. Based on information gathered, the department did not find sufficient evidence to support allegation " Residents not being changed timely” Allegation: Staff are not following residents’ dietary requirements The complainant alleges that R1 was fed items that are restricted on their diet. LPA spoke with Executive Director Adrienne Craig the allegation. Per Director Craig-Aziz, facility is able to accommodate all dietary needs and dietary requirements are in the kitchen. Residents sometimes request items that are not on their dietary lists and if the requirements are not due to a dietary restriction by doctor, we give them what they ask for. LPA reviewed documents for R1, which shows they are not on a medically restricted diet. LPA interviewed residents regarding allegation and of the 6 residents interviewed 5 stated facility was able to accommodate their dietary requirements. Of the staff interviewed, 6 out of 6 stated the facility was able to and had accommodated a wide variety of diets, and also added that residents occasionally requested items that were not part of their dietary requirements and that staff complied. Based on information gathered, the department did not find sufficient evidence to support allegation “Staff are not following residents’ dietary requirements.” Continued on 9099-C Allegation: Residents hygiene needs are not being met The complainant alleges that R1 and other residents have been found wearing the same clothing as the previous day or are improperly dressed. The complainant also alleged that facility staff are not brushing residents’ teeth. LPA spoke with residents (R1-R6) regarding the allegations. Due to diagnosis, four of those interviewed might have misunderstood the questions, but all 6 of those interviewed stated their hygiene needs are being met whether through their own efforts or those of the staff. LPA interviewed S1-S6 regarding allegation. Of the 6 interviewed, all 6 stated that resident hygiene needs are being met. Residents teeth are brushed daily and all residents are dressed in clean clothing at least once a day if not more often. Based on information gathered, the department did not find sufficient evidence to support allegation " Residents hygiene needs are not being met Allegation: Residents are not being showered timely The complainant alleges that facility residents are not being bathed regularly. Per facility administrator Adrienne Craig-Aziz, residents are showered at least twice a week but can receive more showers as requested and it is outlined in their care plans. LPA spoke with residents (R1-R6) regarding showers. Due to diagnosis, four of those interviewed might have misunderstood the questions, but 6 out of 6 resident stated they shower on their own or with some assistance and they are getting regular showers. Of the staff questioned, 6 out of 6 stated residents are bathed weekly per schedule, with small changes to the schedule due to residents requesting to shower at a later time/date. Based on information gathered, the department did find sufficient evidence to support allegation " Residents are not being showered timely” Continued on 9099-C Allegation: Facility does not have activities for residents The complainant alleges that there are no activities for the memory care residents. LPA Cifuentes spoke to administrator regarding allegation. Per Ms. Craig Azziz the facility has everything from physical fitness, play games, puzzles, coloring, painting. Other activities are facility wide and announced to memory care that the activity will be in the communal area or if there are outings, like to Mel’s dinner, people from the entire facility are invited. LPA spoke with residents (R1-R6) regarding the allegation. Due to diagnosis, four of those interviewed might have misunderstood the questions, but all 6 residents stated the facility has activities. Of those 6, four stated they participated and 2 stated they did not participate. LPA interviewed staff and of those interviewed 6 out of 6 stated facility has a variety of activities for memory care residents. Based on information gathered, the department did find sufficient evidence to support allegation " Facility does not have activities for residents” Allegation: Insufficient staffing The complainant alleges that on October 24, 2021, at least two residents did not receive their morning meds due to insufficient staff. This allegation was recently investigated in complaint 11-AS-20211025121323. As both complaints reference the same incident, and allegation was already substantiated, LPA Cifuentes is unsubstantiating the allegation on this complaint. Based on information gathered, the department did not find sufficient evidence to support allegation " Insufficient staffing Allegation: Residents are not being fed timely The complainant alleges that R2 was chewing on a cord as they had not been fed. LPA spoke with administrator Adrienne Craig-Aziz regarding allegation. She stated that meals are delivered to the third floor at 8am, 11:30am and 4:30 pm like clockwork, it is very rarely late and if so it is not more than 15 minutes. LPA spoke with residents (R1-R6) regarding the allegation. Due to diagnosis, four of those interviewed might have misunderstood the questions, but all 6 of those interviewed stated food was received timely with no issues. . Based on information gathered, the department did not find sufficient evidence to support allegation " Residents are not being fed timely” The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegations: " Residents not being changed timely”, “Staff are not following residents dietary requirements”, “Residents hygiene needs are not being met”, “Residents are not being showered timely”, “Facility does not have activities for residents”, “Insufficient staffing”, “Residents are not being fed timely.” Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099's were provided to Executive Director Vladimir Kaplan. INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff not adequately supervising resident resulting in resident sucking on a window blind cord The complainant alleges that on October 24, 2021, they found R2 chewing on the end of a window blind cord for at least thirty minutes and no staff were present. LPA spoke to Executive Director Adrienne Craig Aziz, who confirmed that R2 was found chewing on the end of a window blind cord on 10/24/2021. Per Ms. Craig Aziz, this is due to residents medical condition. LPA spoke with residents (R1-R6) regarding the allegation. Out of those interviewed 1 out of 6 saw another resident chewing on a window blind cord. LPA spoke with S1-S6 regarding allegation. Of those interviewed, 2 out of 6 stated there was a resident who like to put non-edible items in there mouth. Based on information gathered, the department did find sufficient evidence to support allegation " Staff not adequately supervising resident resulting in resident sucking on a window blind cord Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Executive Director Vladimir Kaplan.the state’s words, verbatim · CDSS document, Jan 12, 2022 · control 11-AS-20211025115141

