Belmont Village Calabasas

Allegation investigated: Staff did not ensure resident had enough liquids, resulting in dehydration

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation for the allegation listed above at 11:20AM. LPA was greeted by staff and met with Executive Director (ED) Cyntia Drachenberg. Entrance interview conducted. During today's visit, LPA conducted a brief physical plant tour and no health and safety concerns were noted. During the initial visit on 05/27/2026, LPA conducted a brief physical plant tour, interviewed five (5) staff and attempted an interview with one (1) resident, reviewed and obtained copies of pertinent documents, and discussed allegation with the ED. REPORT CONTINUED ON LIC9099-C. Unsubstantiated It was alleged that Resident #1 (R1) was hospitalized for severe dehydration due to staff neglecting to provide liquids to R1. LPA interviewed five (5) staff members, attempted to interview R1, and interviewed two (2) responsible parties of R1 during the course of the investigation. All interviews confirmed that R1 is encouraged to drink liquids by facility staff, but R1 tends to refuse. Per regulation, R1 has the personal right to refuse, and the facility cannot force R1 to consume liquids if R1 declines. Responsible parties stated that they had no concerns regarding staff members’ attempts to encourage liquid consumption and have witnessed staff actively encourage R1. Staff and responsible parties stated that the facility also tries to increase R1’s liquid intake by providing soup, flavored waters, and popsicles. LPA reviewed R1’s care plan dated 05/27/2026 which states that staff shall “encourage fluids throughout the day- offer juice/water.” LPA reviewed R1’s hospital discharge paperwork which documents a diagnosis of hyponatremia. R1 was hospitalized from 05/20/2026-05/25/2026. LPA observed R1 and no immediate health and safety concerns were noted. Based on interview and record review, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation “Staff did not ensure resident had enough liquids, resulting in dehydration” is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 29-AS-20260524171417

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 11:20AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 07/06/2026. LPA met with Executive Director (ED) Cyntia Drachenberg and explained the reason for the visit. During today’s visit, LPA conducted a brief physical plant tour to ensure there are no immediate health and safety hazards, conducted interviews with three (3) staff members, one (1) visitor, and one (1) resident, and reviewed and obtained copies of pertinent documents. On 07/12/2026, the Department received an incident report stating that on 07/06/2026, Resident #1 (R1) was found at a nearby gas station outside of the facility by Staff #1 (S1). R1 was safely escorted back to the facility where an assessment was performed and no injuries or abnormal vitals were observed. R1’s primary care physician and responsible parties were notified. ED Drachenberg stated that following the incident, R1’s care plan was updated to reflect 24/7 private caregiver oversight to prevent R1 unsafely wandering or leaving the facility unassisted. ED also stated that an elopement drill in-service was conducted with all staff and online trainings were provided. LPA interviewed R1 and one (1) visitor and no concerns regarding lack of supervision or staffing were noted. LPA observed the memory care unit to be secured, and the front entrance/exit monitored by the front desk. An additional report may follow if warranted. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Zabel Chochian arrived at this facility to continue the required annual inspection initiated on 3/10/2026. Upon arrival LPA met with the Executive Director (ED), Cynthia Dachenberg and reason for the visit was stated. Beginning at 1pm the LPA and the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Sufficient snacks and beverages observed. Facility is also stocked with sufficient emergency food and water supply. A digital system is used to capture residents prescribed diets, allergies, and food preferences. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floors. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all observed appropriately furnished. All activity rooms and theater appeared clean. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 02/11/2026. Annual Fire alarm/sprinkler system was tested on 3/21/2025 by West Coast Fire.According to ED and records reviewed the annual inspection was completed and repairs were made last week; they are wait for a retest.Copy of the retest/inspection will be sent to the department once completed. Resident Units: The LPA toured ten (10) randomly selected rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The resident units and common area restrooms observed fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the resident room tours LPA interviewed ten (10) residents. The water temperature was tested throughout the visit including resident unit restrooms and public restrooms. Hot water measured between required range (105*F-120*F) in resident unit restrooms. MEDICATION: Medication review started at 2:30p.m. The LPA reviewed medications for two residents during the visit. Medications are centrally stored and inaccessible to residents in the Wellness Center located on the second floor. Two out of two resident medications reviewed; residents medication matched centrally stored medication record; one medication current used by resident that was filled in 2025 was missing the centrally stored record. According to staff and ED the record was pulled and filed in storage to thin out the current file. Staff and ED stated that they will pull the records from storage and moving forward staff will ensure that centrally stored medication records with medication resident is currently taking stay in the residents records. Memory care unit exit doors and fence gates observed locked and not a delayed egress system. ED received information that the memory care unit is a locked perimeter with no delayed egress on the exit doors. Follow-up needed to clarify if the facility memory care is cleared for locked perimeter or delayed egress. Fire clearance dated 2/16/2018 indicates "Delayed egress/locked perimeter approved for memory care". No deficiency cited during today's visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian arrived at this facility to conduct a required annual visit. Upon arrival, LPA observed residents in the dining and common area. All required postings observed near the residents mail box area. LPA met with the Executive Director (ED),Cynthia Drachenberg and reason for the visit was stated. During the visit, LPA began the annual inspection with the following: RECORDS REVIEW: Personnel records were requested for review. Beginning at approximately 11:30a.m. LPA reviewed ten (10) personnel records for, but not limited to job application, health assessments, TB results, criminal record clearances, first aid/CPR certification and required training. Staff files reviewed all had required records. Resident records were requested for review. At approximately 1p.m. LPA reviewed twelve (12) resident files for, but not limited to admissions agreements, medical assessment, updated appraisals, and personal rights. Two (2) out of the twelve resident files reviewed required updated medical assessments. ED stated that they will inquire and check their backlog filing for those identified missing records. LPA reviewed facility's Infection Control Plan, Emergency and Disaster Plan at approximately 3:30pm. Due to time constraints, the LPA will return at a later date to continue the annual inspection. No health and safety issues observed during today's visit. Exit interview held and copy of report provided.the state’s words, verbatim · CDSS document, Mar 10, 2026

Allegation investigated: Staff did not ensure food was free from contamination.

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced initial complaint visit to this facility. Upon arrival LPA was greeted by staff. LPA met with Executive Director (ED) Cynthia Dranchenberg, reason for the visit was explained. On 01/12/2026, the Department received the above listed allegation. Information was received that there is concern with food safety at this facility. Reporting party (RP) states about two weeks ago (exact date unknown), RP found several hairs in their lunch. RP stated the kitchen staff do not cover their hair properly. On 01/16/2026 Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. LPA interviewed facility Chef Alvaro Nunez and facility kitchen/dining procedures and policies were discussed. Copies of documents relevant to the investigation was requested. Chef Nunez reported that the kitchen staff preparing meals wear gloves and hair nets. Staff working in the kitchen stations preparing meals observed with gloves and hair nets on during initial visit. (Continue to LIC9099c) Unsubstantiated The chef reported that servers/staff not preparing/handling food are not required to wear hairnets or gloves. Sufficient supply of gloves and hairnets observed in the kitchen. LPA reviewed the facility's most recent dietary audit report dated 12/12/2025. Report revealed that facility is in compliance and meet standards in Personnel hygiene - food handled properly; hair restraints and gloves used (worn in food production areas). On 2/24/2026, LPA conducted a subsequent complaint visit. LPA conducted random interviews with four (4) staff; LPA also met with and interviewed twelve (12) random residents from approximately 12pm-2:30pm. Staff interviewed reported that they also eat the facility food 3-4 times in the week and they reported no issues with the food received. Staff denied ever finding any hair in their food. Resident interviews revealed that the food service is good and they never experienced any issues with "hair in their food". Twelve out twelve residents interviewed expressed being very satisfied with the food service and dining experience. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation "Staff did not ensure food was free from contamination" is deemed unsubstantiated at this time. Exit interview held and copy of report provided.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 29-AS-20260112093403

Allegation investigated: Facility is charging resident for services not received. Staff did not accord resident privacy.

