Avantgarde Senior Living of Tarzana

Allegation investigated: Personnel qualifications

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at pm to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was contacted and arrived later. During initial visit, on 06/26/23, LPA Smith conducted tour of physical plant and conducted interviews from approximately 10:15 am -12:50 pm. Personnel qualifications It was alleged that the Administrator conducted themself in an unprofessional manner. During initial visit LPA Smith conducted interview with administrator. LPA was unable to interview Reporting Party (RP) as RP was unreachable via contact information provided. During this visit LPA interviewed 5 (five) residents and six (6) staff from 1:10 pm- 2:20 pm. Interview with administrator revealed that always conducts self in professional manner and treats everyone with respect whether in person, over phone or via email. (Cont to 9099C) Unsubstantiated (Cont from 9099) Also revealed hired as administrator only works in that capacity. Records review reveal current administrator license on file. Administrator had current trainings on file to include but not limited to Dementia and memory care. Interview with five (5) residents reveal administrator to be pleasant, informative, professional, and helpful. Interview with eight (8) staff reveal administrator to be knowledgeable, helpful, and professional at all times. Staff # 2 (S2) shares office with administrator and revealed that the administrator is always respectful, kind and professional. Based on interviews and record review during this and previous licensing visits there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this timethe state’s words, verbatim · CDSS document, Oct 3, 2023 · control 31-AS-20230622091845

Allegation investigated: Resident sustained a fracture due to staff neglect Staff handled resident in a rough manner causing bruises Residents sustained unexplained injuries due to neglect Staff are inappropriately medicating residents Staff is forcefeeding resident

At 9:30 a.m. on 09/12/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with Staff #1 (S1) and later the Director and disclosed the reason for the visit. LPA interviewed staff and residents between 9:35 a.m. and 3:00 p.m. today, reviewed records at 3:00 p.m., and toured the facility at 9:45 a.m. and 4:30 p.m. No immediate health and safety risks were observed. Regarding the allegation “Resident sustained a fracture due to staff neglect” it was alleged Resident #1 (R1) fractured their wrist due to neglect. Interview with S1 today at 2:40 p.m. today revealed R1 reported elbow pain at approximately 9:30 a.m. on 09/09/2023. S1 reported the incident properly thereafter. Unsubstantiated Record review at 3:00 p.m. today revealed R1 was taken to the hospital where it was discovered that R1 broke a bone in their elbow. R1’s care plan stated staff were to check on R1 every two hours. A supervision log revealed R1 was checked last at 9:00 a.m. on 09/09/2023. Therefore, the facility properly attended to and supervised R1. Based on interviews and record review, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff handled resident in a rough manner causing bruises” it was alleged Staff #2 (S2) caused bruising on the hand of Resident #2 (R2) after squeezing too hard. LPA observed R2’s hand today at 2:15 p.m. today and observed no bruising or discoloration. Interview with R2 today at 2:15 p.m. revealed R2 was not in pain and S2 did not squeeze too hard during the alleged incident. Interviews with other residents between 10:00 a.m. and 2:25 p.m. today revealed staff do not handle residents roughy. Interview with S2 at 1:25 p.m. and Staff #3 (S3) at 2:00 p.m. today revealed R2 often punched S2, S3, and other staff members. Based on interviews and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Residents sustained unexplained injuries due to neglect” it was alleged Resident #3 (R3) had unexplained bruising on their legs. Observations at 4:30 p.m. today revealed R3 had no bruising or discoloration on their legs. Interviews with residents between 10:00 a.m. and 2:25 p.m. today revealed no residents had unexplained injuries. Interview with S2 at 1:25 p.m. and S3 at 2:00 p.m. today revealed staff performed daily body checks for R3 and did not observe any bruising or discoloration. Record review at 3:00 p.m. today revealed R3 fell at the facility and was properly assisted by staff afterwards. Based on interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff are inappropriately medicating residents”, it was alleged residents were provided medication to make them sleepy. Resident interviews between 10:00 a.m. and 2:25 p.m. today revealed no residents took or were provided medication which was not prescribed. Staff interviews between 9:35 a.m. and 2:40 p.m. today revealed physician orders were followed when assisting residents with medication. Record review today at 3:00 p.m. confirmed staff followed physicians orders when assisting with medications. No additional medication was provided to make residents sleepy. During observations of the medication room at 2:40 p.m., LPA observed medication matched physician’s orders and medication lists. Based on interviews, record review, and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff is force feeding resident” it was alleged Resident #4 (R4) was fed too fast and choked. Attempted interview with R4 today at 11:25 a.m. did not reveal any information. Interviews with S2 at 1:25 p.m. and S3 at 2:00 p.m. today revealed staff are trained on proper feeding techniques. S2 recalled approximately 3 weeks ago, R4 choked during lunch. S2 assisted with removing the food and reassessed R4 for any further pain. LPA observed staff feeding residents during lunch today between 11:30 a.m and 12:15 p.m. and noticed proper feeding techniques applied. Based on interviews and observations, there is insufficient evidence to confirm the validity of the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 31-AS-20230911115014

Allegation investigated: Resident developed a pressure injury due to neglect by staff Facility staff are not repositioning resident Facility staff failed to monitor resident's water and food intake resulting in hospitalization

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with staff, Alberta Cedano and Joyce Matinez. They were advised of the complaint. Today's investigation consisited of a physical plant inspection to insure the health and safety of the residents in care, which was conducted approximately 9:00am-10:00am. Between 10:00am to 11:30am interviews were made with facility staff and Resident 1 (R1). Between 11:30am to 1:00pm, LPA conducted a record review and requested for copies of R1's records. Resident developed a pressure injury due to neglect by staff/Facility staff are not repositioning resident: In regards to the allegation, it was reported that the facility was not turning R1 as frequently as they should have, therefore causing a pressure injury. It's unspecified where the pressure injury is located as there was no pictures provided. Also not disclosed were the stages of the wound. Interviews with four (4) of four (4) staff reveal that R1 does not have any pressure injuries greater than a stage II. Interviews with staff Unsubstantiated also reveals that R1 is repositioned every two hours. Review of R1's records reveal that R1 is receiving hospice care, and only indicates a stage II at the coccyx, being treated by hospice and facility staff. No indication on file that R1 has anything greater than a stage II injury. Also observed during review of R1's records is confirmation that staff has been changing R1's diaper and repositioning R1 every two hours. No indication that the injury has progressed. Moreover, R1's medical assessment and appraisals does not indicate a history of any skin condition or breakdowns. Based on the information obtained, there was insufficient evidence to prove that R1 developed a pressure injury due to staff neglect in not repositioning R1. Therefore, the allegation is deemed Unsubstantiated at this time. Facility staff failed to monitor resident's water and food intake resulting in hospitalization: In regards to the allegation, it was reported that R1 was taken to the hospital, on or about 07/12/23 for a high fever and possible UTI. It's alleged that R1 had not been fed enough to keep their weight up, was dehydrated, and had a pressure injury. Interview with four (4) of four (4) staff reveal that R1 was sent to the hospital for weakness and loss of appetite. Copy of the Incident Report was obtained to confirm that R1 was sent to the hospital, despite hospice orders. Staff stated R1 does have a pressure injury, but it was being monitored by hospice and facility staff, R1 was being repositioned, and the injury wasn't greater than a stage II. Also, at admission, R1 weighed 161, but because R1 was experiencing a loss of appetite, R1 was last weighed at 158 lbs. Review of R1's discharge papers did not indicate an admitting diagnosis of a high fever and UTI. R1 was admitted to the hospital for another diagnosis on or around 07/02/23 and discharged with new orders to treat their infection approximately seven days after. LPA was able to interview R1 who did admit there are times that they had no appetite to eat, despite staff's encouragement to have their meals. R1 gave no indication, nor alleged staff failing to monitor their water and food intake causing them to go to the hospital. Based on the information obtained, there was insufficient evidence to prove that facility staff failed to monitor resident's water and food intake resulting in hospitalization . Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 27, 2023 · control 31-AS-20230725162316

Allegation investigated: Staff did not issue responsible party of a refund

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Carolina Garcia-Trejo and explained the reason for the visit. LPA conducted physical plant tour at 12:39 PM, requested copies of facility documents relevant to the investigation at 1:02 PM and interviewed staff and Executive Director between 1:10 PM to 2:30 PM. It was alleged that the Power of Attorney (POA) of Resident #1 (R1) did not receive a refund for the unused portion of the advance payment made when R1 passed on 12/28/22. LPA's interview with R1's POA today at 12:40 PM revealed that the POA has already received the refund check about four (4) days ago with the total amount of $580.65, the amount the POA had requested. LPA's record review today at around 1:30 PM revealed that the check was sent on 07/02/23. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA's interview with the staff today at 2:00 PM revealed that R1's POA came to the facility to pick up R1's belongings a week after R1 passed, though most of it was donated by the POA to the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 5, 2023 · control 31-AS-20230629152337

Allegation investigated: Staff refused to admit resident back to facility Staff is withholding residents personal belonging

