Belmont Village Encino

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 11:57AM for a Case Management Deficiencies visit. The LPA met with the Executive Director (ED) Lance Shenk. Entrance interview conducted. At 12:07PM, the LPA and ED toured the physical plant areas, and no immediate concerns were observed. Between approximately 12:50PM and 2:00PM, the LPA interviewed the ED and Director of Resident Care Services (DRCS) Karen Pasten, and reviewed Resident #1’s (R1) records. On 05/29/2026, the facility self-reported that R1 eloped from the facility on 05/28/2026. The Incident Report documented that at approximately 2PM, a staff observed R1 unattended approximately one (1) block away from the facility. The staff immediately notified the community and R1 was escorted back to the facility. R1 was then assessed by a nurse, appropriate notifications were made, and documentation including R1’s care plan was updated. With consent, R1 currently utilizes a WanderGuard bracelet and the facility provided staff training regarding elopement protocols and prevention. Report Continued on LIC 809-C Interview with the ED and DRCS revealed that R1 had eloped through the lobby doors during the concierge staff’s break change. There was additionally a community group outing in the lobby and it was reported that R1 walked through the group and out the door without staff noticing. The DRCS reported that R1 had eloped for approximately thirty (30) minutes where a care staff then observed R1 unattended outside of the community. Review of R1’s Physician Reported dated 03/10/2025 documented R1 to be confused/disoriented with mild cognitive impairment. R1 was not indicated to have wandering behavior, however was unable to leave the facility unattended due to cognitive decline. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 18, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above as the Licensee did not meet R1’s care and supervision needs that resulted in an elopement which posed/poses an immediate health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The facility provided staff in-service training regarding elopement procedures and preventions on 05/28/2026. POC cleared.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 11:57AM for a Case Management Deficiencies visit. The LPA met with the Executive Director (ED) Lance Shenk. Entrance interview conducted. At 12:07PM, the LPA and ED toured the physical plant areas, and no immediate concerns were observed. Between approximately 12:50PM and 2:00PM, the LPA interviewed the ED and Director of Resident Care Services (DRCS) Karen Pasten, and reviewed Resident #1’s (R1) records. On 05/29/2026, the facility self-reported that R1 eloped from the facility on 05/28/2026. The Incident Report documented that at approximately 2PM, a staff observed R1 unattended approximately one (1) block away from the facility. The staff immediately notified the community and R1 was escorted back to the facility. R1 was then assessed by a nurse, appropriate notifications were made, and documentation including R1’s care plan was updated. With consent, R1 currently utilizes a WanderGuard bracelet and the facility provided staff training regarding elopement protocols and prevention. Report Continued on LIC 809-C Interview with the ED and DRCS revealed that R1 had eloped through the lobby doors during the concierge staff’s break change. There was additionally a community group outing in the lobby and it was reported that R1 walked through the group and out the door without staff noticing. The DRCS reported that R1 had eloped for approximately thirty (30) minutes where a care staff then observed R1 unattended outside of the community. Review of R1’s Physician Reported dated 03/10/2025 documented R1 to be confused/disoriented with mild cognitive impairment. R1 was not indicated to have wandering behavior, however was unable to leave the facility unattended due to cognitive decline. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jun 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 18, 2026

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above as the Licensee did not meet R1’s care and supervision needs that resulted in an elopement which posed/poses an immediate health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: The facility provided staff in-service training regarding elopement procedures and preventions on 05/28/2026. POC cleared.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management to deliver findings for a self-reported sexual assault. The LPA arrived at 12:29PM and met with Executive Director (ED) Lance Shenk. Entrance interview conducted. On 01/27/2026, the Department received a notification of an alleged staff on resident sexual assault that reportedly occurred a week prior. On 01/28/2026, the LPA conducted an initial visit. Beginning at 9:43AM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. Between 02/04/2026 and 05/15/2026, the Department interviewed the ED, Resident #1 (R1), family, and staff. During today’s visit, the LPA and ED conducted a physical plant tour at 12:40PM, and no immediate concerns were observed. The following was then determined: It was reported that Staff #1 (S1) solicited R1 to leave the facility over the course of multiple days, transported R1 to S1’s home, and sexually assaulted R1. It was further revealed that R1 initially disclosed the assault to Staff #2 (S2) and Staff #3 (S3) on 01/25/2026 and 01/27/2026. However, neither staff reported the allegation to the facility’s On Duty Nurse nor the ED at that time. S2 and S3 stated they believed they were required to report directly to the ED in-person and therefore did not report the alleged abuse immediately. R1 also reported the allegation to the On Duty Nurse on 01/27/2026, at which time the On Duty Nurse immediately notified the ED. Report Continued on LIC 809-C Interviews with the ED at that time, Abigail Traxler, and R1’s family indicated their belief that the allegation may be unfounded due to R1’s declining condition. The ED reported that an internal investigation was conducted, including a review of facility video footage covering all entrances and exits. The internal investigation determined that R1 did not leave the premises during the alleged time frame. R1’s family also reported that between 2018-2019, R1 underwent an irreversible surgical procedure that makes sexual activity impossible. The family further expressed no concerns regarding the facility staff or the care and services provided. An interview with R1 was attempted but unsuccessful due to R1’s diagnosis and decline in condition. R1’s Wandering Potential Assessment dated 06/17/2025 indicated that R1 was independently mobile and cognitively impaired with poor decision-making skills. Record review further revealed that prior to the allegation, R1 experienced a fall on 01/11/2026, during which they hit their head, were hospitalized, and an arachnoid cyst was discovered. During the investigation, R1 was again hospitalized and diagnosed with acute metabolic encephalopathy, described as “a rapid-onset, reversible, or treatable global brain dysfunction causing confusion, altered consciousness, or delirium resulting from systemic diseases rather than direct brain injury.” Thus, leaving R1 no longer verbal. S1 denied the allegation against them and stated R1’s decline in condition may have attributed to the allegation. S1 reported no inappropriate behavior initiated on their end and that R1 often inquired about S1’s personal life and touched their arm. S1 stated that they were no longer comfortable providing services to R1 which they reported to management and removed R1 from S1’s care. At this time, no further investigation is required regarding the sexual assault allegation. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, May 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 29, 2026