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility today to deliver investigation finding. LPA met with the Director of Resident Care Services, Diana Alvarado and reason for visit was discussed. On 10/28/2024, the Department received the above listed allegations. On 10/30/2024, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. From approximately 11am- 2pm, LPA conducted interview with ten (10) randomly selected residents including resident #1. From approximately 2pm-3pm, LPA reviewed R1’s records and conducted interview with staff. Following is a summary of the allegations and finding: Regarding allegation - Facility is charging resident for services not received: Information was received that R1 was hospitalized in 9/2024; when R1 returned to the community it was suggested that R1 hire a private aide for temporary assistance which would be less expensive than what the facility would charge for additional services. (Continue to LIC9099c) Substantiated R1 paid approximately $280 a day for the private aide. It was reported that R1 also received a billed from the facility for two months rent which included charges for additional services. According to R1 the additional services facility was charging was provided by the private aides which was already paid. It was confirmed through interviews and records review that R1 was charged/billed in error for additional services not rendered. R1 and ED confirmed that a credit was issued for the additional service charges. Based on the information obtained through record review and interviews; the allegations “Facility is charging resident for services not received”, is deemed substantiated at this time. Regarding allegation: Staff did not accord resident privacy: Information was provided that while R1 was on an outing, facility staff entered R1's room and took all medications (OTC, prescribed, and vitamins). To investigate this allegation, LPA conducted interview with R1, staff and reviewed records. Interviews revealed that R1 was hospitalized temporarily in 9/2024 due to a medication error. Records reviewed revealed that R1 was able to store and handle own medications. Staff confirmed that they entered R1’s room when R1 was not home and removed all medications. Staff expressed that for safety reasons it was the only solution at the time as a result of R1 mismanaging medication. Based on the information obtained through record review and interviews; the allegation “Staff did not accord resident privacy”, is deemed substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies are cited (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided. Information was received that on 10/27/2024 the facility ran out of R1's prescription for Percocet, which R1 had to take daily for pain. Apparently, staff had not re-ordered the medication on time and R1 had to go all day without pain medication because the pharmacy uses a system called "Guardian" and the medications are only delivered in the evening. Interview with staff and records review confirmed that the medication in question was a narcotic and needed an order form the doctor for staff to send out for refill. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff did not ensure that resident is provided their medication(s) as prescribed” is deemed unsubstantiated at this time. Regarding allegation: Staff are not following resident's physician order: Information was received that facility refused to follow order from R1’s primary care physician stating that R1 can store and administer OTC and vitamins. Staff interviewed stated that the physician order was received in the evening on 10/21/2024, however a new physician report was required therefore until that was completed and returned medication was held. Staff reported that the OTC and vitamins was returned to R1 when the physician report was completed by the primary doctor in 11/2024. Random residents interviewed reported no issues with facility medication management. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff are not following resident's physician order” is deemed unsubstantiated at this time. Exit interview held. Copy of the report provided.the state’s words, verbatim · CDSS document, May 18, 2025 · control 29-AS-20241028122537

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 30, 2025

Personal Rights of Residents in All Facilities:(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: Based on interviews conducted, licensee did not comply with above section cited. Staff went into resident's room without prior permission and removed resident #1's medications.the state’s words, verbatim · CDSS document, May 18, 2025

Plan of correction: Executive Director shall provide a plan of correction on how they will maintain future compliance with Personal Rights of Residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: May 30, 2025

The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidence by: Based on records review and interviews, licensee did not comply with section cited above. R1 was billed for services not provided by facility staff.the state’s words, verbatim · CDSS document, May 18, 2025

Plan of correction: Executive Director shall provide evidence that the billing errors have been resolved. Also include a statement of future compliance plan.

Allegation investigated: Staff did not ensure resident had their oxygen when out of room Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility today to deliver investigation finding. LPA met with the Director of Resident Care services Diana Alvarado and reason for the visit was discussed. On 01/17/2025, the Department received the above listed allegations. On 01/24/2025, Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit. From approximately 11am- 1:45pm LPA and Mrs. Alvarado toured the facility common areas and resident rooms. Interviews were conducted during the tour with 6 (six) randomly selected residents and 2 (two) other potential witnesses. On 02/19/2025, during a subsequent complaint visit for another complaint, LPA Chochian reviewed resident records and interviewed six (6) staff members. Following is a summary of the allegations and finding: (Continue to LIC9099c) Substantiated Regarding allegations - Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings: Information was received that Resident #1 (R1) was not on continuous oxygen from approximately 01/09/2025 – 01/17/2025. According to the reporting party the facility evacuated on 01/09/2025 due to the Kenneth fire and R1’s portable oxygen was lost. Staff did not ensure R1 was on continuous oxygen. R1 went to a hair appointment without a supply of oxygen. It was confirmed through interviews and records review that there is an order on file from R1’s physician that R1 requires continues (24 hours) oxygen use. Staff interviewed confirmed that R1’s portable oxygen cord was lost during the evacuation period. Staff stated that R1 was provide with a concentrator which was used in room and when R1 would go down for meals. R1’s facility records reviewed with staff revealed that R1’s assessments/care plan did not indicate that R1 is required 24-hour oxygen use. Staff could not confirm that R1 was monitored and ensured that when R1 left the room or went out of the facility was with oxygen. Based on the information obtained through record review and interviews; the allegations “Staff did not ensure resident had their oxygen when out of room and Staff did not safeguard resident's personal belongings”, is deemed substantiated at this time. On 02/19/2025, during a subsequent complaint visit for another complaint, LPA Chochian reviewed medication records and interviewed additional staff. Following is summary of the investigation: On 01/24/2025, From approximately 11am- 1:45pm LPA and Mrs. Alvarado toured the facility common areas and resident rooms. Interviews were conducted during the tour with 6 (six) randomly selected residents and 2 (two) other potential witnesses. Also during the tour LPA visited the medication room and reviewed random sample centrally stored medication records with staff. Residents interviewed reported no issues or concerns with receiving care services from staff. Resident expressed being satisfied with staff providing care and medication service. Resident #1 was out of the building during LPA’s visit therefore was unable to be interviewed at that time. LPA was able to communicate with resident #1 on 05/09/2025 however resident was not able to provide much information due to decline in health. Resident did express being satisfied with the staff at the facility. Resident was unable to recall the alleged incident related to medications being left in resident’s room. LPA conducted a sample review of the centrally stored medication records for the month of January 2025 and found no discrepancies at the time. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff are not checking on resident” and “Staff are mismanaging resident’s medication” is deemed unsubstantiated at this time. Exit interview held and copy of report provided.the state’s words, verbatim · CDSS document, May 18, 2025 · control 29-AS-20250117145754

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 30, 2025

Personal Rights of Residents in All Facilities To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on records review and interviews conducted, the licensee did not comply with the section cited above. R1 is to be on continous oxygen use. Staff did not ensure R1 was with oxygen when out the room from approximately 1/9/2025 to 1/17/2025.the state’s words, verbatim · CDSS document, May 18, 2025

Plan of correction: Executive Director shall provide a plan of correction on how they will maintain future compliance with Personal Rights of Residents.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 30, 2025

(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidence by: Based on interviews conducted, the licensee did not comply with the section cited above. R1's portable oxygen charging cord was missing/lost.the state’s words, verbatim · CDSS document, May 18, 2025

Plan of correction: Executive Director shall provide a plan of correction on how they will maintain future compliance with regards to safeguarding residents' personal property.

Allegation investigated: Staff do not administer resident's medications as prescribed.

Licensing Program Analysts (LPAs) Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:22 a.m., the LPAs met with staff and explained the reason for the visit. At 10:35 a.m., Executive Director (ED) Nancy Nelson met with the LPAs. During the initial visit conducted on 3/20/2024 between 9:50 a.m. and 5:10 p.m., LPA Peraldi and LPM Heffernan conducted a physical plant tour and conducted a review of medication, medication records, policy and procedures with medication technician. During today’s visit, the LPAs conducted a physical plant tour and conducted interviews with the ED, two (2) staff and four (4) residents. Between 12:50 p.m. and 1:22 p.m., the LPAs conducted a review of medication and medication documentation with medication technician for four (4) residents. The LPAs also obtained copies of pertinent documents on both visits. Continued on LIC 9099-C. Substantiated Regarding the allegation: Staff do not administer resident's medications as prescribed. On 03/19/2024, the Department received a complaint alleging staff not dispensing medications as prescribed to Resident #1 (R1). During the initial visit on 03/20/2024, starting at 2:16 p.m., LPA Peraldi conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #1’s medications, Amlodipoine 5MG tab quantity 90 (1 tablet by mouth once daily) and Oxybutynin ER 5MG tab quantity 88 (1 tablet by mouth once daily) both had the fill date of 12/14/2023 and were observed to have multiple tablets remaining. During the medication review, staff could not provide a start date. However, regardless of start date and based off the date filled, if staff assisted R1 with R1’s medication as prescribed, the medication should have been finished and new bottles ordered or filled. During today’s visit, the LPAs conducted a review of medication and medication documentation with medication technicians for four (4) residents and observed no errors. Based on medication review, observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff do not administer resident's medications as prescribed” is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 29-AS-20240319090812