On 07/3/2023 at 10:30 Am Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an unannounced subsequent complaint investigation. Upon arrival, LPA was greeted by the administrator, and the purpose of the visit was explained. Between 12:00- 1:00 PM, LPA interviewed eight (8) more residents. LPA conducted interviews with the Administrator at 1:15 PM, with witness(es) and eight (8) of 136 residents and two (2) of four (4) of front desk staff. A review of facility files and/or document was conducted at approximately at 2:00 PM including but not limited the resident file for Resident #1 (R-1). Allegation 1#: Staff refused to admit resident back to the facility The complainant advised that the facility didn't admit R-1 back to the facility. The Administrator denied the allegation. The information obtained during records reviews and interviews indicated that R-1 self admitted to the Skilled Nursing Facility (SNF) in November of 2022 without providing the required notice to the facility. (LIC 9099 Continued) Unsubstantiated R-1 ceased to pay rent at that time and departed with R-1’s personal belongings. There is no evidence that R-1 requested re-admission subsequent to leaving in November of 2022. Allegation: Staff is withholding residents' personal belongings The complainant advised that the facility withheld the personal belongings of Resident #1. Based on interview with the administrator and Resident Personal Property and Valuables (LIC621), R1's belongings were picked up on 11/07/2022. In addition, S1 and S2 have confirmed that the facility's front desk hasn't got any phone calls from R1. Moreover, S1 was a witness when R1's belongings were picked up. S1 and S2 denied the above allegation. There's insufficient evidence to either confirm the above allegations. The allegations are deemed UNSUBSTANTIATED. Copy of the report provided and exit interview conductedthe state’s words, verbatim · CDSS document, Jul 3, 2023 · control 31-AS-20230615153708

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Tihesha Smith conducted a Case Management visit in conjunction with complaint (31-AS-20230622091845) and met with staff. LPA Smith observed staff setting up/preparing meals in courtyard. LPA discussing with staff #1 and staff #2 revealed that kitchen plumbing was repaired. LPA interview with Administrator revealed that the incident was not reported to the Community Care Licensing Department (CCLD). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. Occurrences, such as epidemic outbreaks, poisonings, catastrophes, or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours. LPA informed the Administrator that all staff members are mandated reporters and are all responsible for reporting. During today’s visit, the Administrator provided a copy of the written Incident Report. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report given.the state’s words, verbatim · CDSS document, Jun 26, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jun 30, 2023

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, …. or major accidents which threaten the welfare, safety or health of residents, … shall be reported within 24 hours either by telephone or facsimile to the licensing agency. Based on interview, administrator revealed she failed to notify the department, regarding the kitchen plumbing incident that occurred on 05/26/23, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2023

Plan of correction: Lincensee/Administrator shall ensure a written report is submitted to the licensing agency and provide signed and dated statement noting understanding of Reporting Requirements to LPA by POC date:06/30/23 LIC 624 faxed and copy received at time of visit. Statement pending.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs), Mariana Agban and Angela Panushkina, conducted a CASE MANAGEMENT visit in conjunction with a complaint (#31-AS-20230615153708) and met with the Administrator. LPAs explained the reason for the visit. LPAs were informed that on 11/04/22 R1 checked self into Skilled Nursing Facility (SNF) and the incident was not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. During today’s visit, the Administrator provided a copy of a written Incident Report. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report given emailed to the Executive Director.the state’s words, verbatim · CDSS document, Jun 23, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Jun 30, 2023

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in A, B & D... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPAs during todays visit, the licensee did not comply with the section cited above by failing to notify CCLD regarding the incidents that occurred on 11/04/22 with R1, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 23, 2023

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.

Allegation investigated: Staff are not following the admission agreement

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Executive Director Carolina Garcia-Trejo and explained the reason for the visit. LPA conducted physical plant tour at 9:50 AM, requested copies of facility documents relevant to the investigation at 10:15 AM and interviewed staff between 11:00 AM to 12:00 PM. LPA also conducted records review between 12:00 PM and 1:30 PM and requested additional documents. It was alleged that the facility did not reimburse Resident #1 (R1)'s community fee in accordance with the facility's admission agreement. LPA's record review today between 12:00 PM and 1:30 PM revealed that the facility sent the refund check to R1's Power of Attorney (POA) on 05/10/23 with amount of $2100.00 representing 60% of pro rated refund for the Community Fee per the admission agreement. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Admission agreement states that: " A Refund of 60 percent of the preadmission fee in excess of $500 shall be provided if the resident leaves for any reason during the second month of residency." LPA's further record review also revealed that R1 was admitted on 12/08/22 and moved on to another facility on 01/17/23 from the hospital. LPA's interview with the administrator today at 11:00 AM revealed that the administrator instructed the facility's accountant to send the check to R1's POA and was told that the accountant sent the check on 05/10/23, the accountant however, quit on 05/12/23 but LPA was able to obtain a copy of the check sent. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 25, 2023 · control 31-AS-20230523110505

Allegation investigated: Financial Abuse

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Evelin Rios. Upon arrival, LPA Rios met with Abigail Gigante the Administrator Assistant and Maria Juarez who assisted the LPA with the visit. The administrator Carolina Garcia-Trejo met us after. Regarding the allegation of financial abuse; it was reported that prior facility administrator was terminated because she committed Financial Abuse/embezzlement while working at the facility. During the 10/18/2021 visit, LPA Avetisyan requested documentation and detailed information related to the complaint. On 10/19/2021 LPA received the incident report, SOC 341, and a brief explanation. On 10/20/2021 LPA Avetisyan requested further information on the timeline of events and recourse the facility took. On 08/09/2022 LPA Avetisyan requested a status on the police investigation and insurance company investigation. On 01/07/2023 LPA Rios reviewed documents received by LPA Avetisyan. These include but are not limited to insurance company acknowledgment of new claims and a police report made for the above allegation reported 07/20/2021. (LIC 9099 continued) Substantiated On 01/11/2023 from 10:14 a.m. to 10:46 a.m. LPA Rios obtained and reviewed copies of pertinent information for the investigation. From 10:46 a.m. to 11:45 a.m. LPA reviewed documents and records. From 12:00 p.m. to 12:30 p.m. LPA interviewed administrator Carolina. Carolina corroborated that the previous administrator was terminated due to multiple concerns one being embezzlement. Therefore, the allegation stating financial abuse; prior facility administrator was terminated because she committed Financial Abuse/embezzlement while working at the facility is Substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights provided, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 11, 2023 · control 31-AS-20211013141439

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jan 12, 2023

(a)...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: (8) To be free from neglect, financial exploitation... Based on LPA's interviews and record review, the licensee failed to ensure that the resident’s personal rights were observed and respected by the previous administrator. This poses an immediate safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Jan 11, 2023

Plan of correction: Facility terminated the previous administrator and cleared overdue balances from residents identified to have been in collections by previous administrator's actions. No POC required at this time.

Allegation investigated: Facility staff not providing adequate supervision.

Licensing Program Analyst (LPA) Michael Cava conducted a 10 day complaint visit to the facility to investigate the above allegation. On or around 12/27/22, it was reported that Resident 1 (R1) has hit Resident 2 (R2) several times. R2 did not provide details, but only one date, which was June 2021. No other recent dates were provided. No witnesses were identified. A full body assessment was made for R2, but no visible bruising was observed. Facility staff were aware of the incident, and offerred to seperate both residents, but R2 declined to do so. R1 and R2 are husband and wife. LPA met with the assistant administrator, Abigail Gigante, and advised her of the complaint. During the course of the investigation, interviews, record review and physical plant inspections were made. At approximately 9:30am to 11:00am, interviews conducted with staff and residents. Per interviews with staff, they are not aware of R1 being physically aggressive towards R2, as it was never brought up to their attention. Staff is aware of R1 being verbally aggressive towards R2. Staff informed the LPA Unsubstantiated that they have tried to offer R2 a separate room to avoid getting yelled at from R1, but R2 has declined to do so multiple times. Staff further stated that one of the reasons that R1 elevates their voice towards R2 is because R2 is hard of hearing. LPA is unable to interview R1 at this time as R1 is out for rehabilitation. Return date has yet to be determined. Attempts to interview R2 does confirm that R2 is hard of hearing. R2 does deny the allegation of staff failing to provide adequate supervision and confirms they declined to move to another room. Neighboring residents that reside near or next to R1 and R2 had no concerns regarding the two as they've never witnessed or observed R1 ever being aggressive to R2. The resident's responsible party was made aware of R1 elevating their voice towards R2. Plans have yet to be made to determine if both should be separated. A review of R1's records do not indicate any confusion, disorientation, or aggressive behaviors. Although there are some cognitive impairment noted, R1 is able to follow instructions. There were no notes or record documented to indicate that either R1 or R2 have non-compliance issues with the house rules (not getting along with one another and/or others). Based on the information obtained, there was insufficient evidence to corroborate the allegation of facility staff not providing adequate supervision. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jan 4, 2023 · control 31-AS-20221228115253

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with the assistant administrator, Abigail Gigante, and explained the reason for the visit. The facility is a two story building, that has a rooftop storage. The first and second floors are for resident occupancy. The third level/rooftop storage only used for storage for maintenance and emergency food supplies. It is not accessible to residents, and needs a key at the elevator to access. . At approximately 9:30am, with the assistance of the assistant administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired. There are carbon monoxide detectors throughout the facility that functions properly. There are also fire extinguishers located in the hallways of the first and second floors. The charge date is October 12, 2022. Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food properly stored in the refrigerator and freezer. Bedrooms: The facility has a total of 108 bedrooms that are combined shared or private. All private rooms are located on the first floor. LPAs observed bedrooms, for both private and shared, to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: All resident bedrooms, private and shared, have their own bathroom. Bathrooms were properly supplied and had functional fixtures. Hot water temperature ranged between 111 to 119 degrees Fahrenheit. Common Areas: These included the tv/living room, located near the lobby at the front of the building, activity room and dining area. The facility also has a cafe located on the first floor. The common areas were properly furnished and clean. The auditory alarms in the memory care at the entrance and exit doors were on and functional at the time of the visit. You need a code to enter and exit the memory care unit. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area, front and back entrance were free of hazards. The laundry area is located on the second floor. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: The medication room is located on the second floor. Medication and Medication Records were review for proper documentation. Medication room is locked at all times. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.the state’s words, verbatim · CDSS document, Dec 23, 2022