(a) Facility personnel shall at all times be… competent to provide the services necessary to meet resident needs… This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section in 2 staff did not follow mandated reporting requirements which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: A staff in-service training was conducted on 05/22/2026 regarding mandated reporting. The Licensee will conduct the training with absent staff at the time and provide proof by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 12:29PM for a required one-year visit. The LPA met with the Executive Director (ED) Lance Shenk. Entrance interview conducted. At 12:40PM, the LPA and ED 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 following was observed: RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 102.9 degrees F and 111.6 degrees F. COMMON AREAS: The facility has five (5) total floors, one (1) being the garage/basement. The basement provided general parking, contained emergency food and water, and general storage as well as extra facility supplies/emergency supplies. On the first floor, there was the concierge desk, the great room, common restrooms, bistro, bistro patio, staff lockers, dining room, courtyard, kitchen, and memory care unit. Report Continued on LIC 809-C The memory care unit contained resident units, common restrooms, a courtyard, laundry room, and office. On the second floor, there was a wellness center, resident units, town hall room, activity room, balcony, and common restrooms. On the third floor, there was a beauty salon, resident units, discovery room, gym, card room, laundry room, and common restrooms. On the fourth floor, there was a laundry room, resident units, terrace rooftop, office, and common restrooms. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were found in the hallway on the first floor. There were no bodies of water observed during today’s visit. KITCHEN: The main kitchen is located on the first floor, attached to the main dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F. INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. There were fire extinguishers throughout the facility, which were serviced on 09/26/2025. The fire alarm system is tested annually with the last inspection on 07/08/2025 by Absolute Fire Protection, INC. Emergency disaster drills are conducted as required with the last drill on 5/14/2026. Due to time constraints, the LPA will return at a later date to continue the annual. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, May 28, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit after the facility self-reported an alleged sexual assault. The LPA arrived at 9:43AM and met with Executive Director (ED) Abigail Traxler. Entrance interview conducted. On 01/27/2026, the Department received a notification of an alleged staff on resident sexual assault that reportedly occurred a week prior. During today’s visit, the LPA and ED conducted a physical plant tour at 9:53AM and no immediate concerns were observed. Beginning at 12:25PM, the LPA reviewed and obtained pertinent documents including the SOC 341 and Incident Report. The ED was advised that the case was referred to the Investigations Branch (IB). The LPA determined that further investigation is needed. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Staff did not ensure resident's hygiene needs were being met

Licensing Program Analyst (LPA) Quoc Huynh conducted a subseuqent complaint visit to deliver findings for the above allegation. The LPA arrived at 10:36AM and met with Memory Care Unit (MCU) Director Kate Blackman. Entrance interview conducted. On 12/29/2025, the LPA conducted an initial visit. Between 9:33AM and 11:45AM, the LPA conducted a physical plant tour, interviewed the Executive Director and MCU Director, interviewed two (2) staff, and reviewed and obtained pertinent documents. During today’s visit between 10:44AM and 2:02PM, the LPA conducted a physical plant tour and interviewed five (5) residents and three (3) staff. No immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegation: “Staff did not ensure resident's hygiene needs were being met” It was reported that resident hygiene needs such as washing hands were not maintained which resulted in Resident #1 (R1) contracting Clostridioides Difficile (C. Diff). Interview with residents revealed no overall concerns about the facility’s cleaning protocols. Residents stated they frequently observe staff cleaning/sanitizing their rooms in addition to common areas. Residents also had no concerns regarding their hygiene needs and expressed that they always feel clean. Residents reported washing their hands as frequently as they can with staff assistance. Staff reported that residents with illnesses or contagious diseases are kept in isolation in their rooms or sent to the hospital. During this time, personal protective equipment (PPE) is provided outside the rooms for staff utilization when providing care. As an extra precaution, typically one (1) staff is assigned to that resident’s care to prevent further contamination. Residents who are symptom free and cleared of their illness will then return to the community and staff then clean the infected rooms which include laundry services and sanitizing/disinfecting all surfaces. During day-to-day operations, the facility’s common areas are cleaned frequently with staff access to cleaning chemicals if needed. Housekeepers and the maintenance team provide deep cleanings during the overnight shifts. Staff reported hand sanitizing stations throughout the facility for everyone to use in addition to following hand washing and glove precautions. Specifically, the MCU utilizes hand wipes before meals to accommodate resident preferences. Record review revealed that R1 experienced a change of condition on 08/29/2024 and was subsequently transferred to the hospital. On 08/31/2024, R1 returned to the facility with an eye infection and was prescribed antibiotics. R1 later tested positive for C. Diff on 09/02/2024, was sent to the hospital, and returned to the facility on 09/17/2024 with negative results. On 10/01/2024, R1 showed symptoms of C. Diff, was transferred to the hospital, and returned to the facility on 10/11/2024. Medication review revealed that R1 was not prescribed antibiotics in August 2024; however, in September 2024 R1 took three (3) antibiotics and two (2) antibiotics in October 2024. Report Continued on LIC 9099-C It was also revealed that Resident #2 (R2) had C. Diff in March 2024 and was sent to the hospital until asymptomatic and returned to the facility and has not had C. Diff since. Furthermore, R1 moved to the MCU from Assisted Living in December 2023, and R2 moved to the MCU from Assisted Living on 02/19/2025. Although it was possible both residents may have been in contact at community events, R1 and R2 were not in contact while actively diagnosed with C. Diff. Per information released by the U. S. Centers for Disease Control and Prevention (CDC) on 12/18/2024, C. Diff is common among individuals in healthcare settings such as hospitals and nursing homes. It is spread from person to person through feces and inactive spores in the environment that can be activated by swallowing the spores. The CDC reported C. Diff infections can also occur when taking antibiotics which result in C. Diff side effects. It was recommended to reduce the spread by washing hands with soap and water after restroom use and before meals. Based on interviews and record review, the facility followed infection control procedures and ensured residents’ hygiene were maintained. Additionally, R1 visited the hospital and was prescribed antibiotics shortly before contracting C. Diff, which may have increased their risk of exposure. Although R1 did contract C. Diff, there is not sufficient evidence to prove the alleged violation was a result of resident hygiene needs being unmet, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 29-AS-20251223144304