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 10, 2025

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: The ED will submit a statement of understanding of the regulation and how they will continue follow their their medication procedures.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Quoc Huynh and Emily Peraldi arrived unannounced at 10:20AM for a Case Management Annual Continuation visit from 03/12/2025. The LPAs met with Executive Director (ED) Nancy Nelson and explained the reason for the visit. Entrance interview conducted. During the visit, LPAs conducted review of the following: RECORDS: Personnel records were reviewed at 11:00AM. The LPAs reviewed six personnel records for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, and first aid/CPR certification. Staff files reviewed were in compliance with regulation at this time. Resident records were reviewed at 11:55AM. The LPAs reviewed five files for, but not limited to admissions agreements, medical assessment, and updated appraisals. Resident records reviewed were in order at this time. At 12:30PM, the LPAs 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. The facility was observed to be in compliance at this time. Fire alarm/sprinkler system was last tested on 03/21/2025 by West Coast Fire with a follow up to be scheduled to close the inspection. Report Continued on LIC 809-C MEDICATION: Medication reviews occurred at 12:50PM (Memory Care unit) and 1:25PM (2nd floor Wellness Center). The LPAs reviewed medications for four residents during the visit. Medications are centrally stored and inaccessible to residents in the Wellness Center located on the second floor. Four out of four resident medications reviewed were documented and stored in compliance with regulation at this time. Four residents and two staff were interviewed. No complaints noted. No deficiency cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2025

Allegation investigated: Facility failed to seek timely medical attention for resident resulting in a questionable death. Staff inappropriately handled the residents resulting in bruising. Staff did not provide a resident care service as agreed. Residents sustained pressure injuries due to neglect. Resident fell due to staff neglect. Staff did not respond to a resident's calls for assistance. Staff violated residents’ personal rights. Facility retained a resident requiring a higher level of care.

Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to this facility today to deliver investigation finding. LPA met with Executive Director (ED) Nancy Nelson and explained the reason for the visit. On 03/04/2024, the Department received the above listed allegations with lack of pertinent information. On 03/07/2024, at approximately 8:30 a.m., LPA Chochian left voicemail message for the reporting party, however no return call was received. An email was also sent on 03/07/2024 to the reporting party and no response was received. Licensing Program Analyst (LPA) Zabel Chochian conducted the initial complaint visit on 03/07/2024 and met with the ED. Allegations were briefly discussed with ED. A toured of the facility was conducted at approximately 3:30pm to ensure there are no immediate health and safety concerns. Residents in “The Neighborhood” were unable to be interviewed due to lack of capacity. (Continue to LIC9099c) Unsubstantiated Staff was interviewed at approximately 4pm and facility records were reviewed. Additional attempts were made to reach the reporting party on 05/10/2024; 08/15/2024; 11/19/2024; and on 01/14/2025 but was unsuccessful. A subsequent visit was conducted on 02/19/2025, and interviews were conducted with six (6) staff from approximately 11:30am-3:00pm; additional records pertaining to former resident (R1) were requested and reviewed; interview conducted with potential witnesses. Following is a summary of the allegations and investigation finding: Regarding Allegation: Facility failed to seek timely medical attention for resident resulting in a questionable death. Information was provided that resident #1 (R1) was observed showing signs of a stroke on 01/09/2024 and facility did not seek timely medical attention for R1; resident passed away within 48 hours. No additional information was provided about the resident’s questionable death identifiers. Several attempts were made to reach the reporting party to obtain additional information however no response was received. To investigate the allegation, the LPA reviewed the Department’s database for Death Reports (LIC624 A). The LIC 624A report received in our office on 01/12/2024, indicate the manner of death to be of natural causes due to conditions contributing to death. Facility staff interviewed reported that R1 was not observed showing any signs of a stroke prior to death. R1 was admitted to Affinity Healthcare Resources on 12/30/2023. The hospice notes reflect that due to R1’s poor prognosis and declining condition, family wished to decrease hospitalization and treatment and opted for hospice care for palliative measures and symptom management. R1 was seen by the hospice nurse for routine skilled nursing and support services. Resident was placed on comfort care level of care for respiratory distress and pain; discharge summary obtained from Affinity Healthcare Resource noted resident #1’s terminal diagnosis of Athscl Heart disease of native coronary artery. On 01/11/2024, resident expired peacefully with hospice nurse and family at bedside; immediate cause of death documented as “cardiopulmonary arrest”. Based on the information obtained through record review and interviews; the allegations “Facility failed to seek timely medical attention for resident resulting in a questionable death”, is deemed Unsubstantiated at this time. (Continue to LIC9099c) Regarding allegations: 1) Staff inappropriately handled the residents resulting in bruising; 2) Staff did not provide a resident care service as agreed; 3) Residents sustained pressure injuries due to neglect; 4) Resident fell due to staff neglect; 5) Staff did not respond to a resident's calls for assistance; 6) Staff violated residents’ personal rights; 7) Facility retained a resident requiring a higher level of care. Reporting party was contacted several times to gather supporting information for these allegations and no response was received; no resident names or dates of alleged incidents was provided. To investigate these allegations LPA conducted interview with facility ED and staff; toured the memory care unit and assisted living side. Residents of the “Neighborhood” were unable to be interviewed due to lack of capacity. Random interviews were conducted with residents residing in the assisted living side and other potential witnesses; no mistreatment or neglect was reported. LPA also reviewed facility incident and death reports from 11/2023 – 1/2024; no discrepancies found. ED and Director of Resident Care Services stated that facility did not retain any resident requiring higher level of care; no resident retained with pressure injury greater than stage 2. Based on the information obtained through facility record review and interviews conducted allegations listed above are deemed Unsubstantiated at this time. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 29-AS-20240304152506

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Zabel Chochian arrived at this facility to conduct a required annual visit. At approximately 10:30 a.m., the LPA met with the Executive Director (ED), Nancy Nelson and reason for the visit was stated. Entrance checklist provided and reviewed with ED. Between 11:15 a.m. and 1:45 p.m., the LPA and the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floor. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all are appropriately furnished. All activity rooms and common spaces appeared clean and in good repair. A theater and salon are located on the third (3rd) floor. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 01/27/2025. Fire alarm/sprinkler system was tested last on 2/19/2024 and is scheduled for 3/24-25/2025. Resident Units: The LPA, and ED toured twelve (12) randomly selected rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The resident units and common area restrooms observed fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The water temperature was tested throughout the visit including resident unit restrooms and public restrooms; and water measured between 117.0– 120.2 degrees Fahrenheit. Throughout the resident room tours, LPA interviewed four (4) residents. Outside areas: There are multiple outdoor patios equipped with furniture for resident use as well as covered areas for resident use. The in-ground pool is appropriately fenced. (Continue to LIC809c). Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Sufficient snacks and beverages observed. Facility is also stocked with sufficient emergency food and water supply. A digital system is used to capture residents prescribed diets, allergies, and food preferences. Documentation obtained: Copy of the liability insurance, resident roster, staff roster (LIC500), Infection Control Plan, copy of menu, last dieticians report vehicle service record Emergency and Disaster Plan. Due to time constraints, the LPA will return at a later date to review staff and resident records including medication procedures and record keeping. No health and safety issues observed during today's visit. Exit interview conducted and copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

