Beverly Hills Terrace

Allegation investigated: Staff restrained resident in care.

On 09/20/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Assistant Administrator Cesilia Torres. The investigation consisted of the following: LPA requested service documents and interviewed residents (R1-R8) and staff (S1-S4). A plant inspection of the facility was conducted. There were no deficiencies found during any visits. Investigation revealed: Unsubstantiated Allegation: Staff restrained resident in care. LPA conducted interviews with residents (R1-R8) and there were no concerns with a resident being restrained while in care at the facility. Residents (R1-R7) stated residents (R1-R7) has not witnessed another resident being restrained while in care at the facility. Staff (S1-S4) stated staff (S1-S4) has not witnessed a resident restrained while in care at the facility. Staff (S1-S4) stated staff (S1-S4) has not restrained a resident while in care at the facility. Staff (S1-S4) stated staff (S1-S4) has no concerns with a resident being restrained while in care. During LPA investigation visit, LPA did not observe any residents restrained while in care at the facility. LPA did not observe any restraints on mobility devices during interviews with residents (R1-R8). Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Cesilia Torres and a hard copy was provided.the state’s words, verbatim · CDSS document, Sep 20, 2022 · control 11-AS-20220913100958

Allegation investigated: Resident sustained an injury from a fall while in care. Regarding allegation: Staff did not properly report an incident regarding a resident.

On 6/2/22, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Administrator Bella Naygas and Assistant Administrator Cesilia Torres and explained the purpose of todays visit. The investigation consisted of the following: On 5/17/22, LPA toured the facility and conducted a health and safety check. LPA obtained the following documents: LIC 500 and Staff Roster, Residents #1-3 admission agreements, most recent physician reports/appraisals, emergency contacts and medication records. LPA conducted interviews with the Administrator and assistant, staff members #1-5 and residents #1-4. Regarding allegation: Resident sustained an injury from a fall while in care. On 5/17/22 and 5/27/22, LPA interviewed Bells Naygas regarding the above allegation and she stated LIC 9099-C is on the next page. Substantiated wasn’t aware of any residents sustaining injuries from a fall but later admitted R1 sustained injuries last month and only a bruising. She stated resident did not need to go to the hospital and R1 was seen by home health nurse the following day. LPA interviewed assistant administrator Cesilia Torres and she stated was not aware of any resident falling last month. LPA interviewed staff S1, stated there was no resident that had fell and suffered injuries but later admitted to R1 falling but stated did not see what happened but was informed of the incident. LPA interviewed staff members #2-#5, they stated R1 had fell last month and had suffered bleeding and bruising to face. LPA interview residents #1, stated suffered injuries to face the later part of April. R1 stated was assisted by a caregiver, who was supposed to transport him from the wheelchair to the bed. R1 stated caregiver proceeded to hold up by the shirt and fell onto the bed rails two times and face was injured. R1 stated caregiver kept apologizing and applied ice to face. LPA interviewed residents #2-4, they stated wasn’t aware of a resident falling. LPA obtained copy of the report log and R1 had an eye injury and was bleeding. Based on documents and interviews the above allegation is substantiated. Regarding allegation: Staff did not properly report an incident regarding a resident. On 5/17/22 and 5/27/22, LPA interviewed Bells Naygas. She stated they did not complete an incident report for R1. She stated they haven’t done an incident reports in a long time but will start submitting them. LPA interview Cesilia Torres and she stated no incident reports was completed regarding the incident. LPA interviewed staff members # 1-5 and no incident report was made regarding R1. They also stated for incidents that happen they will log in a notbook in the office and will report to staff in charge. LPA observed log book in the office of R1 incident and there was no incident report made. Based on documents and interviews the above allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D and LIC 421 FC-Failure to Correct and Repeat Violation. Exit interview was conducted and a copy of the report and appeal rights was given to Cesilia Torres..the state’s words, verbatim · CDSS document, Jun 2, 2022 · control 11-AS-20220510121555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 9, 2022

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings ... This requirement is not met as evidence by: Based on observation and interview conducted on 5/17/22 and 5/27/22, Administrator and staff stated R1's sustained and injury and was not taken to the hospital. This poses an immediate/Potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Administrator will review regulation and will train staff. Administrator will also submit a plan on how she will prevent residents from falling while in care to LPA by poc due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 82711(a)(1) · Plan of correction due date: Jun 9, 2022

87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days.. This requirement was not met as evidence by: Based on observation and interview conducted on 5/17/22 and 5/27/22, Administrator and staff did not report to CCLD R1's incident. This poses an immediate/Potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Administrator will provided to LPA incident report regarding R1 and will review regulation and train staff on the regulation and how to report incident. Administrator will submit a plan on how they will maintain reporting requirements to LPA by poc due date.

Allegation investigated: Resident was hit while in care.