Allegation investigated: Staff do not treat resident with respect Staff do not follow through with residents medical appointments

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the assistant administrator, Abigail Gigante, and staff Joyce Martinez and Alberta Cedano, and advised them of the allegations. During the course of the investigation, interviews with staff and residents were made. Records were also reviewed and copies obtained. Between 9:30am to 12:00pm, interviews were made with staff and residents. From 12:00pm to approximately 1:00pm, Resident 1 (R1) records were reviewed. Staff do not treat residents with respect: In regards to the allegation, it was reported that some residents are being treated differently than others. LPA conducted interviews with ten of ten residents. There were no complaints or concerns from these residents about being treated different, or better than the other. According to the assistant administrator and staff, they haven't received any complaints either regarding residents being treated differently from one Unsubstantiated another. Based on the information obtained through interviews, there was insufficient evidence to corroborate the allegation of staff not treating residents with respect and/or differently. Therefore, the allegation is deemed Unsubstantiated at this time. Staff do not follow through with residents medical appointments: In regards to the allegation, it was reported that staff is not helping Resident 1 (R1) with eye appointments. Also staff never followed up with subsequent eye visits so R1 could get glasses. LPA interviewed R1, who confirms the allegation, but according to facility staff, R1 is independent, and able to make their own appointments. Furthermore, staff states that they do assist R1 in making all their medical and dental appointments, but R1 refuses to go to them. Most recently staff confirms that R1 refused to go to their eye appointment on at least a couple occasions. LPA called R1's social worker, and nurse practitioner to confirm staff's statements for R1 refusing to go to their medical appointments. Both the social worker and nurse practitioner confirmed information provided by facility staff. The social worker confirmed that on or about August 2022, R1 refused twice to go to their eye doctor appointment, stating both times transportation arrangements were made, but R1 refused to come down from their room to make the appointment. Staff states that they continue to encourage R1 to make their medical appointment, and follows up. R1 continues to state they do and are independent and can make decisions on their own. R1's primary physician and responsible party/closest relative are aware of R1's behavior and independence. Furthermore, a review of R1's files indicate that R1 is independent and can arrange their own transportation. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not following through with the resident's medical appointments. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Nov 1, 2022 · control 31-AS-20221024115542

Allegation investigated: Staff do not answer the authorized representatives questions regarding the resident Staff are not providing the authorized representative with updated requested medication lists Staff do not ensure the Dr. orders for new medications have been received

Licensing Program Analyst (LPA) MIchael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the assistant administrator, Abigail Gigante and advised her of the visit. At approximately 9:45am to 11:30am, interviews with Abigail, front desk staff and two med techs were made. An attempt was also made to interview Resident 1 (R1), but due to their diagnosis, R1 is not responsive to the LPA's questions. From 11:30am to 1:00pm, LPA conducted a review of R1's files and obtained some copies for record. From 1:00pm to 2:00pm, a physical plant inspection of the common areas was made. Staff do not answer the authorized representative questions regarding the resident: In regards to the allegation, it was reported that when R1's family would call the facility to ask what the resident's current condition is, staff will tell them that, that is not their job to report this and won't give the family information on R1. Interviews with the administrator, front desk staff and both med tech staff deny the allegation. According to front desk staff, they would either transfer the family's call to memory care Unsubstantiated or page someone from memory care that there is a call waiting. If no response, the front desk staff would take the call and try to assist the caller as much as they can, or advise them that call will be made back shortly. Interviews with two med techs from memory care also deny the allegation. Both med techs stated that R1's family call at least once a week. Both med techs stated that they would either take the call immediately, or if busy would call the family back immediately and provide the family the the information they requested for. Both med techs have never gotten any complaints that they never returned any calls to R1's family, or to other resident families for that matter. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not answering calls/questions from a resident's authorized representative. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are not providing the authorized representative with updated requested medication lists: In regards to the allegation, it was reported that when R1 goes to their doctor appointments, they will ask the facility staff to send them an updated medication list. The list the family receive are not updated, wrong or missing medications. Interview with the assistant administrator and both med techs deny the allegation. The assistant administrator and both med techs state they provide R1's family with their request for R1's medication list. Within the last three months, R1 has only received one new order on September 30, 2022, for Seroquel, for an increase in dosage. Prior to that, the last time R1's doctor issued new orders was on June 13, 2022, for a restart and medication adjustment. LPA obtained copies of both orders. Med tech and assistant administrator stated this information was provided to R1's family per their request. If anything new were to come in, they would forward that information to the family as well. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing the resident's authorized representative an updated medication list. Therefore, the allegation is deemed Unsubstantiated at this time.. Staff do not ensure the Dr. orders for new medications have been received: In regards to the allegation, it was reported that R1's doctor changed R1's prescription for Seroquel. The family will call the facility to tell them the doctor's office will be faxing in the new order for Seroquel, but staff states they never received it. According to both med techs, the latest order for Seroquel, which is prescribed to increase the dosage was received on September 30, 2022. A copy of this order was obtained. Doctor's office called to confirm. No new orders given since then. Based on the information obtained, the allegation of staff not not insuring order for new medication not being received is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 31-AS-20221010101800

Allegation investigated: Staff is threatening to drug resident Facility did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Carol Garcia-Trejo, and advised her of the visit. During the course of the investigation, LPA conducted an inspection of the physical plant to insure the health and safety of the clients, interviews and record review. Staff is threatening to drug resident: In regards to this complaint, it's being alleged that Resident 1 (R1) is being abused by a staff named "Roberta", who is threatening to use needles to "drug up" R1. Interviews with administrator and staff deny the allegation. Interviews with ten of ten residents also deny that they've been threatened by staff of getting drugged. According to administrator, there is no staff by the name of Roberta employed at this facility. A review of the staff schedule and Licensing Information System (LIS) profile confirms that there is no staff Unsubstantiated employed at the facility that go by that name. Further information from the administrator reveal that R1 has been refusing to take their medication. Review of the facility medication records confirm that R1 has been refusing to take their medicine and their primary physician and Nurse Practitioner (NP)has been notified. Per administrator, R1 was told by the NP that if they continue to refuse medication, R1 would get placed on a 5150 hold. LPA made contact with R1's doctor office to verify this information and it was confirmed there. Based on the information obtained, there was insufficient evidence to corroborate the allegation of facility staff threatening to drug R1. Therefore, the allegation is deemed Unsubstantiated at this time. Facility did not safeguard resident's personal belongings: In regards to the allegation, it was reported that staff has been entering R1's room and taking R1's Styrofoam cups. Interviews with the administrator and staff deny the allegation. Interviews with ten of ten residents also expressed no complaints or concerns that facility is not safeguarding their belongings. According to the administrator, Law Enforcement was called by R1, and they responded to a complaint made by R1. When the officers appeared at the facility, they determined that the call wasn't a police matter and deemed it a mental health concern. The officers did not leave a report. Review of R1's records reveal that R1 has some confusion and disorientation. Furthermore, R1 did not complete an inventory list since being admitted. LPA reviewed R1's LIC 621 and it had no entries. Based on the information obtained, there was insufficient evidence to corroborate the allegation of facility not safeguarding R1's personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 22, 2022 · control 31-AS-20220916121535

Allegation investigated: Licensee is in financial distress

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with administrator and explained the reason for this visit. It is alleged that several employees were not being paid during the period of December 2020 through January 2021. LPA conducted initial visit on 1/27/21 and interviewed Erin Mahoney who was the administrator at that time. During today's visit LPA interviewed the current administrator and facility staff who were working during December 2020 from 10-1pm. LPA also obtained and reviewed documents regarding payroll from the period of December 2020-January 2021 from 1-1:45pm. Interviews with facility staff indicated that staff had were paid and there were no issues with staff being paid. Documents obtained show that employees were paid during December 2020 through Janurary 2021. Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 29, 2022 · control 31-AS-20210126132048

Allegation investigated: Staff did not safeguard resident's confidential information.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Carol Trejo and staff, Joyce Martinez, and advised them of the allegation. It was reported that a friend of facility administrator obtained access to Resident 1 (R1's) confidential information due to facility's failure to safeguard R1's information. During the course of the investigation, interviews and record reveiw were made. According to the administrator and staff, they had no idea that the administrator's friend is in contact with R1. They stated the administrator's friend and R1 only met once, when R1 went out to get a haircut. Both administrator and staff does not know that R1 had multiple interactions with the administrator's friend since they've met. They only know R1 to be low key. In addition, R1 doesn't interact with the other residents in care. Unsubstantiated LPA interviewed R1, who confirmed that they've given access to their personal information to the administrator's friend, via mail and telephone calls willingly. R1 stated they receive assistance through the friend normally, and is in contact with the friend every day. In addition, R1 stated that the friend was given access to retrieve R1's mail at R1's home, allowed entrance to enter R1's home to obtain voice messages, and make bank deposits for R1. Based on the information obtained, there was insufficient evidence to prove that staff did not safeguard resident's confidential information. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Aug 24, 2022 · control 31-AS-20220819162959