Allegation investigated: Staff did not meet a resident's laundry needs. Staff falsified a resident's care documents. Staff did not ensure that a resident's room was free of trash. Staff did not prevent residents' from playing in their feces.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial complaint visit was conducted on 03/05/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Director of Resident Care Services, Diana Alvarado . Entrance interview. During the initial visit on 03/05/2024, LPA Arroyo conducted a plant tour at 10:30AM, toured the Neighborhood (Memory Care) and observed five (5) random resident bedrooms starting at 10:33AM, conducted interviews with the ED, six (6) staff members, and three (3) residents between 9:55AM and 2:40PM, conducted a file review at 11:30AM, and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not meet a resident’s laundry needs and staff did not ensure that a resident’s room was free of trash. It was reported that a resident was wearing wet clothes, blankets appeared wet, and the laundry hamper was full of soaking wet clothes. Additionally, the wastebasket in the resident’s room bathroom was full and had not been emptied. During a walkthrough on 03/05/2024, the LPA observed five (5) random resident rooms in the Neighborhood. The rooms appeared relatively clean, linens were not soiled, or wet, dirty laundry was observed in the hamper, and trash cans were not overflowing. Record review and interviews conducted revealed that housekeeping is scheduled at least once a week for each bedroom in memory care. Staff members stated that they are assigned a group of residents to care for daily, and some of their duties include cleaning and maintaining the residents' rooms and doing their laundry. Staff also mentioned that resident bedding is typically changed every few days but will be changed sooner if needed. Interviews further revealed that staff are responsible for taking out the trash; however, any shift can handle taking out the trash as it is included in their assignments. Additionally, interviews with residents corroborated staff statements, as residents confirmed that staff maintain their rooms clean. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegations of “staff did not meet a resident’s laundry needs” and “staff did not ensure that a resident’s room was free of trash”. Therefore, these allegations are deemed Unsubstantiated at this time. It was also alleged that staff falsified a resident’s care documents. It was reported that staff are signing off on completing tasks and caring for residents needs when in fact they have not. Interviews with staff revealed that each team member is assigned specific duties to complete while caring for the residents on a daily basis. Staff sign off after each task is completed to inform the next shift about what still needs to be taken care of. During shift changes, staff typically communicate with one another about tasks that are still pending for the day. Staff mentioned that during crossover, they inform the incoming team if any laundry or cleaning is still required for their assigned residents. Additionally, staff reported that there have been no issues with other shifts failing to complete the tasks assigned to them. Based on interviews conducted with staff, the Department has insufficient evidence to support the allegation of “staff falsified a resident’s care documents”. Therefore, this allegation is deemed Unsubstantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was further alleged that staff did not prevent resident’s from playing in their feces. It was reported that due to lack of staff, residents were left unattended which resulted in residents playing in their feces. Interviews conducted with staff revealed that incontinent residents are typically changed every two (2) hours or sooner if needed. Staff stated that they have never witnessed or encountered any residents playing with their feces. However, there have been occasions when a resident has placed their hand in their pants, resulting in their hand being covered in feces. Despite this, staff have never observed the resident playing with or smearing the feces. Staff reported that they wash the resident's hands and change them, unless the situation is more severe, in which case they will give the resident a shower to ensure they are thoroughly cleaned. Based on interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not prevent resident’s from playing in their feces”. Therefore, this allegation is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. Report was reviewed and copy issued.the state’s words, verbatim · CDSS document, Jan 2, 2025 · control 29-AS-20240301140339

Allegation investigated: Staff not trained to meet residents’ incontinence needs. Staff inappropriately handle residents in care. Staff speak inappropriately to residents in care. Staff do not afford residents in care dignity and respect. Residents had unexplained bruises. Residents’ needs are not being met. Residents is not residing in an appropriate setting. Administrator does not have knowledge of applicable laws and/or regulations.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced complaint investigation visit at the facility to investigate the allegations listed above. LPA Urena met with Nancy Nelson, Executive Director (ED) at 1:45 p.m., and explained the reason for the visit. On 06/16/2023, Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial complaint inspection at the facility today regarding the above allegations. The LPA met with Administrator Nancy Nelson at 12:19 PM and explained the reason for the inspection. Continues on LIC 9099 (pg.2) Unsubstantiated Pg. 2 Staff not trained to meet residents’ incontinence needs. On the allegation that staff are not trained to meet residents’ incontinent needs; it is the concern of the reporting party (RP) that the staff force residents when addressing incontinence needs. On 06/16/2023, LPA Lopez interviewed the RP, and the RP stated that staff and administrator said it’s okay to hold down, or force residents when assisting with incontinence needs. On 08/08/2024, LPA Urena interviewed Nancy Nelson, Executive Director (ED) at 1:45 p.m. Per the ED, the staff receive training on how to address incontinence needs for residents with dementia. It is part of the initial training staff receive. The training is an on-line training (Total Incontinence Management Program (TIM)). Caregivers watch all training videos prior to this validation process. Once caregivers successfully complete the validation checklist, they will then complete a final exam to become TIM certified. The ED denied making such comments. The LPA reviewed training records for five facility staff, and the record review revealed that staff successfully completed incontinent training. Furthermore, the LPA interviewed staff about the process of assisting residents who resist incontinence care. The interviews revealed that the staff may try different techniques to engage the residents to agree to the incontinent care. The staff may distract the residents with questions, or by showing them items that may attract the resident, or ask another staff to assist, “sometimes, a different face, or voice may get the resident to cooperate”. The staff stated that they check residents every two hours and change the diapers as needed. Staff denied forcing or holding down residents while addressing incontinence needs. Although the allegation may have happened or is valid, based on the interviews and record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Continues on LIC 9099 (Pg. 3) (Pg. 3) Staff inappropriately handle residents in care. On the allegation that staff inappropriately handle residents in care; it is the concern of the reporting party (RP) that facility staff force or hold down the residents’ arms while changing their clothing. On 06/16/2023, LPA Lopez interviewed the RP, and the RP stated that staff and administrative stated it’s okay to hold down, or force residents because residents have ‘dementia’. On 08/08/2024, LPA Urena interviewed Nancy Nelson, Executive Director (ED) at 1:45 p.m. Per the ED, the staff learn techniques on how to address residents’ behavior, condition, and to treat residents with respect and dignity, as part of their on-line training. LPA Urena reviewed staff training records, and record review revealed that staff receive training that follows departments regulations. Furthermore, the facility has a skill validation process/checklist, which includes new staff being observed and graded by a designated experienced facility staff. The new staff must follow and complete all tasks in the five (5) page checklist to pass the probationary period. LPA Urena interviewed staff about the process of assisting residents in the memory care unit. The interviews revealed that the staff may try different techniques to engage the residents to agree to the care provided. The staff may distract the residents with questions, or by showing them items that may attract the resident, or ask another staff to assist, “sometimes, a different face, or voice may get the resident to cooperate”. Staff denied using force while assisting residents with dressing. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Staff speak inappropriately to residents in care. On the allegation that staff speak inappropriately to residents in care, it is the concern of the RP that staff violate residents’ personal rights by using inappropriate language, while assisting residents with ADL needs. LPA Urena was unable to interview S1 and S3 as they no longer work for the facility. The LPA interviewed S4 about the allegation and S4 denied speaking in an unrespectful way to residents. The LPA interviewed S2 about witnessing inappropriate language used by other staff, and S2 denied witnessing inappropriate behavior. The LPA interviewed the ED about the concerns with staff’s inappropriate behavior, and the ED stated that if staff is reported to them the concerns are sent to the Human Resources Department and addressed accordingly. Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Continues on pg. 4 Pg. 4 Staff do not afford residents in care dignity and respect. On the allegation that staff do not afford residents in care dignity and respect, it is the concern of the RP that staff (S3) use negative reinforcement techniques to get residents to comply with the staff’s commands, consequently, disrespecting the residents in care. On 06/12/2023, LPA Lopez interviewed the RP, and the RP said they told the ED about the negative reinforcement techniques, and the ED said it was just a joke and the RP wouldn't understand. LPA Urena interviewed the ED about the comments made to the RP, and the ED denied the comments. LPA Urena was unable to interview S3 as the staff is no longer employed by the facility. Although the allegation may have happened or is valid, based on the interviews, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Residents had unexplained bruises. On the allegation that residents had unexplained bruises, it is the concern of the RP that they do not think the bruises observed on residents’ arms and legs are from a fall, but rather from staff being rough with the residents. On 06/12/2023, LPA Lopez met with Interim Director of Nursing (DN) Zara Khatchetarian during record review. The DN said all five residents’ records reviewed use "Safely You". DN said only R2 and R3 had reported falls from Safely You during the month of May. The notes from the falls are documented in the nurses’ notes. R2 had a recorded fall on 05/23/2023 but there was no injury. R3 had a recorded fall on 05/28/23 but R3 was only observed sitting on the floor and there was no actual fall. And on 05/31/2023, R3 was found with agitation and with a skin tear. Although, nursing notes reflect no fall for R2 on 05/23/2023 or for R3 on 05/28/2023. LPA Urena was unable to interview the DN, as they are no longer employed at the facility. Although the allegation may have happened or is valid, based on the interviews, observation, record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Continues pg. 5 Pg. 5 Residents’ needs are not being met. On the allegation that Residents’ needs are not being met. It is the concern of the RP that a resident’s (R4) urine bag was not emptied because staff said they were not trained on how to do it. On 06/12/2023, LPA Lopez, interviewed the RP, and they said that Assisted Living (AL) staff S2 was working in memory care and did not empty a resident’s urine bag, because they were not trained on how to do it. On 08/08/2024, LPA Urena interviewed S2 regarding the training received for catheter care. The S2 stated that they had received training on how to ensure good hygiene and changing/emptying with various catheter types. Furthermore, LPA Urena reviewed training records for S2. The record review revealed that S2 had received training and had passed the Competency Skill Validation test on 04/06/2023. Based on the information obtained through interviews and record review, the facility provided training to S2 on the process for catheter and urine bag care. Therefore, the allegation is deemed Unsubstantiated at this time. Resident is not residing in an appropriate setting. On the allegation that a Resident is not residing in an appropriate setting, the concern of the RP is that R1 was moved from AL to the memory care and the RP does not think R1 belongs in MC. RP said the resident is cognitive and independent with their ADLs. To investigate the allegation, LPA Urena reviewed R1’s medical records, and emails and communication between the ED and R1’s POAs. Medical records indicate that R1 was diagnosed in 2021 with mild cognitive impairment and by 2023 R1 was diagnosed with Alzheimer’s. LPA Urena interviewed the ED, and the ED, stated that R1 began to show signs of decline in mental alertness. Furthermore, the ED stated that a clinical test, the Montreal Cognitive Assessment (MoCA) was administered to R1. The results of the test showed a dramatic decline between 04/26/2021 and 01/11/2022. The concerns for R1 were brought up to R1’s POAs. The ED began communication with R1’s POAs about moving R1 from the Assisted Living (AL) to the Memory Care (MC), started via email on May 3, 2023. In the email, the ED expresses concern for R1’s decline and offers the possibility of moving R1 to the MC. The POAs agreed the move for R1 from the ALC to the MCU approximately on May 22, 2023. Although, in June 2023, communication between the POA (and the facility Activities and Memory Care Specialist) states the concern for R1 is to continue to attend as many activities as R1 is interested in attending in the AL (with assistance from a private caregiver), as agreed in communication with the ED. Based on the information obtained through record review and interview, R1’s POAs agreed to have R1 transferred from the AL to the MC. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg. 6 Pg. 6 Administrator does not have knowledge of applicable laws and/or regulations. On the allegation that the Administrator does not have knowledge of applicable laws and regulations, the concern of the RP, is that the ED stated that caregivers/staff are not mandated reporters. LPA Urena conducted record review to verify the ED’s certification is valid and up to date, and the record review revealed that the ED completed the Residential Care for the Elderly Administrator Certification Program, which was valid Effective: 06/18/2022, with an Expiration Date of: 06/17/2024. The LPA interviewed the ED about their knowledge of the mandated reporter’s role, and about anyone with knowledge of abuse towards the elderly. The ED stated that they understood that anyone can make a report to the CCLD department, and do not necessarily have to be a mandated reporter. The ED denied making statements about staff/caregivers not being mandated reporters. The LPA interviewed staff about their knowledge of making reports to the CCLD department if they observe any type of abuse towards the residents, and staff stated that they were aware of the hotline to make reports if they saw any unprofessional behavior or any type of abuse. Based on the information obtained through record review and interviews, there is not sufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, and a copy of the report was issued. Residents are not receiving assistance timely. On the allegation that residents are not receiving assistance timely, it is the concern of the RP that residents are not receiving assistance right away due to a lack of keys available for staff to use to access the residents’ rooms, consequently residents can be heard calling staff for assistance, but staff cannot get to them due to not having access to a set of keys, staff with keys leaving the facility premises, and not leaving the keys for the standing staff. On 06/16/2023, LPA Lopez interviewed the ED, who confirmed all resident doors in AL and Memory care lock automatically from the outside, but residents are able to get out from the inside. During the physical plant tour, LPA Lopez tested a room and was able to exit the room from the inside. A key is currently needed to unlock the door from the outside. LPA Lopez inquired how staff obtain a key when coming on shift. The ED said that during staff’s shift change, they should be giving their key to the incoming shift, but recently learned that some staff are keeping their keys and taking them home. The ED said every caregiver should have a key, except when the staff is in training. Nelson said the Med techs also have a set a keys to the resident rooms. On 06/12/2023, LPA Lopez interviewed S5 and said they work the NOC shift and the staff from the prior shift would not provide S5 with a set a keys for the residents’ bedrooms and would say it's not their problem. S5 said when they come on shift, the second person is always late leaving S5 with no access to the resident rooms. On 11/21/2024, LPA Urena reviewed communication between staff members S4 and S5, and the communication revealed that S5 continuously reached out to S4 for the set of keys, since S4 had left the facility premises with the set of keys to the residents’ rooms, consequently S5 could not get into the residents’ rooms. LPA Urena was unable to reach S4 for an interview. At the time of LPA Urena’s initial visit to the facility on 08/06/2024, a FOB key system was in place. The system is an electronic key assigned to every staff member as well to residents, to facilitate entry to their rooms. Based on interviews and notes review, S5 was left without a set of residents’ room keys to be able to reach the residents as needed for care and supervision in a timely manner. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted, and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 29-AS-20230612083135