Allegation investigated: Due to staff negligence, resident fell resulting in an injury

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 1:27PM and met with Area Clinical Directors (ACDs) Marina Bonilla and Zara Khatchatrian. Executive Director (ED) Abigail Traxler participated via telephone call. Entrance interview conducted. On 11/20/2025, LPA conducted an initial visit. Between 10:35AM and 2:45PM, the LPA conducted a physical plant tour, interviewed five (5) Residents, five (5) Staff, and the Memory Care Unit (MCU) Director. The LPA also reviewed and obtained pertinent documents. Report Continued on LIC 9099-C Unsubstantiated During today’s visit, the LPA and ACDs conducted a physical plant tour at 1:40PM and no immediate concerns were observed. The following was then determined: Allegation: “Due to staff negligence, resident fell resulting in an injury” It was reported that Resident #1 (R1), a known fall risk, sustained a fall on 06/18/2025 that resulted in a sprained ankle due to staff negligence. Interviews with five (5) residents revealed that falls do not often occur in the MCU and that staff are consistently nearby to provide assistance. Residents reported utilizing assistive devices such as walkers and wheelchairs to prevent falls and stated that staff respond immediately and appropriately if a fall does occur. Staff interviews revealed that fall prevention protocols included motion censored floor and bed mats, bed rails, fall detection cameras in each resident room, and monitoring for behavioral changes. Staff reported that falls in the MCU are infrequent and, when they do occur, they are often “staff assisted,” meaning staff guide residents safely to the floor. Unwitnessed falls reportedly occur on average zero (0) to one (1) time per month. Staff stated that fall procedures include notifying all staff via radio, ensuring the resident is safe, and placing a pillow under the resident’s head. The med-tech and LVN (nurse) then assess the resident’s condition, including range of motion and pain. The LVN also reviews fall detection footage to confirm the fall and determine whether the resident may have hit their head and then decides if hospital transport is necessary and notifies the resident’s family and hospice agency. Staff reported that R1 was initially capable of independently ambulating and required minimal staff assistance with activities of daily living (ADLs). Over time, R1’s condition declined and R1 required assistance with all ADLs. R1 was considered a fall risk when ambulating due to unsteady, shuffling, and twisting feet and required arm support for balance. Staff preferred utilizing R1’s wheelchair for transfers and escorts and reported that R1 received physical therapy (PT). Staff stated they expressed safety concerns to R1’s family; however, the family insisted that staff continue assisting R1 with walking. Report Continued on LIC 9099-C Staff observed family-hired private caregivers assisting R1 with walking and noted instances where R1 appeared to be dragged, prompting staff to intervene. The MCU director stated the facility does not provide two (2) person walking assistance, as this indicates unsafe ambulation. Staff also reported that following R1’s fall, the facility conducted additional in-service training on fall prevention. On 06/18/2025, R1 sustained a fall in their room while Staff #1 (S1) assisted with R1’s morning ADLs. S1 stated they intended to use R1’s wheelchair to escort R1 to the restroom; however, R1 showed signs of wanting to walk. S1 attempted to comply with the family’s request for assisted ambulation. S1 briefly let go of R1 to move the wheelchair out of the path, at which point R1 took several steps independently, lost balance, hit the wall, and fell. Fall detection footage showed S1 entering R1’s room at 7:45AM and providing assistance with ADLs including dressing and incontinence care. S1 positioned R1’s wheelchair at the foot of the bed and walked R1 toward it for support while finishing with dressing. At 7:51:47AM, S1 assisted R1 in letting go of the wheelchair and took five (5) steps toward the hallway before turning to reposition the wheelchair. R1 continued walking independently, taking an additional five (5) steps before losing balance at 7:51:53AM. At this time, S1 turned back toward R1 and immediately rushed to R1. R1 fell leaning towards their left, hit the wall, and hit the floor. S1 notified staff and placed a pillow under R1’s head. The MCU med-tech arrived and conducted an initial assessment, followed by the LVN who completed a secondary assessment. At 7:57AM, R1 was placed in their wheelchair and S1 continued assisting with ADLs. R1’s Resident Appraisal dated 11/03/2023 indicated R1 was ambulatory without assistance. The Resident Assessment and Service Plan dated 07/03/2025 documented R1 to need hands-on assistance with showering, dressing, grooming, incontinence care, feeding, and transfer assistance by one (1) staff with escorts to and from meals and activities. It was also noted that R1 required increased room safety checks due to fall risk and was wheelchair bound. Report Continued on LIC 9099-C Physician Report dated 07/10/2025 indicated R1 was receiving hospice services for a diagnosis of end stage dementia, was non-ambulatory and required assistance with repositioning and transferring. Post-fall X-Rays on 06/21/2025 and 07/02/2025 ruled out fractures on R1’s spine, hips, and knees. A doctor’s visit summary on 07/18/2025, noted the family reported R1 was “walking with some assistance” prior to the fall. The physician assessed R1 as having diffuse sarcopenia and a left ankle sprain as a result from their fall. PT records documented services beginning 03/29/2024 through discharge on 07/21/2025. R1 received therapy to improve fine motor coordination, muscle strength, functional activity tolerance, and standing balance with the goal of independently performing ADLs. R1’s baseline on 09/01/2024 indicated the ability to maintain balance against moderate resistance for approximately ten (10) minutes with standby assist (supervision) for safe ambulation. Additionally, R1 demonstrated fine motor coordination with stand by assistance. On 05/22/2025, PT documented that R1 required maximum arm assistance for gait activities and maximum assistance with transfer. Service Logs recorded ten (10) PT visits post-fall. A PT assessment on 06/25/2025 indicated R1 had potential for improvement but progress was slower than expected. PT documented that R1 required skilled rehabilitation due to impairments including balance deficits, decreased body awareness, cognitive decline, decreased dynamic balance, reduced functional tolerance, decreased attention, strength impairments, pain, and postural alignment issues. Based on interview and record review, R1 was appropriately assessed as a fall risk, and staff were aware of and responsive to R1’s changing condition. Although R1 sustained a fall resulting in an ankle sprain, there is not sufficient evidence to prove the alleged violation was a result of staff negligence, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 29-AS-20251113131525