Type of visit: POC

An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. The purpose of this visit is to follow up on the pending Plan of Corrections (POCs) that were issued during a required annual visit conducted on 01/25/2022 by LPA Avetisyan, Additional citations were issued on 7/27/2022 during a Complaint investigation and Case Management visit. On 1/26/2022 Licensee/Administrator were cited for the following, and complete plan of corrections were not submitted. On 1/26/2022 Administrator faxed LPA written statements however the written statement did not have the information as discussed and documented on the Annual Report. 87608 (a)(5)(B) and 87608 (a)(3) Postural Supports : 87705 (c)(5)(A) Care of Persons with Dementia. 87633 (b) Hospice Care of Terminally Ill Residents 1569.625 (b)(2) Staff Training 87412 (c)(2) Personnel Records. ON 7/27/2022 Licensee/Administrator were cited for the following. As of Todays visit Plan of Corrections have not been submitted. 87468.1 (a)(2) Personal Rights of Residents in all facilities. 87470 (c)(1) Infection Control Requirements 87211 (a)(2) Reporting Requirements. - This deficiency was a repeat citation therefore civil penalty in the amount of $250.00 was issued. Administrator was informed that additional civil penalty in the amount of $100 per day would continue to accrue until a detailed/complete Plan of Correction was submitted to the Department. The licensing report also gave notice that failure to correct the violation between a specified length of time would result in the issuance of additional civil penalties. Because the licensee/administrator failed to make the corrections additional civil penalty of $100 dollars per day has been issued in the amount of $1300.99 (7/28/2022 to 8/9/2022). Additional civil penalties in the amount of $100 per day will continue to accrue until Plan of Correction is submitted. During today's visit the licensee/Administrator were re-cited for the plan of corrections that were not submitted. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 9, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Aug 10, 2022

87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations made during the 7/27/2022 complaint investigation visit the staff did not comply with the section cited above by not wearing face mask/covering while working in the facility which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained/certified in infection control. Administrator will designate staff to screen all visitors for Covid-19 upon arrival. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/10/2022 and completion of training by 8/15/2022. Additionally administrator will submit a signed dated written statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87470(c)(1) · Plan of correction due date: Aug 10, 2022

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. Based on observations made during the 7/27/2022 Complaint Investigation the licensee/administrator did not comply with the cited section by not ensuring staff are following infection control Requirements which poses an immediate Health and Safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained/certified in infection control. Administrator will designate staff to screen all visitors for Covid-19 upon arrival. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/10/2022 and completion of training by 8/15/2022. Additionally administrator will submit a signed dated written statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5)(A) · Plan of correction due date: Aug 12, 2022

Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Based on the 1/25/2022 Annual Visit record review, the licensee did not comply with the section cited above by not ensuring 7 out of 7 residents diagnosed with Dementia had an annual medical assessment and reappraisal which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Licensee/Administrator will review files for all residents diagnosed with dementia and identify those residents who need a current medical assessment and reappraisal. Licensee/Administrator will obtain the required records. Licensee/administrator will submit copies of the updated records for the 7 residents as POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87633(b) · Plan of correction due date: Aug 12, 2022

A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following This requirement is not met as evidenced by: Based on the 1/25/2022 Annual Visit record review, the licensee did not comply with the section cited above by not retaining current complete hospice care plan as required by title 22 for 7 out of 7 residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Licensee/Administrator will review the regulation and records for all 22 residents. Administrator will obtain current, complete hospice care plans for all residents. Administrator will submit the names of all the hospice residents, room numbers and indicate the date the hospice care plans were obtained and indicate that all information required by Title 22 are documented on the care plans. .

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Aug 12, 2022

Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on the 1/25/2022 Annual Visit observation and record review the licensee did not comply with the section cited above by utilizing full bed rails for hospice residents without obtaining a hospice care plan that indicates the need for the full rails which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Licensee/administrator will tour rooms for all hospice residents and identify those who are utilizing full and/or half bed rails. Licensee/Administrator will contact the hospice agencies and obtain current hospice care plans which indicate the need for the full rails or order for half rails. Copies of the hospice care plans will need to be submitted as POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Aug 12, 2022

Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by: Based on the 1/25/2022 Annual Visit observation and record review the licensee did not comply with the section cited above by utilizing half bed rails for 6 residents without a written order from the physician which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 9, 2022

Plan of correction: Licensee/administrator will tour rooms for all residents and identify those who are utilizing bed rails. Licensee/Administrator will contact the physicians and obtain order for postural support for those identified as not having one. Administrator will submit the names of the residents room numbers and dates the orders were obtained as POC.

Allegation investigated: Staff are not wearing masks in the facility.

An unannounced initial 10 day complaint visit was conducted on this day by licensing program analysts (LPA’s) Evelin Rios and Yelena Avetisyan. Approximately 9:30 am upon LPA Rios’s arrival and entrance to the facility the LPA was not properly screened for COVID-19 precautions. LPA Rios were asked to conduct temperature check and Covid-19 screening for herself. LPA Avetisyan arrived to the facility at approximately 10:15 am was asked to conducted temperature check and Covid-19 screening for herself. Upon arrival to the facility LPA Rios met with staff Maria Juarez, who contacted the administrator Carolina Garcia Trejo. Ms. Juarez informed the LPA that administrator would not be able to come to the facility at this time. In regards to the allegation it was reported that the staff are not wearing masks while working or are wearing masks inappropriately. Approximately 9:30 am upon entering the facility LPA Rios observed Staff 1 (S1) at reception wearing a mask inappropriately under their nose. Substantiated Approximately 10 am LPA Rios conducted a tour of the facility including memory care with staff Alberta Cedano Care Coordinator. Upon entering the memory care LPA Rios observed a Staff 2 (S2) wearing a mask inappropriately under their nose. LPA also observed S2 touch their nose and proceeded to put the mask over their nose and continue working without washing/sanitizing their hand. Approximately 10:30 am LPA Rios and Avetisyan conducted a subsequent unassisted tour. Upon entrance to the kitchen LPA’s observed Staff 3 (S3) without a mask, LPA’s then continued walking in the kitchen and observed Staff 4 (S4) with their mask hanging on their ear. LPA’s requested for staff to put on their masks. As LPA’s were walking out of the kitchen they observed S4 wearing a mask inappropriately under their nose. Approximately 11:11 am LPA Avetisyan conducted a telephone interview/discussion with the administrator regarding the complaint investigation, screening protocols and reporting requirement. The LPA's observation support the allegation of staff are not wearing masks therefore the allegation is Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2022 · control 31-AS-20220721125636

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 27, 2022

87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations made during the complaint investigation visit the staff did not comply with the section cited above by not wearing face mask/covering while working in the facility which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained/certified in infection control. Administrator will designate staff to screen all visitors for Covid-19 upon arrival. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 7/28/2022 and completion of training by 8/12/2022. Additionally administrator will submit a signed dated written statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(c)(1) · Plan of correction due date: Jul 27, 2022

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. Based on observations made the licensee/administrator did not comply with the cited section by not ensuring staff are following infection control Requirements which poses an immediate Health and Safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained/certified in infection control. Administrator will designate staff to screen all visitors for Covid-19 upon arrival. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 7/28/2022 and completion of training by 8/12/2022. Additionally administrator will submit a signed dated written statement notifying the department what steps will be taken to ensure staff are wearing masks appropriately at all times while working.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA's) Yelena Avetisyan and Evelin Rios conducted an unannounced Case Management-Deficiencies visit at the facility today due to deficiencies observed during the investigation of complaint control #31-AS-20220721125636. At approximately 10:44 am while conducting a tour of the facility with Alberta Cedano Care Coordinator LPA's observed PPE cart placed near residents room. When asked Ms. Cedano confirmed that the resident in the room tested positive for COVID19. LPA's did not observe droplet precaution At approximately 11:11 am LPA Avetisyan spoke with the administrator Carolina Garcia-Trejo. Per Ms. Trejo she called the Woodland Hills Office on 7/22/2022 and reported the COVID positive, but was unable to provide the name of the staff she spoke with. LPA reminded Ms. Trejo that they need to immediately report to the department anytime they have a resident or staff who tests positive for COVID. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 809-D). Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jul 28, 2022

Each licensee shall furnish to the licensing agency such reports as the Department may require... (2) Occurrences, such as epidemic outbreaks ... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency & to the local health officer when appropriate. This requirement is not met as evidenced by: Based on interview & observation, the licensee did not comply with the section cited above by not reporting a resident tested positive for COVID within 24 hours which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Licensee/Administrator and all support staff will attend 2 hours vendorized training regarding the cited section. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 7/28/2022 and completion of training by 8/12/2022. This is a repeat violation therefore a civil penalty on the amount of $250.00 has been issued. Additional civil penalty in the amount of $100 per day will continue to accrue until a detailed/complete Plan of Correction is received. (1st citation issued 1/25/2022)

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to facility to follow up on an incident report, alleging a possible personal rights violation involving Resident 1 (R1). During the course of the visit, interviews and record review was conducted. A physical plant inspection was also made to insure the health and safety of the residents. Based on interviews and record review, there wasn't enough information to confirm if C1's personal rights were violated. Therefore, no citations issued at this time.the state’s words, verbatim · CDSS document, May 24, 2022

Allegation investigated: Staff are making inappropriate comments towards residents Facility is not providing adequate food service for residents Staff denies residents food