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 26, 2022

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews, LPA Cifuentes found that R2 had been left unsupervised and tried to consume an inedible item. This posses a potential health and safety issue for residents in care.the state’s words, verbatim · CDSS document, Jan 12, 2022

Plan of correction: Licensee will provide a plan to LPA to ensure adequate supervision and redirection as needed by POC due date. POC cleared during visit on 1/12/2022.

Allegation investigated: Residents did not receive medication on a timely basis. Facility does not have sufficient staff to meet the residents' needs.

On 11/3/2021 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced initial complaint investigation at the facility listed above. LPA spoke with staff via telephone call prior to entering the facility to conduct risk assessment questionnaire and was informed that facility had no COVID cases nor do any of the clients have symptoms. LPA arrived at facility and was greeted by Executive Director Adrienne Craig Aziz. LPA explained the purposed of the visit was to investigate the allegations listed above and was granted access to the facility. The investigation consisted of the following: LPA toured facility grounds and interviewed Executive Director Adrienne Craig Aziz, five (5) staff (S1-S5) and five (5) residents (R1-R5). LPA reviewed documents in association with the allegations. Continued on 9099-C Substantiated Allegation: Residents did not receive medication on a timely basis. The complainant alleges that on October 24, 2021, at least two residents did not receive their morning meds. On Tuesday October 26, 2021 LPA Cifuentes received a call from Chad MacDonald, where he stated that on October 24, 2021 the morning medtech called out for their shift and although they tried to find a replacement they were unable to do so at the time. An SIR was received by CCLD via email stating that on October 24, 2021, 28 residents did not receive their morning medications. LPA Cifuentes spoke to Executive Director(ED) Adrienne Craig-Aziz, who confirmed that medtech for Sunday October 24, 2021 called out on October 23, 2021 and that she had reached out to her staff and other Atria communities and several staffing agencies to fill the spot, to no avail. ED then attempted to fill in for the medtech but did not arrive in enough time to pass medications to more than three residents. LPA spoke with residents (R1-R5) regarding their medications. Two of the interviews were not credible due to their diagnosis, one resident’s medication is as needed, another resident administers her own medications. Only the last resident was able to answer about their medications and they stated that they had never had any issues with medications. Of the staff questioned, two out of five stated their had been issues with delayed medications. Allegation: Facility does not have sufficient staff to meet the residents' needs. The complainant alleges that a number of staff have quit and the facility is understaffed. LPA spoke with Executive Director Adrienne Craig Aziz regarding staffing. Executive Director stated during interview that there have been staffing issues since May 2021. At the time, she requested staff from other sites to fill the positions while she interviewed, but that by the time that ended, they had been unable to fill as many positions as they needed. Ms. Craig Aziz convinced Atria to allow her to use a staffing agency and they have five agencies they use to fill callouts. All of the facility staff is participating in filling in where there is a need, for instance today, one of the wait staff called out. An agency was contacted to fill the spot, but could not do so, so the cook assisted in serving the residents. Per Ms. Graig Aziz, she had three caregivers in memory care, two in assisted living, and a medtech for both sections. Sometimes these will be two caregivers in memory care, but if it drops to one, all of the facility staff jump in to help. Having three staff in memory care is new, they had two before. LPA interviewed resident, and two stated they did not feel the facility was short staffed, while the other three were not sure. Of the staff interviewed, four out of five stated the facility was short staffed. Continued on 9099-C Based on information gathered, the department did find sufficient evidence to support allegation " Residents did not receive medication on a timely basis,” “Facility does not have sufficient staff to meet the residents' needs.” Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to Executive Director Adrienne Craig Aziz.the state’s words, verbatim · CDSS document, Nov 3, 2021 · control 11-AS-20211025121323

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 4, 2021

Basic Services Personal assistance and care as needed by the resident...such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on records review and interviews, LPA CIfuentes confimed that on October 24, 2021 residents were not assited with taking medications as prescribed. This posses an immediate health and safety issue for residents in care.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Licensee will provide licensing with confirmation of completed medtech courses for staff via fax by 11/4/2021 POC cleared on day of visit,

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 17, 2021

Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by Based on records review and interviews, LPA CIfuentes confimed that on October 24, 2021 facility did not have a medtech on staff. This posses a potential health and safety issue for residents in care.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Licensee will provide plan to LPA to insure sufficient staff are available for each shift to cover residents needs. Will submit to CCL via fax by POC due date. POC cleared on day of visit