Allegation investigated: Due to staff neglect, a resident sustained an unstageable pressure injury while in care Staff refused to accept resident back from hospital

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. LPA arrived at 9:42AM, met with Executive Director (ED) Abigail Traxler, and explained the reason for the visit. Entrance interview conducted. On 08/04/2025, LPA Huynh conducted an initial complaint visit. Between 9:27AM and 12:25PM, LPA Huynh reviewed and obtained pertinent documents and conducted a physical plant tour. The ED was informed that the first allegation was referred to Community Care Licensing Division’s (CCLD) Investigations Branch (IB). Report Continued on LIC 9099-C Unsubstantiated Between 08/12/2025 and 09/29/2025, Investigator Sonia Torre conducted interviews with relevant parties including facility staff, residents, and family. Investigator Torre also obtained and reviewed additional documents including hospital and hospice records, law enforcement reports, and wound care records. During today’s visit, the LPA, ED, and Memory Care Unit Director conducted a brief physical plant tour at 10:35AM, and no immediate concerns were observed. The following was then determined: Allegation: “Due to staff neglect, a resident sustained an unstageable pressure injury while in care.” It was alleged that due to staff neglect, Resident #1 (R1) sustained an unstageable sacral pressure injury while residing at Belmont Village Encino. R1 had a diagnosis of dementia, hypothyroidism, and congestive heart failure with a documented history of motor impairment and skin breakdown and required assistance with activities of daily living. Facility Nurse Assessments noted R1 had dry skin in the sacral area, discoloration and bruising on the right extremity toe and anterior body, and an open sore on the front head area and redness on the sacral region. Home Health Records from 04/23/2025 to 05/21/2025 noted R1 received services for fungal skin infections and development of Stage II pressure injuries on the buttocks. Wound care was initiated for Stage II injuries on the right buttocks, right posterior upper thigh, and right medial upper thigh. On 05/17/2025, it was documented that the pressure injuries on the right lower buttocks and right upper thighs had healed and required no further care. Hospice Records from 05/22/2025 to 07/17/2025 revealed R1 received two (2) skilled nurse visits and three (3) aide visits per month. Wound care services were provided on 05/31/2025, 06/05/2025, 06/16/2025, 06/17/2025, 06/21/2025, and 06/23/2025. Report Continued on LIC 9099-C On 06/11/2025, R1 was documented to have four (4) Stage III pressure injuries: right posterior lower buttocks, left posterior lower buttocks, left posterior upper buttocks, and left posterior buttocks. On 07/16/2025, facility staff reported wound changes were observed with R1 experiencing increased pain. R1 was transferred to Encino Hospital Medical Center on 07/17/2025 for a higher level of care to address the progressing wounds. R1 was at high risk for further skin breakdown due to impaired nutritional status, limited mobility, multiple comorbidities, altered continence, and impaired skin integrity. Hospital records noted a pre-operative diagnosis of unstageable sacral pressure injury, later determined post-operatively to be Stage III. R1 was discharged to a Skilled Nursing Facility (SNF) on 07/24/2025. Interview with R1’s Responsible Person revealed that R1’s condition declined over the course of three (3) years and required full assistance except for feeding. They reported no concerns about the level of care R1 received and confirmed awareness of R1’s pressure injuries, which were treated through Hospice and wound care. R1 was observed to be repositioned throughout the day; despite this, R1’s wounds did not improve. Interview with four (4) staff confirmed R1’s declining condition and lack of wound improvement. Staff documented R1’s change of condition, notified their Supervisors and Hospice, and it was ultimately determined that R1 required a higher level of care than Hospice could provide. Staff also noted R1 had chronic skin breakdown and eczema, contributing to further complications. Based on record review and interviews, while R1 did experience pressure injuries, there is insufficient evidence to determine that staff neglect caused or contributed to the unstageable sacral wounds. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Report Continued on LIC 9099-C Allegation: “Staff refused to accept resident back from hospital” It was alleged that the facility refused to accept R1 back from the hospital due to their wounds. R1 was transferred to the Hospital on 07/17/2025 and subsequently discharged to a SNF on 07/24/2025. Facility Administrators reported they were not notified by the hospital of R1’s transfer to the SNF. The Director of Nursing later observed R1’s name on a room assignment at the SNF during an unrelated visit and inquired about the transfer. Interview with R1’s Responsible Person confirmed R1 would temporarily reside at the SNF for wound care before returning to Belmont Village Encino. The Director of Nursing also confirmed that R1 would be accepted once wounds improved. During today’s visit, the LPA confirmed R1 returned to the facility. 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.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 29-AS-20250801133138