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to close out the investigation regarding the above facility. During the course of the investigation, interviews and physical plant inspection were made. LPA met with the administrator, Carolina Garcia-Trejo, and advised her of the visit. Staff are making inappropriate comments towards residents: In regards to the allegation, it was reported that a staff had been telling residents that are enrolled in the Assisted Living Waiver (ALW) Program that they shouldn’t be admitted into the facility. At the time of the initial investigation, the facility is retaining approximately 69 residents that are on the ALW program. Random residents on this program were interviewed, and denied this comment was ever made to them. Staff were also interviewed, and they weren’t aware that this comment was made to them, as they’ve never received any complaints or concern from the residents. Based on the information obtained through interviews, there Unsubstantiated wasn’t enough evidence to corroborate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Facility is not providing adequate food service for residents: In regards to the allegation, it was reported that facility has false advertisement regarding their food. Residents were interviewed regarding this allegation, and expressed no complaints or concerns regarding the food service. LPA conducted an inspection of the kitchen to insure an adequate supply of perishable and non-perishable food, and that the food storage is maintained and the food is of good quality and not expired. Menus were also reviewed. Based on the information obtained, there wasn’t enough evidence to prove that the facility is not providing adequate food service. Therefore, the allegation is deemed Unsubstantiated at this time. Staff denies residents food: In regards to the allegation, it was reported that staff have been acting as a “food police” towards residents that are diabetic, or require special diet. Staff was seen taking food off these resident’s plates if they think it was too much. Interviews made with the administrator and staff who deny the allegation. Food is never withheld or taken from residents whether or not they require a special diet. For residents with a special diet, kitchen staff are made aware of their food restrictions and make sure their dietary plan is followed. Residents were interviewed and they also denied food ever being taken from them from staff, or being denied food service. Based on the information obtained, there wasn’t enough evidence to prove the allegation of staff denying residents food. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, May 13, 2022 · control 31-AS-20220209110608

Allegation investigated: Staff did not provide medical attention for resident in care.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. It's being reported that Resident 1 (R1) complained of shortness of breath, but was refused immediate medical attention. LPA Cava met with the administrator, Carolina Garcia-Trejo, and advised her of the allegation. During the course of the investigation, a physical plant inspection, interviews and record review was made. Per interviews with the administrator and staff, R1 had only lived in the facility for two weeks. Since admission, R1 has been aggressive towards staff and had made some false allegations. Regarding the allegation of not being provided immediate medical attention, administrator and staff denies them. Staff stated in the early morning of 4/21/22, on or around 4am, R1 never informed the NOC shift he was experiencing pain. R1 carries a personal cell phone and called 911 on his own to get transported to the hospital. R1 was admitted for treatment, and then transfered to a skilled nursing facility. It is unknown Unsubstantiated if R1 will return back to Avantgarde. R1 will continue to receive treatment and hospice care at the skilled nursing facility at this time. According to R1's relative/responsible person (RRP), she is involved directly with R1's care. She is aware that R1 was experiencing pain on 4/21/22, and that R1 called 911 in the early morning on his own. Facility staff was made aware of this. RRP had no complaints or concerns of the incident or on what had occurred, and also denies the allegation of staff not providing medical attention for resident in care. Based on the information obtained, there wasn't enough evidence to prove the allegation of staff not providing medical attention for resident in care. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 31-AS-20220422121241

Allegation investigated: Staff failed to protect resident from being harmed by another resident. Staff failed to destroy the non-active medications in the facility. Residents receiving hospice care without a cause. Administrator is not available at the facility.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to conclude the investigation regarding the allegations above. LPA met with the administrator, Carolina Garcia-Trejo and advised her of the investigation which consisted of interviews with residents, staff and record review. Staff failed to protect resident from being harmed by another resident: In regards to the allegation, it's being reported that Resident 1 (R1) is physically abusive towards staff and other residents, but staff are not doing anything to protect the other residents. It's also alleged that R1 had bitten another resident. Interviews with staff and residents do not corroborate with the allegation. Furthermore, when an interview was held with the reporting party (RP), they could not provide any witnesses vicitms, date and time of when R1 was aggressive towards other residents. Furthermore, RP could not confirm R1 biting another resident as they did not physically witness the incident. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff failing to protect Unsubstantiated another resident from R1's harm. Therefore, the allegation is deemed Unsubstantiated at this time. Staff failed to destroy the non-active medications in the facility: In regards to the allegation, it was reported that Staff 1 (S1) is not properly destroying medications. S1 keeps expired narcotics in her desk drawer and doesn't keep the refrigerator locked when medications like liquid Morphine or Ativan is being stored there. During the investigation, LPA toured the medication room and did not observe expired narcotics being maintained in the premises at all. There were cabinets and drawers were locked. When asked to open and inspect, no medicine was observed inside. The refrigerator was inspected to insure that locks were in place and maintained when storing any Morphine or Narcotic. In addition to the medication inspection, LPA obtained record copies of centrally stored medication for destruction and disposal for review. No discrepancy observed. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff failing to destroy the non-active medications in the facility. Therefore, the allegation is deemed Unsubstantiated at this time. Residents receiving hospice care without a cause: In regards to the allegation, it was reported that that certain residents receive hospice care, but do not need the services. During the investigation, LPA received a list of the facility's hospice care residents. LPA interviewed staff and obtained hospice records for these residents to confirm hospice services was needed and ordered by their physician. Facility has a hospice waiver for 25. Currently there are 23 residents receiving hospice care. Based on the information obtained, there was insufficient evidence to corroborate the allegation of residents receiving hospice care without cause. Therefore, the allegation is deemed Unsubstantiated at this time. Administrator is not available at the facility: In regards to the allegation, it was alleged that the former administrator, Erin Mahoney, goes to the La Jolla facility every other week. Ms. Mahoney was interviewed by LPA Manya Lefian on 9/18/20. Ms. Mahoney confirmed that she goes to La Jolla twice a week, but there is always sufficient coverage when she is at the La Jolla facility. An LIC 308 was obtained at the time of the initial visit to this investigation indicating that current administrator, Carol Garcia-Trejo and Jason Frahm would cover in place of Ms. Mahoney. A copy of the LIC 500 was also obtained to confirm staff coverage. Mrs. Garcia-Trejo also confirmed coverage while Ms. Mahoney was working at the La Jolla facility. Based on the information obtained, there was insufficient evidence to corroborate the allegation of an administrator not being available. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Apr 15, 2022 · control 31-AS-20200914160454

Allegation investigated: Resident was sexually abused while in care

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit. This complaint was referred to accepted by the Investigations Branch (IB). IB Investigator Harmin Sandhu conducted the investigation. It is alleged that resident #1 (R1) was sexually abused by staff #1 (S1). This investigation consisted of interviews with R1 and facility staff on 12/20/21. R1's physician report was obtained and reviewed. Information obtained from interviews reveal that on 10/28/21 at approximately 11am facility staff went to R1's room, knocked on the door then opened the door and observed S1 partially undressed from the waist down with R1. Facility staff promptly left the room and alerted the administrator. S1 was promptly escorted from the facility. Interviews were conducted with R1 and other facility staff. Information from interviews reveal that S1 and R1 were involved in a consensual sexual relationship. Los Angeles Police Department (LAPD) noted that the relationship was consensual and no incident report from them was filed. Based on the information obtained through interviews this allegation is deemed Unsubstantiated. Exit Interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 25, 2022 · control 31-AS-20211101161122

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Wendell Smith conducted an case management visit in conjunction with a complaint visit 31-AS-20211101161122. LPA met with administrator and explained the reason for this visit. During the course of that investigation it was found through interviews with residents and facility staff that staff # 1(S1) engaged in a sexual relationship with resident #1 (R1). On 10/29/21 S1 was observed in R1's room with their pants around their waist. S1 was immediately removed from the building. Interviews were conducted with R1 and facility staff. Los Angeles Police Department (LAPD) were notified and came to the facility. No report was taken by LAPD due to them determining the relationship was consensual. Since 10/29/21 S1 has relieved of their duties and has not been back to the facility. Deficiency cited on LIC 809 D for conduct inimical. Exit Interview conducted. Appeal Rights explained.the state’s words, verbatim · CDSS document, Mar 25, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(a)(2) · Plan of correction due date: Mar 28, 2022

The Department may prohibit an individual from being employed or allowed in a licensed facility as specified in Health & Safety Code Sections 1569.58 & 1569.59 (a)The department may prohibit any person from being a member of the board of directors, an executive director, a board member, or an officer of a licensee, or a licensed facility by licensee from employing, or. continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of State of CA.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: Administrator shall have an in-service with facility staff regarding proper staff-resident relationships. Copy of in-service will be sent to LPA. This requirement was not met as evidenced by: Based on interviews conducted it was found that S1 engaged in a sexual relationship with R1 which posed an immediate health and safety risk to residents in care.

Allegation investigated: Facility has insects

Licensing Program Analyst (LPA) Gary Tan and Michael Cava conducted a complaint visit to facility to investigate the above allegation. LPAs met with the administrator, Carol Trejo, and explained to her the purpose of the day's visit. It's being alleged that the facility has fleas and it was observed in the resident's room, bed and carpeting. Today's investigation consisted of resident and staff interviews, a physical plant inspection of resident rooms and common areas, and record review. According to staff, on or around 3/11/22, R1 was noticed to be scratching self. When staff assessed R1, they did observe fleas and eggs on her. Home Health was notified, prescription and treatment was applied. Staff stated additional flea medication was prescribed and will be applied to R1 every seven days. Staff stated R1's roommate, Resident 2 (R2) was also assessed and was observed with flea eggs. R2 was also given treatment and prescription. In addition to getting both residents treated for fleas, their room was disinfected and their clothing, blankets and bedsheets were washed. As a preventive measure, for Unsubstantiated any spread of fleas throughout the facility, both R1 and R2 were quarantined temporarily. Their responsible parties were notified, and they didn't express any complaints or concerns. Administrator and staff were asked if the other residents in the facility were affected, and they denied other residents being affected. The source of the fleas may have come from R1 during an outing as until then (on or around 3/11/22), the facility had no issues with fleas. LPAs interviewed random residents, and they denied ever having fleas during their stay at the facility. Review of records indicate that the licensee contracts with ORKIN for monthly service as preventive measures for insects. Review of the invoice did not reveal any outbreak of pest or insects. LPAs also reviewed Home Health records which indicates that they were notified of R1's situation and assisted in providing R1 with treatment. Although two residents were reported to have fleas, the licensee acted accordingly in providing both residents treatment in preventing the spread of fleas throughout the facility. Therefore, based on the information obtained, the allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 17, 2022 · control 31-AS-20220310161117

Allegation investigated: Facility not keeping residents room free from pests. Staff isolates residents.