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 20, 2024

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews, and records review, the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner due to staff lacking room’s keys to access residents, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: The deficiency has been cleared due to new FOB key system, which ensures all staff have a key to access residents in their rooms.

Allegation investigated: Facility illegally evicted a resident in care. Facility did not issue a refund to a resident in care.

On 10/24/2024, Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation visit to deliver final findings for the above allegations. During this visit, LPA met with Executive Director (ED) Nancy Nelson and explained the reason for the visit. On the allegation: Facility illegally evicted a resident in care. It is alleged that after Resident #1 (R1) was physically combative with staff due to R1’s cognitive decline, they were taken to a Psychiatric hospital beginning 01/28/2024. After being at the psychiatric hospital for a few days, R1’s responsible party was contacted by the facility who stated that after evaluation/reappraisal of R1, they could not return to the facility. R1’s responsible party moved their belongings out of the facility on 02/25/2024 and notified the ED. According to the allegation, the facility never provided an eviction notice to R1 and/or their responsible party. Report Continued on LIC 9099-C Unsubstantiated On 04/03/2024, LPA Chochian conducted a complaint investigation visit to the facility above from 10:00am to 11:00am. During this visit, LPA requested and received relevant documentation pertinent to the complaint allegation for record review. LPA Brian Phillips reviewed the documentation. R1’s physician report states that R1 has a primary diagnosis of Alzheimer’s dementia including the loss of cognitive functions. The documented secondary diagnosis for R1 is atypical depressive disorder with negative mood changes due to changing environments. Medical admission assessments by the facility documented that R1 was forgetful/confused with mood/personality changes. The facility admission agreement was signed and dated by the responsible party of R1 on 07/29/2022 prior to R1’s move in date of 07/31/2022. This admission agreement states that the facility can terminate the agreement upon thirty (30) days written and verbal notice to the resident/responsible party if it is determined that the resident has a need not previously identified and a reappraisal has been conducted with the determination that the facility is no longer appropriate. The admission agreement states that the facility is not designed or licensed to provide higher levels of care for serious mental or emotional disorders. If it is determined a resident is a danger to themselves or others and it is inappropriate for a resident remain in their apartment, then they will be asked to leave the facility and the admission agreement will terminate. The facility may discharge a resident if they present an immediate physical threat or danger to themselves or others. A resident may also be discharged if their dementia/mental disorder results in ongoing behavior that requires care and supervision greater than the facility can provide. Interview and documentation provided by Executive Director revealed that on 01/25/2024 the facility held a meeting with R1’s family to discuss R1’s changes in behaviors and possible evaluation for R1’s changing medical condition. R1’s doctor then ordered R1 to be admitted to a psychiatric hospital for further evaluation. On 01/28/2024, R1’s family, who had been in communication with R1’s doctors, indicated a bed was open in the hospital unit and R1’s family took R1 to the psychiatric hospital for a 14-day time period. All licensing agency interviews with facility staff and the responsible party of R1 indicated that the resident would not be returning to the facility after R1 was evaluated/reappraised while in the psychiatric hospital. Although Reporting Party indicated it was the facility that did not allow the resident to return, the Executive Director provided documentation and notes indicating the hospital social worker suggested to R1’s family discharging R1 to a Skilled Nursing Facility (SNF) for further medication adjustments with a doctor onsite. On February 10, 2024, R1’s family member verbally told the facility R1 would likely not be returning to the facility. R1’s family member then began removing R1’s personal belongings from the facility on 02/20/2024. R1’s family member reported to the facility on 02/23/2024 that R1 was discharged to a SNF. On 02/29/2024, R1’s family Report Continued on LIC 9099-C member confirmed R1’s room at the facility was fully vacated, thus terminating the residency contract. Although R1 did not return to the facility following a stay at the psychiatric hospital, it is unclear whether the facility refused the resident to return or if the family and/or hospital social worker made the decision for R1 not to return. R1 was discharged to a SNF, which is a level of care the facility cannot provide per Title 22 regulations. Based on the information gathered, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility illegally evicted a resident in care” is deemed UNSUBSTANTIATED at this time. On the allegation: Facility did not issue a refund to a resident in care. It is alleged that R1 had their personal belongings removed from the facility on 02/25/2024 after being in a psychiatric hospital beginning on 01/28/2024. The allegation requests a refund for the days R1 was out of the facility from 01/28/2024 to 02/25/2024, with the resident not returning to the facility. LPA requested and received a copy of the documented facility residence and services agreement/admission agreement. The facility admission agreement was signed and dated by the responsible party of R1 on 07/29/2022. The facility admission agreement has a refund policy regarding the vacating of an apartment, and the refund of unused portion of monthly fee. The monthly fee is defined in the admission agreement as total combination fee of apartment fees and service plan fees. Supplemental support services/additional services are offered for an additional fee. According to the facility admission agreement signed/dated by the responsible party of R1, the facility fees did not include any additional/supplemental support services for R1 while in care. The monthly fee charged to R1 was the combined apartment fee and the service plan fee. If the admission agreement is terminated, the resident must vacate the apartment and remove all property from it. The resident or their responsible party will remain liable for the monthly fee until the effective termination date and all the resident’s property is removed from their apartment, whichever occurs later. The facility may also charge a resident a property storage fee if they fail to remove their personal belongings by the effective termination date. Following the termination of the admission agreement, the facility will pay the resident or their responsible party a refund equal to any amount owed, minus certain conditions including any expenses incurred to store resident’s property that was not removed upon vacating the apartment. According to the facility admission agreement, R1 is liable for the monthly facility fee until all R1’s property is removed from Report Continued on LIC 9099-C their apartment, as that occurred later than the effective termination date. All licensing agency interviews with facility staff and the responsible party of R1 indicated that the resident would not be returning to the facility following R1's stay in a psychiatric hospital beginning on 01/28/2024, but R1’s property was not removed from the facility until 02/25/2024 by their responsible party, who then notified the facility on 02/29/2024 that all R1’s personal belongings were out of their apartment. Therefore, R1’s responsible party is liable for R1’s monthly fee until 02/29/2024 and the facility is not required to issue a refund for the days R1 was out of the facility from 01/28/2024 to the date R1's belongings were removed. However, LPA Dulek was informed during the subsequent complaint visit that the facility chose to issue a refund to R1's responsible party, which was issued sometime toward the end April or beginning of May 2024. Based on the information gathered, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation “facility did not issue a refund to a resident in care” is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. Copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 29-AS-20240325102029