Allegation investigated: Staff pushed resident. Staff are violating resident’s personal rights. Staff threatened resident. Water temperature not within required range.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility. At 8:30 a.m., the LPA met with staff and explained the reason for the visit. At 9:17 a.m., the Executive Director (ED) Abigail Traxler arrived at the facility. At 10:50 a.m., the LPA met with Director of Resident Care Services (DRCS), Courtney Barber. During the initial visit on 5/16/2024, between 9:28 a.m. and 12:30 p.m., the LPA conducted a brief physical plant tour and interviews with five (5) staff and five (5) residents. During today’s visit, between 9:30 a.m. and 10:37 a.m., the LPA conducted a physical plant tour, an interview with the ED and Staff #1 (S1). During both visits, the LPA requested and obtained copies of pertinent documents. Continued on LIC 9099-C. Unsubstantiated Regarding the allegations: 1.) Staff pushed resident. 2.) Staff are violating resident’s personal rights. 3.) Staff threatened resident. 4.) Water temperature not within required range. On 05/09/2024, the Department received a complaint alleging Staff #1 (S1) and Staff #2 (S2) forcing Resident #1 (R1) into taking a shower in which the water was inconsistent going from scolding hot to ice cold. It was alleged that S1 and S2 threaten R1 and pushed R1 causing R1 to fall. During the initial visit, interview with R1 revealed little to no information regarding the allegations. R1 did not comment on the allegations and stated that there are no concerns regarding staff. R1 did state that R1 can control the shower’s temperature however that the shower controls can be difficult to navigate. Interview with ED conducted on 06/30/2025, revealed that R1 is no longer at the facility. The ED revealed that during the time of the alleged incident, the facility conducted an internal investigation in which both S1 and S2 denied the allegations. The ED stated that after their internal investigation, S1 and S2 were reassigned to work on different floors. The LPA conducted an interview with S1 during today’s visit; S1 denied the allegations. Residents interviewed did not voice any concerns regarding staff. Staff interviews revealed that they have not observed or heard of staff pushing residents or threatening residents. During the initial and subsequent visit, the LPA tested the water temperature throughout the building and found the water temperature to be within required range. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed Unsubstantiated at this time. Exit interview conducted with Courtney Barber. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 29-AS-20240509082740

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 8:55AM for a required one-year visit. The LPA met with Resident Care Services Director (RCSD) Cortney Barber and explained the reason for the visit. Entrance interview conducted. Executive Director (ED) Abigail Traxler arrived at 10:33AM. At 9:45AM, the LPA and RCSD 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 is a five-story building. The following was observed: RESIDENT ROOMS: The LPA observed randomly selected rooms on the first, second, third, and fourth floors and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident restrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 104.5 degrees F and 133.5 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. Additionally, the LPA observed two (2) out of six (6) resident restroom sinks to be clogged and slow to drain during the visit. One (1) resident stated their sink had been clogged “for quite some time” and submitted a work order in addition to notifying staff. RCSD and ED immediately notified the building engineer to repair the sinks’ drainage. Report Continued on LIC 809-C COMMON AREAS: The facility has five (5) total floors: basement/parking garage, first floor, second floor, third floor, and fourth floor. The basement provided general parking, contained emergency food and water, and general storage as well as extra facility supplies/emergency supplies. On the first floor, there was the concierge desk, the great room, common restrooms, bistro, bistro patio, staff lockers, dining room, courtyard, kitchen, and memory care unit. The memory care unit contained resident units, common restrooms, a courtyard, laundry room, and office. On the second floor, there was a wellness center, resident units, town hall room, activity room, balcony, and common restrooms. On the third floor, there was a beauty salon, resident units, discovery room, gym, card room, laundry room, and common restrooms. On the fourth floor, there was a laundry room, resident units, terrace rooftop, office, and common restrooms. LPA Huynh observed common areas to be clean, clear of obstructions/hazards, and furniture was in good condition with patios/courtyards providing shade for residents. Required postings were found in the hallway on the first floor. There were no bodies of water observed during today’s visit. There were fire extinguishers throughout the facility, which were serviced on 09/11/2024. KITCHEN: The main kitchen is located on the first floor, attached to the main dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries which occurs every Wednesday and produce deliveries occurs every Monday, Thursday, and Saturday. There was a sufficient supply of perishable and non-perishable food. The LPA observed the walk-in refrigerator and freezer; food appeared to be of good quality and labeled with expiration dates. Kitchen sinks had signage of tap water delivering above 125 degrees F. MEDICATION: Medication review began at 11:00AM. The LPA reviewed medications for five (5) residents. Medications are maintained locked inaccessible to residents in the Wellness Center located on the second floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. Report Continued on LIC 809-C RECORDS: Resident records were reviewed at 11:38AM. LPA Huynh reviewed five (5) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed six (6) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate training. Staff files reviewed were in compliance with regulation at this time. INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills as required, with the last drill documented on 05/29/2025. Fire alarm system is tested annually with the last inspection on 05/15/2025 by Absolute Fire Inspection, Inc. with a follow up inspection to be determined. Four (4) residents and six (6) staff were interviewed. No complaints noted. LPA Huynh obtained the following documents: LIC 500 Personnel Report, Resident Census/Roster, Emergency Disaster Plan, Infection Control Plan, and Dementia Plan of Operation. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jun 11, 2025