Licensing Program Analyst (LPA) Gary Tan and Michael Cava conducted a complaint visit to facility to investigate the above allegation. LPAs met with the administrator, Carol Trejo, and explained to her the purpose of the day's visit. Today's investigation consisted of resident and staff interviews, a physical plant inspection of resident rooms and common areas, and record review. Facility not keeping residents room free from pests: In regards to the allegation, it's alleged that facility has cockroaches and lice. This investigation is made in conjunction to complaint control # 31-AS-20220310161117, allegation facility has insects. LPAs conducted interviews and record review to address the concern. According to staff, on or around 3/11/22, R1 was noticed to be scratching self. When staff assessed R1, they did observe fleas and eggs on her. Home Health was notified, prescription and treatment was applied. Unsubstantiated Staff stated R1's roommate, Resident 2 (R2) was also assessed and was observed with flea eggs. R2 was also given treatment and prescription. In addition to getting both residents treated for fleas, their room was disinfected and their clothing, blankets and bedsheets were washed. When asked about cockroaches, residents could not recall and denied the allegation that there are cockroaches. LPAs interviewed random residents, and they denied ever having fleas or roaches during their stay at the facility. Review of records indicate that the licensee contracts with ORKIN for monthly service as preventive measures for insects. Review of these invoice did not reveal any outbreak of pest or insects. Based on the information obtained, there wasn't enough evidence to corroborate the allegation that licensee is not keeping resident rooms free of pests. Therefore, the allegation is deemed Unsubstantiated at this time. Staff isolates residents: In regards to the allegation, it was reported that the head nurse is isolating residents. Because two residents were noted to have fleas, according to staff and residents, as a preventive measure, for any spread of fleas throughout the facility, both R1 and R2 were quarantined temporarily. Their responsible parties were notified, and they didn't express any complaints or concerns. Both R1 and R2 were interviewed to address the allegation. Both residents denied ever being isolated. Based on the information obtained, there wasn't enough evidence to corroborate the allegation of staff isolating residents. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 17, 2022 · control 31-AS-20220311130718

Allegation investigated: Unqualified staff assessing resident's care Unqualifeid staff signing off on resident's documents Resident's care is not being assessed for a higher level of care

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a complaint visit to facility to investigate the above allegations. The day's investigation consisted of a physical plant inspection, record review, and interviews with residents and staff. During the course of the investigation, LPAs met and interveiwed with the administrator, Carolina Garcia-Trejo. LPA's conducted a physical plant inspection at 9:02am, requested and reviewed facility documents at 9:35am, and conducted interviews from 10:00am to 12:45pm. Unqualified staff assessing resident's care/Unqualified staff signing off on resident's documents: In regards to the above allegations, it's alleged that Staff 1 and 2 (S1 & S2) are assessing for resident's care, signing prescription forms that are sent to the pharmacy, and placing residents on hospice care, even if the residents do not qualifiy. S1, admits she is not a nurse. Her job title is care coordinator. Unsubstantiated Her duties include scheduling and supervising caregivers. S1 denies assessing for resident's care, signing prescription forms that are sent to the pharmacy, and placing residents on hospice care, even if the residents do not qualify. S1 states only the administrator, who is a licensed nurse does the assessment and reassessment for the residents to insure their needs are being met. S1 states she doesn't sign any refill prescription forms. Resident medications are bubble pack. It gets refilled automatically every 28 days. For prescription medicine that are as needed or in a bottle, either her or another medication staff would call the pharmacy within five days of the prescription medication running out to request a refill. S2, who works for marketing also states she is not a nurse. Some of her duties include processing admission paper work, marketing, and sometimes assist with medications as she previously held the position of a med tech. S2 also denies assessing for resident's care, signing prescription forms that are sent to the pharmacy, and placing residents on hospice care, even if the residents do not qualify. S2 states she may go with the administrator to assist her with resident paperwork, but doesn't do any of the assessments. According to the administrator, she primarily does the pre-assessment/appraisal of the resident prior to admission. She determines them for appropriateness and compatibility. In regards to signing off on documents for hospice care, the administrator denies doing so. She states she is in communication with hospice agency constantly to insure the resident needs are being met. Based on the information obtained it could not be proven that unqualified staff are assessing resident's care or signing off on resident's documents. Therefore, the allegation is deemed Unsubstantiated at this time. Resident's care is not being assessed for a higher level of care: In regards to the allegation it's being alleged that there are dementia residents and residents with severe psychiatric issues that shouldn’t be in assisted living. Reporting Party (RP) alleges that unqualified staff has been signing all forms that are sent to the pharmacy. RP stated that residents are being placed on hospice that don’t even qualify for it because they get a kick back. RP stated that there are 35 residents on hospice and that staff are signing off on that paperwork and not the doctor. Interviews with the administrator and staff reveal that they deny placing residents on hospice or signing off on their paperwork to receive kick backs. Staff stated that only the resident doctors makes the referral of residents to the hospice agency of their choice. The administrator states that she is constantly in communication with the resident's doctor and the hospice agency to insure the resident needs are being met. Currently the facility has 24 residents that are receiving hospice care. The administrator, who also holds an LVN license, stated she primarily does the pre-assessment/appraisal of the resident prior to admission. She determines them for appropriateness and compatibility. Review of records reveal that the facility utilizes three different hospice agencies. Regarding unqualified staff signing all forms that are sent to the pharmacy, both the administrator and staff indicate that medications are bubble pack and refilled automatically every 28 days. For PRN or bottled medication, the med tech would call the pharmacy 5 days prior to the medication running out to request for a refill. Staff confirms that only the doctor signs off on the resident's prescriptions and refills. Based on the information obtained it could not be proven that resident's care is not being assessed for a higher level of care. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 3, 2022 · control 31-AS-20220209110608

Allegation investigated: Staff pushed resident while in care Staff stole resident's personal property

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegations. LPAs met with Executive Director Carol Trejo and explained the reason for the visit. LPAs conducted physical plant tour at 9:02 AM, requested copy of facility documents relevant to the investigation at 9:35 AM and conducted interview with additional staff and residents between 10:00 AM to 12:45 PM. Regarding the allegation that a Staff pushed resident while in care, it was alleged that Staff #1 (S1) pushed Resident #1 (R1). LPA's record review today at 9:40 AM of Police interview with R1 revealed that the alleged incident occurred on 02/04/2022 at 8:00 PM, further review revealed that S1 was not on duty at the reported time of alleged incident. LPA's interview with R1 on 02/15/22 at 11:45 AM revealed that R1 did not remember the date and time of the alleged incident. LPA's interview with Resident #2 (R2) who is the room mate of R1 also revealed that R2 did not witness any incident with S1 and R1 at anytime inside their room. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff stole resident's personal property, it was alleged that R1 stole some money and photograph of R1's family member. LPA's interview with S1 today at 12:05 PM revealed that S1 did not take anything from R1 and was not on duty on the alleged date of the incident. LPA's record review today at 11:45 AM also confirmed that S1 was not on duty on the time of the alleged incident and further review also revealed that none of the alleged missing item is on R1's Personal property and valuables (LIC 621). Based on the information gathered during this and prior visit, the allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 3, 2022 · control 31-AS-20220207120245

Allegation investigated: Facility is out of ratio with hospice resident's Unqualified Director operating facility Resident's are being overmedicated

Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a complaint visit to facility to investigate the above allegations. The day's investigation consisted of a physical plant inspection, record review, and held interviews with residents and staff. During the course of the investigation, LPAs met and interveiwed with the operations manager, David Aguiniga. LPA's conducted a physical plant inspection from 9:35am to 10:30am, requested and reviewed facility documents at 10:30am, and conducted interviews from 10:45am to 1:00pm. Facility is out of ratio with hospice residents: In regards to the above allegation, a review of the facility license indicate that facility has a hospice waiver approved for 25. Mr. Aguiniga and staff conducted a count to confirm how many facility residents are receiving hospice care. Their count reveals 22 residents receiving hospice care. LPAs Tan and Cava Unsubstantiated conducted a record review and verified there are 22 residents receiving hospice care. Based on interviews and record review, it could not be proven that facility is retaining more residents receiving hospice care than approved for. Therefore, the allegation is deemed Unsubstantiated at this time. Unqualified Director operating facility: In regards to the above allegation, it was reported that Carol Trejo is not a qualified administrator. LPAs Tan and Cava conducted a record review pertaining to Ms. Trejo. Review of the facility file indicate that Carolina Garcia-Trejo is listed as the facility administrator. Review of facility files further indicates that Ms. Trejo has been employed by the facility since July 2018. She was hired as a wellness director at that time. She was then placed as interim administrator in February 2021, then promoted to the position permanently in June 2021. LPAs obtained a copy of Ms. Trejo's certificate and it is effective from 12/7/20 through 4/23/22. Based on interviews and a review of staff and facility records, it could not be proven that there is an unqualified director in charge of facility operation. Therefore, the allegation is deemed Unsubstantiated at this time. Resident's are being over-medicated: In regards to the above allegation, it was reported that all residents are being drugged with psychotrophic drugs. The reporting party did not identify resident names. The investigation consisted of LPAs Tan and Cava interviewing residents and reviewing the facility's medication log. Interviews with residents do not corroborate with the allegation. Residents did not express any concerns regarding their medication management. LPAs did not observe any discrepancies while reviewing the facility's medication log. Based on interviews with residents and a review of and facility medication records, it could not be proven that residents are being over-medicated. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 15, 2022 · control 31-AS-20220209110608