Allegation investigated: Staff are forcing residents into the shower while in care

Licensing Program Analyst (LPA) Valeria Conway made a subsequent complaint visit to facility to deliver complaint findings. Administrator was unavailable during today's visit, but authorized Diana Alvarado, Director of Resident Care Services to sign today's reports. LPA explained the purpose of the visit. Entrance interview conducted. It was alleged that staff are forcing residents into the shower. It was further reported that staff are forced residents into the shower even if the resident screams or refuses. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 On 02/08/2024, LPAs V. Conway and K. Dulek conducted an initial 10-day visit. During the visit, LPAs conducted a tour of the physical plant at 10:15 A.M. LPAs also conducted interviews with Administrator, staff, and several residents between 10:15 A.M. to 11:20 P.M and obtained pertinent documents relevant to the investigation. On 08/28/2024, LPA V. Conway interviewed a random number of residents and staff. Additionally, LPA attempted to contact the Reporting Party (RP) on 02/06/2024, 02/07/24 and on 08/24/2024, however, was not successful. Information gathered during the course of the investigation reflected staff do not force residents into taking showers. If a resident does not want to shower, staff will try to verbally convince them by explaining how beneficial it is to get their bodies clean. Additionally, staff stated that they are aware of the residents’ personal right to refuse and if the resident does refuse, staff will notate the refusal on the daily staff notes and then inform Med-Techs/Director of Nursing. The Director of Nursing will then in return notify the residents responsible party and the primary care physician (PCP). Interviews with residents revealed that they are well taken care of and had no concerns. Furthermore, residents stated that no staff try to make them do things against their will. Record review of the facility shower schedule consisted of a schedule for each resident and a bath/shower monitoring form that staff use to document when a resident refuses a shower or bath. Based on the information gathered during the course of the investigation, the Department does not have sufficient evidence to support the allegation, therefore the allegation "Staff are forcing residents into the shower while in care" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 29-AS-20240201230214

Allegation investigated: Staff did not ensure resident was adequately fed

Licensing Program Analyst (LPA) Valeria Conway made a subsequent complaint visit to facility to deliver complaint findings. Administrator was unavailable during today's visit, but authorized Diana Alvarado, Director of Resident Care Services to sign today's reports. LPA explained the purpose of the visit. Entrance interview conducted. It was alleged that the staff did not ensure resident was adequately fed, as it was reported that staff did not ensure meals were delivered to Resident #1 (R1) for several days following a physicians change in the residents dietary order. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 On 02/27/2024, LPAs V. Conway and M. Arroyo conducted an initial 10-day visit. During today’s visit, the LPAs conducted a physical plant tour to ensure there are no immediate health and safety concerns at 10:58 a.m. At 11:10 a.m., the LPAs toured the Memory Care unit and observed random resident bedrooms.Between 10:20 a.m. and 2:15 p.m., the LPAs conducted interviews with the ED, three (3) staff, five (5) residents including R1, and two (2) private caregivers (PCG). At 11:48 a.m., the LPAs also conducted a resident file review and obtained copies of pertinent documents relevant to the investigation. Additionally, on 08/28/2024, LPA Conway conducted additional interviews with random staff, and hospice agency staff that were providing services to R1. Interviews conducted revealed that facility staff consistently deliver pureed food to R1. However, R1 has been refusing the meals. Interviews with hospice agency staff reflected that a new order for pureed food and nutritional drinks were sent over for R1 on 08/25/2023. On 08/26/2023, Hospice agency staff contacted the facility staff to ensure that the new dietary orders were been followed. Facility staff confirmed new orders and informed hospice staff that R1 also refused to eat the pureed food. On 08/29/2023, hospice nurse met with R1 who expressed that they did not want to eat the provided food. Hospice physician ordered nutritional drinks for R1 to ensure they receive an adequate source of nutrients during this time. This measure was intended to support R1’s nutritional needs as pat of their care plan. Moreover, information gathered during the course of the investigation reflected that for those residents that are unable to go to the dining room, staff deliver their meals directly to the residents’ rooms three (3) times a day. Additionally, all employees have access to a board in the kitchen displaying a list of residents’ names, along with their special diets, food allergies and unit numbers. ED stated that as soon the facility receives a new physicians order for a special diet, management immediately communicate those changes to the chef, who promptly updates the meals served to the resident. Based on information gathered, the Department does not have sufficient evidence to determine that the R1 was not adequately fed. Therefore, the above allegation “staff did not ensure resident was adequately fed" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 29-AS-20240220152012

Allegation investigated: Neglect/Lack of Supervision – Resident #1 (R1) suffered multiple falls resulting in injuries Staff did not ensure that resident’s medication(s) were ordered in a timely manner Staff did not reassess resident as necessary