Allegation investigated: Unlawful eviction Facility staff financially abused resident

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a subsequent complaint investigation at 10:50AM. LPA met with Executive Director (ED) Abigail Traxler. Reason for the visit was explained. During today’s visit, LPA Barutyan conducted interviews with two (2) residents and ED Traxler and reviewed and obtained copies of pertinent documents. During the initial visit on 04/23/2024 beginning at 09:25AM, LPA E. Peraldi conducted an interview with ED Traxler, obtained copies of pertinent documents, conducted an interview with one (1) staff, and conducted a physical plant tour with the ED. CONTINUED ON LIC 9099-C. Unsubstantiated Report Continued from LIC 9099. It was alleged that previous ED Ralph Balbin issued an eviction to Resident #1 (R1) without proper 30-days’ notice. Interviews with ED, responsible party of R1, and staff revealed that it was determined R1 had a change of condition requiring the resident to be placed in memory care to meet higher care needs. Facility management verbally informed R1 and responsible party of R1 on approximately 11/15/2022 that R1 will need to move to the memory care unit by 12/01/2022 or the facility will move forward with eviction proceedings on the basis that the facility is unable to meet the care needs of R1. Facility was notified by R1’s responsible party on 11/30/2022 that R1 will move out of the facility. R1 voluntarily moved out of the facility on 12/03/2022. No eviction notice was issued to R1 by the facility and no eviction notice was received by the Department for R1. Furthermore, R1’s admission agreement signed and dated on 12/30/2017 states the facility “upon thirty (30) day’s notice” may terminate the agreement if the facility “and the person who performs the reappraisal believe that the Community is no longer appropriate for [the resident]” and for “failure to comply with the general policies of the Community” which include possible termination if the resident/responsible party of resident “refuse to accept services required in order for [the facility] to meet [the resident’s] needs.” R1’s long-term physician confirmed R1’s change of condition in a signed letter dated 05/10/2022 stating that R1 “is dependent in in [their] basic and instrumental activities of daily living” (ADLs) and “is at risk for wandering and requires substantial supervision.” However, on 12/01/2022, R1 received a second opinion from their primary care provider who stated that they “support the decision of not moving the patient to Memory Unit at this time, given [the patient’s] current cognitive functional level.” On 11/26/2022, R1’s long-term psychologist also recommended that R1 “not go into Memory Care at Belmont Encino because it will be overly restrictive and insufficiently stimulating.” However, as no eviction notice was issued by the facility, the services required for the facility to meet R1’s care needs were refused, and a proper 30-day notice of moving was not provided, the information obtained through interview and record review for this investigation did not include evidence sufficient to corroborate the allegation. 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 “Unlawful eviction” is deemed UNSUBSTANTIATED at this time. It was further alleged that facility staff financially abused R1 by overcharging for unused services and rent. LPA reviewed R1’s ledger from 01/01/2022 - 12/31/2023 and observed a monthly rent charge of $11,575.00 automatically charged to the card on file every 1st day of the month and extra services charged every 15th day of the month. Report Continued on LIC 9099-C. Report Continued from LIC 9099-C. Additional charges were observed for services such as outings, haircuts, and escorts. R1 was charged $11,575.00 monthly rent on 12/01/2022 and was incorrectly automatically charged $129.56 on 12/15/2022 for multiple outings and an escort after moving; $17.93 outing, $41.63 outing, and $70 escort. R1’s ledger from 01/01/2023 documents that the extra services of $129.56 automatically charged after R1 moved out of the facility were returned to the account. A total of $11,829.56 ($129.56 of extra services not used + $125.00 recurring total incontinence management supplies (TIMs) fee automatically charged on 01/01/2023 + $11,575.00 monthly fee automatically charged on 01/01/2023) was returned to the account on 01/05/2023. On 01/15/2023, R1’s account was then credited a total of $10,770.41 ($115.07 TIMs fee + 10,655.34 monthly fee) for the period of 01/04/2023 – 01/31/2023, making the total balance $1,059.15 ($11,829.56 - 10,770.41). R1’s admission agreement signed and dated on 12/30/2017 states under “termination by resident” that a resident “may terminate this Agreement at any time, with or without cause, by giving the Executive Director thirty (30) days’ prior written notice of termination” and the resident “will continue to be responsible for [their] full Monthly Fee until the thirty (30) day period has expired.” The facility was notified by R1’s responsible party on 11/30/2022 that R1 will move out of the facility, meaning that the thirty (30) day period would be from 11/30/2022 – 12/30/2022. R1 moved out of the facility on 12/03/2022. R1 was charged for the period of 12/03/2022 – 01/03/2023, totaling $1,059.15 after accounting for the full December 2022 rent of $11,575.00 and $125.00 recurring TIMs fee charged on 12/01/2022. Therefore, the remaining balance of $1,059.15 ($9.93 recurring TIMs fee + $919.66 monthly rent) is for the three (3) additional days in January 2023 counting for thirty (30) days after R1 moving, 12/03/2022. However, R1 moved out within the thirty (30) day notice was that was received by the facility on 11/30/2022. The facility dropped the balance of $1,059.15 on 04/30/2024. The information obtained for this investigation did not include evidence sufficient to corroborate the allegation. 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 “Facility staff financially abused resident” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 29-AS-20240417163437