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not issue refund to resident's POA

Licensing Program Analyst (LPA) Wendell Smith made an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit. Regarding the allegation it is alleged that resident #1 (R1) moved out and the facility did not refund R1's pre-admission fee. LPA interviewed the administrator regarding this allegation from 1:30-1:45pm. LPA also reviewed R1's admission agreement from 1:45-2:10pm. LPA also interviewed R1's responsible person regarding this allegation. Information from a review of R1's admission agreement found that if the resident has lived in the facility for four or more months, the licensee may, but is not required to make a refund of the preadmission fee. It was noted that R1 lived in the facility from 7/5/21 through 1/13/22 which is more that four months. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Exit Interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 1, 2022 · control 31-AS-20220131121000

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced required annual inspection to the facility. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Carolina Garcia'Trejo and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition. Per administrator they are currently not using the dinning room in Assisted Living as a precaution. BEDROOMS: The LPA observed randomly selected resident rooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. LPA observed carpeting stained/dirty and blind broken in residents rooms. A discussion was held with the administrator who stated they will be shampooing the carpets once dinning room is opened. Administrator also agreed to inspect all resident rooms, create a maintenance log to document all rooms that need repairs. She will then ensure that maintenance completed the required repairs. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap and paper towels. COMMON SPACES: Common areas include the dining room, activity room and patio. In the common areas, walls, flooring and furniture were checked for cleanliness and good condition. The fire extinguisher in the hallways were fully charged and was last serviced 3/2021. Required postings were observed throughout the common hallways in Assisted Living but were not posted in memory care. Administrator agreed to post the required postings in Memory Care. Record Reviews: LPA conducted review or resident and staff files from approximately 10:45 am to 1:00 pm and observed the following. Licensee does not have current physicians report for 7 out of 7 resident who have a diagnosis of Major Neurocognitive disorder. Licensee does not have current/completed hospice care plan for 7 out of 7 residents who are currently receiving hospice services. A discussion was held with the administrator on 10/20/2021 regarding obtaining current, complete hospice care plans for all residents. 2 out of 7 hospice residents utilize full bed rails however licensee does not have hospice care plan that indicates the need for the full rails 5 out of 7 residents are utilizing half rails however licensee does not have physician orders to utilize the rails. Licensee is retaining bedridden residents in rooms that do not have bedridden fire clearance. (Rm 201, 12 A & 12 B, 229 A) At 2:24 pm LPA spoke with the administrator regarding ambulatory status of for the 24 hospice residents. Administrator informed the LPA that 8 of the resident are unable to independently reposition in bed and are considered bedridden. 4 of the 8 residents are residing in rooms that do not have bedridden fire clearance. Staff records were reviewed and observed to be complete with the required documentation. All staff have criminal record clearance and are associated to the facility. While reviewing staff files LPA observed 6 out of 8 staff do not have required training. 2 out of 2 newly hired staff training verification was not properly documented. Staff do not have current first aid/CPR training. A discussion was held with the administrator who stated she will review staff files and schedule training for all staff who do not have the required annual training's, including first aid/CPR, Also during today's visit while conducting a tour of the facility at 1:05 pm LPA was informed by the administrator that beginning of January they had 2 residents who tested positive for COVID. LPA was informed that incident reports were faxed to the Woodland Hills South Regional office, however while reviewing the report LPA observed that the fax number was not for the department. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in storage and the facility is able to obtain additional supplies as needed. The LPA observed resident and staff temperature logs, visitation screening questions, and cleaning log. The facility’s cleaning protocol is sufficient. Staff and residents were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA and Administrator discussed the recent PIN as it relates to visitation and staff vaccination requirements. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. This facility keeps track of vaccination rates for current staff. The facility’s policies and procedures as it pertains to infection control are adequate. Prior to the completion of the visit LPA requested for the following to be submitted. Documentation to change the administrator of the facility to Carolina Garcia'Trejo. Copy of current Liability insurance. Exit interview conducted. Copy of Report citations and Civil Penalties emailed to the administrator.the state’s words, verbatim · CDSS document, Jan 25, 2022

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Staff left residents in soiled diapers for an extended period of time Staff did not administer residents medication in a timely manner Facility is understaffed

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with the administrator and explained the reason for this visit. LPA conducted a physical plant tour to ensure no immediate health and safety concerns from 11:10-11:30am. Staff left residents in soiled diapers for an extended period of time it is alleged that residents are not being changed in a timely manner. LPA conducted an intial visit on 11/5/21 where LPA conducted interviews with residents regarding this allegation. During today's visit LPA interviewed residents who require assistance with incontinent care from 12pm-2pm. Interviews revealed that residents are satisfied with the time it is taking to get changed when they need assistance. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Unsubstantiated Staff did not administer residents medication in a timely manner It is alleged that staff are not getting their medication in a timely manner. LPA conducted interviews with residents from 12pm-2pm and staff from 2-3pm regarding this allegation. Interviews revealed that residents are receiving their medication at a scheduled time and that there have been no issues with medication being given. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. Facility is understaffed It is alleged that the facility does not have enough staff and that staff are working from 6am-6pm consistently. LPA conducted interviews with residents and staff regarding this allegation from approximately 12-3pm. LPA also obtained a staff schedule to show coverage for the facility. Based on the information obtained through interviews and schedule review this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.the state’s words, verbatim · CDSS document, Nov 19, 2021 · control 31-AS-20211103144234

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced case management visit. LPA met with the administrator and explained the reason for this visit. Upon entry to the facility a physical plant tour was conducted to ensure no immediate health and safety issues were present. During the physical plant tour no immediate health and safety issues were noted. Facility submitted an serious incident report to licensing regarding an incident where a staff member (S1) was seen in a resident #1 (R1) room acting inappropriately. S1 was immediately escorted out of the building. Administrator conducted interviews with other staff and R1. Administrator called law enforcement, Adult Protective Services(APS), Long Term Care Ombudsman (LTCO), and R1's family and informed them about the alleged incident. LPA conducted interviews with the administrator and facility staff. LPA asked for and received copies of S1's file and R1's file. Due to the need for more information a follow up visit will be made at another time. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 1, 2021

Allegation investigated: Smoke alarms are not working. Staff working with hospice residents are not qualified.

An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Regarding the allegation of Smoke alarms were not working it was reported that there was a small fire in the room of a resident in the memory care caused by a lamp, the smoke alarms did not go off when the fire was occurring. On 10/18/2021 LPA conducted a tour of the room indicated on the complaint and spoke with the current administrator. While touring the room LPA did not observe any smoke damage. According to Ms. Trejo the family of the resident brought a new lamp and did not completely remove the plastic. When the lamp was turned on it melted the plastic causing very little smoke. Per administrator the incident did not cause a fire and did not cause heavy smoke to be in the rooms and believes that is the reason the smoke alarms were not activated. On 10/20/2021 at 8:30 am LPA conducted telephone interview with LAFD Inspector regarding the allegation. According to the inspector the smoke detectors will not always activate when there is a small fire, it all depends on the amount/severity of the smoke in relation to where the smoke detectors are located. Unsubstantiated During todays visit LPA conducted interview with the med-tech who was working when the incident occurred. According to the med-tech she was notified by a caregiver of a smoke smell in the memory care. Both staff entered the room indicated in the complaint and saw the plastic on the lamp was smoking. Med-Tech immediately removed the lamp ensured it was no longer smoking and placed it outside the facility. Both staff took the residents out of the room and opened the windows to clear the air. Med-Tech stated that there wasn't a fire and only a small amount of smoke, however there was a strong smoke smell. During this visit LPA along with the maintenance director tested the smoke detectors in memory care and confirmed that it was working properly. Based on the information obtained the allegation is Unsubstantiated at this time. Regarding allegation of : Staff working with hospice residents are not qualified it was reported that the facility staff are providing shower assistance to residents in place of the hospice agency staff. It was also reported that the licensee has hired a current facility staff to provide showers for the residents in place of the hospice staff. On 10/18/2021 LPA conducted interview with the administrator who reported that the hospice agency listed in the complaint provides a staff who is at the facility Monday through Friday from 6:00 am to 2:00 pm. The hospice staff along with facility staff provide showers to the hospice residents. Additionally on 10/18/2021 at approximately 1:02 pm LPA conducted interview with Staff 1 (S1) who is the hospice agency staff. Per S1 she provides assistance to those residents who are receiving services from the agency she works for. S1 stated that there are other staff who come on Tuesdays, Wednesdays and Fridays. S1 stated that she is paid by the hospice agency and is a licensed CHHS. During this visit LPA obtained information that S1 also works for the facility as a med-tech on the days she is listed scheduled to work for the hospice agency. At 3:49 pm LPA re-interviewed S1 who confirmed working for the facility and the hospice agency. Staff also confirmed that she is paid from the hospice agency and the facility separately. Based on the information obtained the allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 20, 2021 · control 31-AS-20211013141439

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not issue Resident's Representative a refund. Facility did not provide Resident's Representative written notice of policies regarding contract termination upon death in a timely manner.