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Executive Director Nancy Nelson and explained the reason for the visit. On 02/14/2024, the Department received a complaint of neglect/lack of supervision. Resident #1 (R1) suffered multiple falls resulting in injuries. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Peter Zertuche. On 02/15/2024, from 10:30 a.m. to 1:30 p.m., LPA Balisi conducted an unannounced initial complaint visit. Upon arrival LPA Balisi met with executive director/administrator Nancy Nelson and explained the reason for the visit. At approximately 11:00 a.m. the LPA toured the physical plant, interviewed staff, and reviewed and obtained copies of pertinent documentation relevant to the investigation. Substantiated continued from 9099 On 02/27/2024, at approximately 9:30 a.m., Investigator Zertuche conducted interviews with R1’s resident representative; on 03/28/2024, from approximately 8:30 a.m. to 10:00 a.m., with the Residential Care Director and staff; on 04/24/2024, at approximately 12:30 p.m., with R1’s resident representative; and on 05/15/2024, at approximately 4:30 p.m., with R1’s Primary Care Physician. In addition, the investigator reviewed West Hills Hospital medical records, and other facility file documents related to R1. According to the facility file documents reviewed, R1 was admitted to the facility on 09/08/2020. R1’s physician's report, dated 08/03/2023, showed a diagnosis of cerebral infarction (stroke) as well as seizure disorder and depression. R1 was listed as non-ambulatory due to physical condition. A physician's report, dated 08/14/2020, was similar except that R1 had the capacity for self-care such as bathing and grooming self. There were two incident reports included, dated 11/10/2021, where R1 sustained a fall and injured their hand. The second incident occurred on 07/30/2023 where R1 was found on the floor after an unobserved fall sustaining facial swelling and skin tears to chin. Facility notes indicated R1 had various additional unwitnessed falls on 05/10/2021, 02/25/2022 (returned from ER with cast- no further information), 09/06/2022, 12/22/2022, 01/24/2023, 02/08/2023, 03/28/2023, 04/04/2023, 06/15/2023, 07/01/2023. According to the facility's service agreement, they are to regularly assess residents to assure they are receiving care and services appropriate to their needs. There were several assessments included with the documentation from October 2020 to February 2024 documenting R1 as a fall risk and is to be checked during each shift with the last assessment stating, "fall risk - safety room checks with increased frequency due to fall risk." There was a fall risk assessment in R1’s file but it was blank. Due to the numerous falls, a private caregiver was provided by R1’s resident representatives. A review of the West Hills Hospital medical records revealed there were numerous visits to the hospital for R1 due to unwitnessed falls where R1 sustained several injuries to the head, arms, legs, and chin along with fractures to the ribs and wrist occurring between June 2021 and July 2023. There were also a couple of visits regarding seizures, altered mental status and weakness. Many of the visit notes showed R1 was unable to communicate listing R1 as being confused and several notes indicated there was no report of abuse or neglect. Continued from 9099-C On the allegation “Neglect/Lack of Supervision – Resident #1 (R1) suffered multiple falls resulting in injuries” – Medical and facility records show that R1 sustained at least 12 falls over a two-year period, mostly unwitnessed, sustaining numerous injuries. Most of the falls were sustained in the last six months where R1 fell at least seven times prior to going on hospice care. Staff members reported R1 was independent but had increased supervision due to the falls. However, R1 continued to fall. R1’s family reported the facility's care was insufficient, so they hired a private caregiver after the last fall stating staff members rarely checked on R1 when they were visiting. Based on the evidence of at least seven falls in a short time, it appears as if R1 required a higher level of care that the facility did not provide, resulting in sufficient evidence to substantiate neglect/lack of supervision. Therefore, the allegation is deemed substantiated at this time. It was additionally reported that "Staff did not ensure that resident's medication(s) were ordered in a timely manner" as it was alleged that R1 did not get medication(s) administered on 12/30/2023 due to medications not being ordered. Interviews conducted and records review revealed the following medications were not delivered in time for R1's PM dosing: Amlodipine 2.5mg, Docusate Sodium 100 mg, Losartan 25 mg, Melatonin 5 mg, Metroprolol Tartrate 50 mg and Mirtazapine 15 mg. LPA's Interview with Kelly Penrose, LVN Director of Resident Care Services further revealed that medications are typically ordered seven (7) days out , but staff could not confirm why the medication did not arrive as scheduled at this time, Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegations occurred. Therefore, the allegations that “Staff did not ensure that resident's medication(s) were ordered in a timely manner” has been deemed Substantiated at this time. It was reported that "Staff did not reassess resident as necessary" as it was alleged that R1 was never reassessed after having multiple falls. LPA's records review of daily nurse logs revealed R1 sustained eight (8) falls on the following dates: 05/10/2021, 11/10/2021, 09/06/2022, 01/04/2023, 01/24/2023, 04/04/2023, 06/15/2023, and 07/11/2023. LPA's records review of reappraisals revealed that re-appraisals were only conducted two (2) times after R1 fell on 09/06/2022 and 04/04/2023. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegations occurred. Therefore, the allegations that “Staff did not reassess resident as necessary" has been deemed Substantiated at this time. Continued from 9099-C A $500 immediate civil penalty is assessed today. The Executive Director was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued It was reported that "Staff did not provide assistance to resident in a timely manner" as it was alleged that staff were not responding to R1's call button in a timely manner and did not provide oxygen treatment as prescribed. LPA's interviews conducted with seven (7) residents revealed that all (7) have typically had to wait approx. 5 to 10 mins when requesting assistance from staff. Interviews with residents further revealed they did not express any potential or immediate concerns that staff would not provide assistance in a timely manner. Interviews conducted with ten (10) staff revealed that when residents call for assistance they typically attempt to service resident within five (5) minutes. If it ever gets to a wait time of ten (10 ) mins there are alarms located at the concierge desk and the medication room that signals when a resident has waited (10) minutes and staff are alerted to get to that resident right away. In addition all (10) staff have never observed any resident not receive their oxygen treatment as prescribed. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not provide assistance to resident in a timely manner"” is deemed Unsubstantiated at this time. It was reported that "Facility charged resident for services not rendered" as it was alleged that R1 was signed up for "Enhanced Personal Care II" , but services were not provided. Interviews conducted and records review reflected that a reassessment was conducted on 08/03/2023 and facility staff notified the family / responsible party of R1 to sign R1 up for "Enhanced Personal Care II", which included bathing or transfer assistance by (2) staff member, feeding assistance by one staff member, assistance with changing continence products and any service included in "Enhanced Personal Care I (Hands-on assistance with showering four or more times per week, transfer assistance by one staff member, assistance with changing continence products and any service included in basic personal care). The Enhanced Personal Care II services began on approx. 08/30/2023. Interviews conducted with ten (10) staff revealed that part of their protocol is to check on each resident in their assignment at the start of their shift. For the morning shift, this involves aiding with brushing their teeth, toileting, getting dressed then assist to dining room if the resident would like to eat. Throughout the day residents are checked at least every 2 hours and upon request. Residents are typically showered at least twice a week, but depending on their care plan some residents may also get showered every day. continued from 9099-C Further interviews conducted with the (10) staff confirmed they have never observed a resident who required incontinent care, showering assistance, feeding assistance, two-person assistance, or checks every two hours not receiving those services. Interviews with private caregivers who began serving R1 in August 2023 revealed that they have never seen facility staff fail to provide showering assistance, feeding assistance, two-person assistance, or checks every two hours. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Facility charged resident for services not rendered” is deemed Unsubstantiated at this time. It was reported that "Staff did not ensure that Residents were supplied with a call pendant while in care," as it was alleged that R1 did not have a call pendant due to a shortage of items. Interviews conducted and records review revealed R1 received a new pendant on 09/15/2020. Interviews conducted with ten(10) staff revealed that all (10) have always observed R1 with a pendant. Furthermore each staff interviewed do not recall a time when it was mentioned to family, residents or other staff that there was a national pendant shortage. In addition, LPAs interview with the private caregivers revealed they have always observed R1 to be in possession of a pendant. LPA's interview with seven (7) residents revealed that one (1) out of seven (7) residents uses a pendant. In the event of an emergency, the other six (6) residents stated they would use one of the multiple pull cords in the room. In addition all (7) residents interviewed do not recall of hearing about a national pendant shortage from staff and all did not express any potential or immediate concerns of not being able to obtain a pendant upon request. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure that Residents were supplied with a call pendant while in care” is deemed Unsubstantiated at this time. Continued from 9099-C It was reported that “Staff do not assist with residents' incontinence needs as necessary” as it was alleged that R1 is not being changed in a timely manner. Interviews conducted with ten (10) staff revealed that residents are checked before the start of every shift and at least every two (2) hours throughout their shift. Eight (8) out of the (10) staff interviewed stated they have never observed a resident to be heavily soiled. Two (2) out of the (10) staff stated that they have observed some residents heavily soiled, but it is unclear if it was due to being soiled for a long time or if the resident had a heavy bowel / bladder moment. Interviews conducted with private caregivers revealed they have not never observed R1 to be severely soiled due to not being changed in a timely manner, however they have observed R1 heavily soiled due to a heavy bladder movement. Furthermore, the private caregiver did not express any potential or immediate concerns that facility staff would not provide incontinence service in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not assist with residents' incontinence needs as necessary” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 29-AS-20240214112429

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 30, 2024

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Due to a lack of supervision, R1 sustained multiple falls resulting in multiple injuries, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee agreed to submit a plan on how they will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL via e-mail by COB 08/30/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 30, 2024

Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 did not receive their prescribed medications on 12/30/23,which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The Licensee has agreed to review regulation cited and submit a statement of understanding to CCL via email by COB 08/30/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a)(3) · Plan of correction due date: Sep 6, 2024

Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as R1 was observed to have sustained (8) falls and a reappraisal was only conducted (2) times. This poses / posed a potential health, safety and personal right rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding to LPA via email by COB 09/06/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240214112429). LPA met with Executive Director Nancy Nelson and explained the reason for the visit. During the Department’s investigation of complaint # 29-AS-20240214112429, the following deficiencies were observed: A review of the facility notes revealed that on several dates (11/10/2021, 12/22/2022, 02/25/2022, 02/08/2023, 03/28/2023, and 04/04/2023) Resident #1 (R1) had unwitnessed falls which required visits to the Emergency Room. There were no incident reports submitted to Community Care Licensing (CCL) for the dates noted. On 07/30/2023, after an unwitnessed fall in the bathroom, R1 suffered facial swelling on the right side and a skin tear to chin and was admitted to the hospital. R1 was placed on Affinity hospice and discharged back to the facility. The facility did not submit a hospice notification to CCL. Citations issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Aug 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(B) · Plan of correction due date: Sep 6, 2024

(a) Each licensee shall furnish to the licensing agency...(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit incident reports for R1’s numerous unwitnessed falls which required hospital visits, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The licensee will submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL via email by 09/06/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632(d)(2) · Plan of correction due date: Sep 6, 2024

The licensee shall notify the Department in writing within five working days... name and date of admission to the facility and the name and address of the hospice.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit hospice notification to CCL when R1 was placed on hospice 07/30/2023, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The licensee will submit a plan describing how you will ensure the Department receives hospice notifications. Submit proof to CCL via email by COB 09/06/2024

Allegation investigated: Resident sustained unexplained bruises

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegation listed above. LPA arrived at the facility at 02:05PM and was greeted by the concierge. LPA met with Executive Director (ED) Nancy Nelson at 02:13PM. Entrance interview conducted. During today's visit, LPA interviewed staff between 02:22PM and 03:00PM. During an initial complaint visit which took place on 01/30/2024, LPA interviewed facility management at 09:26AM, toured the facility with Executive Director and Director of Resident Care Services at 11:42AM. No immediate health and safety hazards were observed during facility tour. LPA obtained copies of documents pertinent to the investigation. During an unrelated complaint investigation on 02/08/2024, LPA conducted resident interviews and discussed Resident #1 (R1) who is named in the complaint with the ED and Director of Resident Care Services. Throughout the course of the investigation, LPA reviewed pertinent documents. The following was then determined: Continued on LIC 9099-C Unsubstantiated The complaint alleges that R1 sustained unexplained bruising while at the facility. Record review revealed that R1 had a diagnosis of dementia and resided in the facility's memory care unit. While residing at the facility, staff indicated that R1's dementia progressed and that R1's behaviors escalated. R1 became difficult to care for, as R1 became more aggressive with staff and refused care. Nurse's notes reviewed indicated R1 had an unwitnessed fall on 01/12/2024, which resulted in staff calling 9-1-1 and obtaining outside medical treatment for R1. Staff interviewed indicated that R1 was aggressive when EMTs arrived to take R1 to the hospital. R1 was large in stature and that 4 EMTs were observed holding R1 to the gurney while taking R1 out of the facility. Resident returned from the hospital the same day with no known injuries noted. On 01/16/2024 and 01/17/2024, bruising was noted on R1's forehead, nose and under eye. Staff notes indicate family was informed of the noted bruising. On 01/19/2024, additional bruising was noted on R1's arms, hip and back and R1 was taken to urgent care for observation of the bruising. Text messages between facility and PCP were provided to LPA indicating the bruising and request for outside medical treatment. Staff interviewed indicated that at the time of the allegation, R1 had increasing paranoia and possible hallucinations. R1 reported not trusting care staff and refused full body showering. Therefore, staff was unable to clearly observe R1 for physical changes or bruising timely, as R1 refused observation. As R1 refused observation and a full body check for injuries, it is difficult to ascertain when the bruising occurred and whether the resident was present at the facility during the time of the alleged bruising. Additionally, as the bruising was noted but of unknown origin, there is no way of knowing how the bruising occurred and whether it was a result of a lack of care and supervision at the facility. Both residents and staff interviewed indicated they have never heard of or observed any staff being rough with the residents and residents feel safe at the facility. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore the allegation "resident sustained unexplained bruising" is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 29-AS-20240123152644

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Emily Peraldi and Licensing Program Manager (LPM) Kristin Heffernan arrived at the facility unannounced to conduct a required annual visit. At 9:50 a.m., the LPA was greeted by staff. At 9:58 a.m., the LPA met with the Executive Director (ED), Nancy Nelson and explained the reason for the visit. Between 10:57 a.m. and 12:46 p.m., the LPA and LPM along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The facility is a three (3) story building. Resident rooms are located throughout three floors. The neighborhood (memory care unit) is located on the first (1st) floor; Circle of Friends units and assisted living units are located on the second (2nd) and third (3rd) floor. Common spaces on the first floor include the reception area/lobby, bistro, dining room, and fitness room. The remaining floors each have their common spaces for activities, and all have appropriate furniture. All activity rooms and common spaces appeared clean and in good repair. A theater and salon are located on the third floor. Activity schedules are posted throughout the facility. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 04/05/2023. Fire alarm/sprinkler system was tested on 02/19/2024. Kitchen: Dining is located on the first floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. Residents do not have access to the kitchen; dangerous items are stored inaccessible to residents. The menu was available for viewing and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents. Continued on LIC 809C. Resident Units: The LPA, LPM and ED toured fourteen (14) randomly selected resident rooms throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Restrooms: The LPA, LPM and ED observed restrooms in fourteen (14) resident units and common area restrooms. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. The water temperature was tested throughout the visit including resident unit restrooms and common areas, and water measured between 107.4– 121.0 degrees Fahrenheit. The ED stated that the water temperature is going to be adjusted. Outside areas: There are multiple outdoor patios equipped with furniture for resident use as well as covered areas for resident use. The in-ground pool was appropriately fenced per regulation. Parking is available for residents and visitors. Starting at 1:59 p.m., the LPA and LPM conducted a review of medication, medication records, policy and procedures with medication technician. Audit for six (6) residents revealed that facility staff did not accurately record medications or had missing information on the Centrally Stored Medication and Destruction Record (CSMDR) for all six (6) residents’ medications reviewed. Three (3) out of six (6) residents’ medications reviewed, (Resident #1, Resident #2, Resident #3) did not have completed, or up-to-date CSMDR. The remaining three (3) out of six (6) residents’ medications reviewed, (Resident #4, Resident #5 and Resident #6) did not have CSMDR present during the medication review. The Director of Resident Care Services, Kelly Penrose, stated that facility staff will receive medication training and look for the missing CSMDR. Documentation: The LPA obtained a copy of the liability insurance, resident roster, and staff roster, Infection Control Plan, Emergency and Disaster Plan. Throughout the visit, LPA Peraldi interviewed four (4) residents. Due to time constraints, the LPA will return at a later date to complete the annual. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 20, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management visit regarding an incident which took place on 10/18/2023 involving Resident 1 (R1). LPA met with Executive Director (ED) Nancy Nelson and Resident Care Director (RCD) Zara Khatchatrian, RN, and explained the reason for the visit. At 10:00 a.m. LPA interviewed the ED and RCD, regarding the incident report they submitted for R1. On 10/18/2023, R1 was not responding to stimuli and staff called 9-1-1. R1 was admitted to the hospital with an initial diagnosis of severe dehydration. R1 was admitted to the facility in July of 2023. Prior to moving into the facility, R1 was at home with a 24/7 private caregiver. Upon admission to the facility, R1 was eating finger foods but started losing their appetite. Staff encourage residents to eat and drink but R1 would eat and then remove the food from their mouth. R1 also did not like to drink much. At 10:30 a.m. LPA reviewed R1's facility file. After their stay at the hospital, R1 returned to the facility on 10/21/2023. The discharge paperwork from the hospital stated R1 was admitted for sepsis. R1 returned to the facility from the hospital with redness in a few areas. R1's physician ordered home health. A home health nurse visits three times a week for R1's rash to assess and ensure the redness does not progress further. R1's physician also ordered an appetite stimulant. At 11:28 LPA toured the memory care unit and met R1. LPA interviewed the Memory Care Coordinator at 11:31 and interviewed a caregiver at 11:35 a.m. The staff encourage residents to drink water, juice, and other beverages they enjoy. Beverages are offered at all meals, snacks, after activities and during medication pass. R1 has been prescribed a pureed diet and is eating well but still does not like to drink fluids. They continue to offer R1 different beverage options and encourage hydration. Based on the information obtained, it appears R1's needs are being met based on R1's care plan and medical orders. No deficiencies observed. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 15, 2023