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit as information received during the investigation of Complaint Control #29-AS-20240417163437 confirmed an error in accounting. The purpose of the visit is to issue a citation for a deficiency observed during the subsequent complaint investigation. During the visit on 02/25/2025, LPA reviewed Resident #1 (R1)’s ledger from 01/01/2017 – 12/31/2024. R1’s admission agreement signed and dated on 12/30/2017 states under “termination by resident” that a resident “may terminate this Agreement at any time, with or without cause, by giving the Executive Director thirty (30) days’ prior written notice of termination” and the resident “will continue to be responsible for [their] full Monthly Fee until the thirty (30) day period has expired.” The facility was notified by R1’s responsible party on 11/30/2022 that R1 will move out of the facility, meaning that the thirty (30) day period would be from 11/30/2022 – 12/30/2022. R1 moved out of the facility on 12/03/2022. R1 was charged for the period of 12/03/2022 – 01/03/2023, totaling $1,059.15 after accounting for the full December 2022 rent of $11,575.00 and $125.00 recurring total incontinence management supplies (TIMs) fee charged on 12/01/2022. Therefore, the remaining balance of $1,059.15 ($9.93 TIMs fee + $919.66 monthly rent) is for the three (3) additional days in January 2023 which was counted for thirty (30) days after R1 moving, 12/03/2022. However, R1 moved out within the thirty (30) day notice was that was received by the facility on 11/30/2022. R1 was overcharged in error for the period of 12/31/2022 – 01/03/2023. Report Continued on LIC 809-C. Report Continued from LIC 809. While R1/responsible party of R1 did not pay the wrongfully charged $1,059.15 balance from 01/01/2023 – 01/03/2023, R1 paid the full monthly fee of $11,575.00 + $125.00 TIMs fee for December 2022 on 12/01/2022, which includes payment for the day of 12/31/2022. The $1,059.15 balance was dropped on 04/30/2024. The facility owes R1/responsible party of R1 payment for the day of 12/31/2022, a total of $377.42 ($373.39 daily fee + $4.03 TIMs fee) as this falls outside of the thirty (30) day period of the move out notice provided on 11/30/2022. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 25, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a) · Plan of correction due date: Mar 11, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as Resident #1 (R1) was wrongfully overcharged a total of $1,436.57 which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 25, 2025

Plan of correction: The facility did not receive payment for the 01/01/2023-01/03/2023 balance of $1,059.15. ED stated they will issue a check for the balance owed, $377.42, and have it mailed to R1/responsible party of R1 and submit proof to CCL by 03/11/2025.