Licensing Program Analyst(s) Wendell Smith and LaQueena Lacy conducted an unannounced initial complaint visit to investigate the allegations above. LPA met with the administrator and explained the reason for this visit. Upon entry to the facility a physical plant tour was conducted from 9:45am-10:00 am to ensure no immediate health and safety issues. No immediate health and safety issues were noted during the walk through. Facility did not issue Resident's Representative a refund Regarding this allegation it is alleged that resident # 1(R1) rent was paid in advance for October 2021 and that R1 passed away on 9/24/21 and the facility has not issued a refund for the October 2021 payment. LPA's conducted interviews with the administrator and facility staff regarding this allegation from 10-10:20am. LPA's reviewed R1's facility file and obtained copies of pertinent information related to R1's file from 10:20-11:00am. Unsubstantiated Information obtained from interviews with facility staff and R1's responsible person revealed that R1 passed away on 9/24/21. At that point R1's rent for September 2021 was already paid. R1's responsible person received a pro-rated check from the facility in the amount of 217.80 dollars for the pro-rated amount for September 2021. LPA's obtained and reviewed Billing invoices for R1. It shows that R1's rent for October 2021 had not been paid as of yet. Based on the information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Facility did not provide Resident's Representative written notice of policies regarding contract termination upon death in a timely manner. It is alleged that R1's responsible person have not received any written notice regarding fees assessed after R1 passed and their property remained in the unit. LPA's conducted interview with the administrator and reviewed R1's facility file. Information revealed that R1's responsible party was not charged any fees after R1 passed. R1's family came to the facility on the day R1 passed and took the personal belongings they wanted and the rest of what they did not want they said could be donated. Based on the information obtained through interviews this allegation is deemed Unsubstantiated. No additional fees were charged after R1 passed away. Exit Interview conducted.the state’s words, verbatim · CDSS document, Oct 5, 2021 · control 31-AS-20210929150409

Allegation investigated: Staff are not administering medications to residents according to physicians instructions. Staff are not allowing resident to purchase a new bed. Staff are not allowing resident to go outdoors.

Licensing Program Analyst(s) Wendell Smith and LaQueena Lacy conducted an unannounced subsequent complaint visit to investigate the allegations above. LPA met with the administrator and explained the reason for this visit. Staff are not administering medications to residents according to physicians instructions. It is alleged that the facility changed resident # 1(R1) medication without permission and R1 was not receiving their medication as prescribed. From 12:15-1:00PM LPA's reviewed R1's medication record from January to March 2021. LPA obtained copies of pertinent information related to the allegation. LPA's interviewed facility staff from 1:00-1:15pm. LPA's were not able to interview R1 due to R1 passing on 9/24/21. Interviews revealed that R1's family picked R1's pharmacy and that R1 had their own physician Based on information obtained through interviews and record review this allegation is deemed Unsubstantiated at this time. Unsubstantiated Staff are not allowing resident to purchase new bed It is alleged that facility staff would not let R1 purchase a new bed. LPA previously conducted interviews with R1's responsible person and the former administrator of the facility. Interviews revealed that R1 did provide R1 a bed when they moved in and that R1's family wanted R1 to have a different bed but wanted the facility to pay for a different bed. Administrator stated they never stopped R1's family from buying a new bed for R1. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time. There is not enough information to state that the facility stopped R1's family from purchasing a new bed for R1. Staff are not allowing resident to go outdoors. It is alleged that in January 2021 R1 was having a visit with their family and wanted to go outside with their family but was denied the right to do so. LPA previously conducted interviews with the former administrator and R1's responsible person. During today's visit interviews were conducted with staff and residents regarding this allegation. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.the state’s words, verbatim · CDSS document, Oct 5, 2021 · control 31-AS-20210120115809

Allegation investigated: Staff do not ensure the residents are properly fed while in care Residents personal belongings are mishandled while in care

Licensing Program Analyst (LPA) Calvin Tsui and Alex Pritz conducted a unannounced complaint visit to invesitgate the allegations of "Staff do not ensure the residents are properly fed while in care" and "Residents personal belongings are mishandled while in care". For the allegation. "Staff do not ensure the residents are properly fed while in care" the allegation indicates the food is in poor quality and the portions are too small, the meals are served at inconsistant times resulting in residents going hungry. At 11:30 a.m. LPA's interviewed 10% of facility census; 5/5 residents interviewed in memory care and 8/8 interviewed in assisted living stated that they where getting enought to eat. Furthermore, LPA observed residents asking for seconds during lunch and getting more. The allegation is unsubstantiated. Unsubstantiated Licensing Program Analyst (LPA) Calvin Tsui and Alex Pritz conducted a unannounced complaint visit to invesitgate the allegations of "Staff do not ensure the residents are properly fed while in care" and "Residents personal belongings are mishandled while in care". For the allegation, "Residents personal belongings are mishandled while in care." The allegation is that resident items are lost in laundry. At 11:30 a.m. LPA's interviewed 10% of facility census; 5/5 residents interviewed in memory care and 8/8 interviewed in assisted living stated that they have not lost items in laundry. This allegation is unsubstantiated. report reviewed signed and delivered. exit interview conducted, no deficiency cited.the state’s words, verbatim · CDSS document, Sep 28, 2021 · control 31-AS-20210915103232

Allegation investigated: Staff failed to check on residents in a timely manner

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to further investigate the allegation above. LPA met with the administrator and explained the reason for this visit. Regarding the allegation above it is alleged that staff failed to check on residents in a timely manner when they pushed their pendant in their room. LPA had previously conducted visits regarding this allegation on 6/18/21 and 1/29/21. During today's visit LPA conducted interviews with random residents regarding the allegation from 11:30-12:30pm. Based on the information obtained during interviews this allegation is still deemed Unsubstantiated. Exit Interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 27, 2021 · control 31-AS-20210127105116

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Residents are not able to communicate with staff. Facility phone doesn’t get answered because of not enough staff. Resident not being provided adequate service.

Licensing Program Analyst (LPA) Wendell Smith made an unannounced subsequent visit to finish investigation into the allegations above. LPA met with facility staff and explained the reason for this visit. LPA conducted an initial visit to this facility on 8/17/21. Residents are not able to communicate with staff It is alleged that residents are not able to communicate with staff due to staff not speaking english. LPA conducted interviews from approximately 10am-11:30am with various residents regarding this allegation. Information from interviews reveal that residents are able to communicate sufficiently with facility staff. LPA also spoke with various staff throughout the visit and was able to communicate with staff in English. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Unsubstantiated Facility phone doesn’t get answered because of not enough staff. It is alleged that the front desk does not answer the telephone in a timely manner. LPA conducted interviews with residents from 10am-11:30 am. Interviews revealed that residents have not had an issue when calling the front desk for assistance. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Resident not being provided adequate service. It is alleged that residents are not being provided baths due to a lack of staff and that the food service is lacking because of staff. LPA conducted a physical plant walk through and conducted interviews with residents from 10-11:30pm. LPA also observed lunch being served in the memory care unit at 11am. From 11:30am-12pm LPA observed lunch being served in the assisted living side of the facility. Based on the interviews conducted and what was observed during this visit this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Aug 24, 2021 · control 31-AS-20210816082350

Allegation investigated: Facility failed to report Covid Cases

Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit. LPA met with the administrator and explained the reason for this visit. Regarding the allegation above it is alleged that facility failed to report they had active covid cases. At approximately 12:30 pm LPA conducted an interview with the administrator regarding this allegation. Administrator stated that they did covid testing on 7/27/21 and on 7/30/21 late in the afternoon the results came back that one resident and one staff were positive. They then called Department of Public Health and notified them of the situation. Facility then conducted mandatory covid testing for all residents and staff from 4pm-8pm on 7/30/21. They received the results today and all were negative including the two that were initially positive. LPA received an incident report regarding the covid cases this morning at 9:28 am. Based on the information obtained through interviews and documentation received this allegation is deemed Unsubstantiated at this time. Facility did report the positive covid cases in a timely manner. Exit Interview conducted. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 2, 2021 · control 31-AS-20210730150302

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff did not give resident a sufficient amount of water Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit to this facility to further investigate the above stated allegations. LPA met with Assistant Care Coordinator Jero Argota and explained the reason for the visit. LPA also talked to the new Executive Director Carolina Garcia Trejo on the phone and designated Mr. Argota to sign the report. At around 9:00 AM, LPA conducted physical plant tour. At 10:00 AM, LPA requested copy of pertinent facility documents relevant to the investigation. At 11:02 AM to 2:30 PM, LPA conducted interview with staff and residents. Regarding the allegation that Staff did not give resident a sufficient amount of water, LPA interview with five (5) Memory Care Unit staff today between 11:02 to 2:30 PM revealed that staff conduct routine check to ensure that all residents are comfortable and their needs are met. LPA interview with staff present during the incident on 05/22/2020 where Resident #1 (R1) was screaming for water, revealed that R1 had just had dinner and had water and juice on R1's bedside. LPA record review today at 2:35 PM revealed that R1 had a diagnosis or Dementia and confusion. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) LPA interview with Resident #2 (R2) also revealed that staff always provide R2 water whenever R2 asked for it. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Regarding the allegation that Staff handled resident in a rough manner, LPA interview with five (5) memory care staff between 11:02 AM to 2:34 PM, revealed that no one witnessed any staff mistreating and/or rough handing any resident at any time and LPA interview with staff present during the incident on 05/22/2020, denied rough handling or mistreating R1 in anyway. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 24, 2021 · control 31-AS-20200601091800