Allegation investigated: Unqualified staff are administering medication to residents. Staff are not keeping accurate resident records. Staff are not submitting unusual incident reports.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings for the allegations listed above. The LPA met with Executive Director (ED) Abigail Traxler and explained the reason for the visit. On 08/15/2023, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced initial visit to investigate the allegations listed above. The LPA met with Executive Director (ED) Abigail Traxler at 10:30 a.m. and explained the reason for the visit. The LPA interviewed the staff from 11:30 a.m. to 1:00 p.m. and the residents from 1:30 p.m. to 2:00 p.m. The LPA Requested records pertinent to the investigation, a resident roster (LIC 9020), and staff roster (LIC 500). Continues on LIC 9099C... Substantiated Pg. 2 Unqualified staff are administering medication to residents. On the allegation that staff are administering medications to residents, it is the reporting party’s concern that unqualified staff are conducting blood sugar tests and giving insulin injections to residents. To investigate the allegation, LPA Urena conducted staff and residents’ interviews and reviewed documents pertinent to the allegation. Residents’ interviews revealed that they receive insulin injections from different staff. Three (3) out of five (5) residents were able to provide the names of staff who administer the injections; the names provided names were of staff who are considered skilled professionals. The staff interviewed stated that the Licensed Vocational Nurse (LVN) give the insulin injections to residents who have prescriptions for insulin, and also conduct blood sugar testing. The staff added that they have seven residents with prescriptions for insulin. Six out of seven residents have a device called either Freestyle-Libre or Dexcone attached to their arm; these devices give automatic blood sugar level readings through an application on a reading phone type device. The arm devices are changed every two weeks by the LVNs. One resident is using the Freestyle device and uses the lancet to prick their finger and get a reading through a device used for this type of blood sugar testing. The residents receive the insulin injections once to three times a day, depending on the physicians’ orders. The insulin injections are administered to the residents in the comfort of their rooms. The insulin injections are administered in the residents’ abdomen area. The insulin injections are recorded in the facility’s electronic system ‘Acuflow-Electronic Medication Administration Record(E-MAR) by the staff who administered the injections. The initials of the staff are then recorded in the E-MAR. LPA Urena conducted record review of printouts of the E-MAR and ‘Diabetic Flow Sheet’ (DFS). During the record review, it was observed that the initials of staff 1 (S1) are printed on the DFS for resident 1 (R1) as the staff who administered the insulin injection on 08/12/2023 at 8:00 a.m. Furthermore, LPA Urena observed that the E-MAR printouts for resident 2 (R2) dated for August 2023, have the initials of staff 2 (S2), and the initials are printed on at least seven (7) different dates during the month of August 2023, which shows that S2 administered insulin injections to R2 and conducted blood sugar testing. Additionally, it was observed that the E-MAR records for R3, R4 and R5, indicate that S3 administered insulin injections and conducted blood sugar testing during the month of August 2023. Staff S1, S2, and S3 are not appropriately skilled professionals to administer injections. Continues on Pg. 3 LIC 9099C... Pg. 3 Based on the information obtained through interviews and record review, and although staff and residents’ interviews revealed that skilled professionals had administered the insulin injections to residents; the record review revealed that five (5) out of seven(7) residents had received either an injection or blood sugar testing from staff (S1, S2, and S3) who are not deemed based on regulations, skilled professionals. Therefore, the allegation that ‘Unqualified staff are administering medication to residents’, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Exit interview was conducted. A copy of the report and Appeal Rights were issued. Pg 2. Staff are not keeping accurate resident records. On the allegation that staff are not keeping accurate resident records, it is the reporting party’s concern that medication errors have occurred due to the mishandling of medications. To investigate the allegation, LPA Urena conducted a random medication audit, and interviewed staff. During the medication audit conducted for 10 residents and compared against the Centrally Stored Medication and Destruction Record (LIC622), no errors were found. The medications are generally contained in bubble packets created by the pharmacy filling the prescriptions. The packets are labeled as AM, PM, and Night. Staff interviews revealed that the medication assistance happens at the Wellness Center (WC). Residents are accompanied by their caregivers to the WC. At the WC a med tech or a Licensed Vocational Nurse (LVN) signs in to the system, gathers the resident’s box of medications, opens the Electronic Medication Administration Record(E-MAR) scans the bubble/multi packet barcode; after scanning the barcode, a picture of the pills and the resident's picture appear on the screen and is compared to the resident standing in front of the staff. Furthermore, if a medication has been discontinued by the doctor, a red flash pops up indicating that the medication has been discontinued. The med tech or the LVN then pops the pills from the bubble packet, and hands them to the resident in a cup. Residents receive the medications along with a glass of water and take the medication in front of the staff. Based on the information obtained through record review and staff interviews, it appears that the current facility’s system Acuflow-Electronic Medication Administration Record(E-MAR), ensures that staff keep accurate medication records, assisting with the medication, and ensuring that staff assisting with medications are recorded. Therefore, the allegation of ‘Staff are not keeping accurate resident records’ is deemed Unsubstantiated at this time. Continues on pg 3 LIC 9099C... Pg.3 Staff are not submitting unusual incident reports. On the allegation that staff are not submitting unusual incident reports, it is the reporting party’s concern that facility staff are not reporting incidents and medication’s errors to the Community Care Licensing Department. To investigate the allegation, the LPA conducted record review of incidents reports and interviewed six (6) staff about the steps they follow to report incidents, which staff is responsible for filling out the incident reports (LIC 624) and submitting them to the CCLD. Staff interviews revealed that any medication errors are reported to the Director of Residents Care Services (DRCS). The DRCS submits reports to the Executive Director (ED), and the ED submits reports to CCLD. The protocol is to immediately inform the resident’s responsible party/family, and the physician of the medication error. Residents are under observation and vitals are taken for the next 24 to 48 hours, and the ED conducts an internal investigation. LPA Urena conducted an internal data system review of LICs 624 submitted by the facility to CCLD from 01/01/2023 to 07/01/2024; no LICs 624 related to medication errors were found; however, the LPA found several LICs 624 submitted by the facility to notify the CCLD about incidents that occurred at the facility. Based on the information obtained through interviews and record review, the allegation of staff not submitting unusual incident reports could not be verified. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. Copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 29-AS-20230807125538

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87629(a)(b)(1) · Plan of correction due date: Jul 26, 2024

87629 (a) (b)(1)-The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following:(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as five (5) out of seven (7) residents received injections from unskilled professionals, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: The Executive Director9ED) has agreed to review the regulations as they pertain to skilled professionals providing injections, and to conduct training to ensure that staff understand their roles and understand the regulations pertaining to injections provided by skilled professionals. The ED will submit proof of the training to the department by July 26th.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Emily Peraldi and Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 8:00 a.m., the LPA was greeted by staff and explained the reason for the visit. At 9:35 a.m., the Director of Resident Care Services (DRCS), Courtney Barber arrived at the facility. Files: Between 9:25 a.m. and 11:55 a.m., the LPAs conducted a file review for seven (7) residents and seven (7) staff. Resident records were reviewed for, but not limited to: care plans, medical assessments, admissions agreement, consent forms. Resident records were in order. Personnel records were reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and training documentation showing required training completed. Personnel files were in order. Starting at 9:35 a.m., LPA Peraldi conducted a review of medication, medication records, policy and procedures with medication technician for ten (10) residents. No errors observed during the medication review. The LPAs obtained a copy of the resident roster, and staff schedule. Due to time constraints, the LPA will return at a later date to complete the annual. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2024