On 05/26/22 Licensing Program Analyst (LPA) Jade Jordan, conducted an unannounced visit regarding allegation(s) above. LPA was met by Facility Administrator Bella Naygas, and the purpose of the visit was explained. Investigation Consisted of Physical Plant Tour, Staff Interviews, Resident interview, Record Review and copies of Physicians Report/ Needs Services, Staff and Resident Roster. Regarding Allegation: “Resident was hit while in care.” On 05/22/22 Reporting party states that Resident (R1) stated to Emergency Room Physician that they were punched/hit chest, at the facility person unknown person. Reporting Party states that C1 was interviewed by Hospital Social Worker and stated that they were punched/hitted in the face, by a black man. Name not known. Report indicates that hospital Social worker and Physician stated that R1 did not have any abnormal bruising on face, or trunk. Unsubstantiated Interviews conducted with Administrator, and caregivers generally stated that they have not had any complaints from R1 regarding an assault by anyone in the facility. 3 Staff Stated that R1 often leaves the facility with a friend. Interviews with R1 Stated that “they are 6’6 and that no one messes with them, and they have not been hit or punched by anyone.” Interviews with R2-R8 Generally stated they have not witnessed any resident in care being punched or hit at the facility. Based on LPA observation, interviews and record review The Department Finds “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.” An exit interview conducted, copy of this report provided. No citations issued during this visit.the state’s words, verbatim · CDSS document, May 26, 2022 · control 11-AS-20220523161131

Allegation investigated: Resident has unidentified bites on their body whle in care

This report serves as an amendment to the complaint report created on 05/26/2022. This report supersedes the complaint investigation findings reflected on the complaint report created on 05/26/2022, However this report was created on 4/14/23. On 1/19/22 Licensing Program Analyst (LPA) Martessa Brown conducted a 10 day visit regarding the e above listed allegations. LPA met with Cesilia Torres, the facility Assistant Administrator and the purpose of the visit was explained. LPA obtained the following documents: LIC 500 and Staff Roster, Residents #1-2 admission agreements, most recent physician reports/appraisals, needs & service, emergency contacts, medication list and records. LPA requested incident reports, pest control invoices for the past 6 months due by 1/25/22. On 5/17/22 and 5/26/22 , Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Bella Naygas the Administrator and the purpose of the visit was explained. LPA toured the medication room and reviewed R1-2 medications and logs. LPA conducted interviews with the administrator, residents #R2-R7, Staff #1-7. The investigation revealed the following: LIC 9099-C is on the next page. Substantiated Regarding the allegation: Resident has unidentified bites on their body while in care On 5/17/22 LPA interviewed Bells Naygas regarding the above allegation and she stated was not aware of any residents having scabies or bedbugs and pest control comes out to the facility once a month. LPA interviewed staff #1-7, staff stated facility had a problem bedbug and did not have scabies. LPA did not interview R1 due to not being at the facility. LPA interview residents (R2-R7), 2 out of 7 residents stated they had bedbugs in their bedrooms. LPA interviewed Witness (W1) and stated resident R1 was diagnosed with scabies when admitted to the hospital. LPA reviewed hospital records and it was indicated R1 had scabies. During the investigation the administrator did not identify that R1 had scabies and needed to have R1 seen by the doctor. Based on Interviews and documents gathered during this investigation, LPA found sufficient evidence to support that the above-mentioned allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted and a copy of the report and appeal rights was given to Cesilia Torres.the state’s words, verbatim · CDSS document, May 26, 2022 · control 11-AS-20220114151554

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(C)(5) · Plan of correction due date: May 27, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(C)Because of potential dangers related to the medication itself, or due to physical arrangements in the facility...(5) Each resident's medication shall be stored ..This requirement was not met as evidenced by: Based on observation and interviews conducted, LPA observed medication room and the residents medications were already prepared in a container 2 days in advance by administrator. This is an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 26, 2022

Plan of correction: Administrator will review the regulation and have an in-service training with all staff and have all staff sign training . Administrator will provide proof to LPA via email by 5/27/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 1, 2022

87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observation, interviews conducted and documents. LPA conducted interviews with residents, staff and social worker and it was confirmed facility has scabies and bed bugs. This is a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, May 26, 2022

Plan of correction: Administrator will review the regulation to ensure residents are to accorded safe and healthy conditions. Administrator will send a statement and come up with a plan on how she will ensure residents are provided healthful and comfortable environment. Administrator will provide proof to LPA by 6/1/22.

Type of visit: POC

On 3/1/22, Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Case Management- Legal/Plan of Corrections visit to the above facility regarding deficiencies issued on 2/17/22. LPA met with Bella Naygas-Administrator and explained the purpose of the visit. During today’s visit LPA observed upon entry on the left side of the building, Covid-19 station. LPA observed screening visitor log book and hand sanitizer. LPA also elevator not operating with a sign in front that stated do not enter. 87468.1 (2) Personal Rights of Residents in All Facilities. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. On today’s visit the POC was cleared. On 3/1/22 at 12:00 PM LPA observed Covid-19 screening station visitors log book and hand sanitizer. LPA also observed in the office Covid-19 screening questions for staff. 87303 (a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. LIC-809 is on the next page. On today’s visit the POC was not cleared. On 3/1/22 at 12:05 PM LPA observed elevator was still not operating and signs were posted. LPA was informed at the time of visit plan of correction was sent requesting more time. LPA called and spoke with LPM Hammond and extension has been granted until 3/15/22. An exit interview was conducted. “The licensee was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.”the state’s words, verbatim · CDSS document, Mar 1, 2022

Allegation investigated: Facility is not preventing the spread of COVID-19. Facility is in disrepair.

On 2/17/2022, Licensing Program Analyst (LPA) Martessa Brown and (LPM) Janae Hammond conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Bella Naygas the Administrator ad Cesilia Torres Assistant Administrator and the purpose of the visit was explained. The investigation consisted of the following: on 2/17/2022, LPA and LPM toured the physical plants. LPA observed on the 1st floor elevator southside of the building was not working. LPA conducted interviews with the Administrator, staff #2-4 and residents #1-7. LPA/LPM obtained the following documents: Resident/Staff Roster and elevator company contract/invoice completion. The investigation revealed the following: Regarding allegation: Facility does not properly screen for COVID-19. LIC 9099-C is on the next page Substantiated It is alleged that facility failed to properly screen visitors for Covid-19 On 2/17/22 LPA interviewed Bells Naygas regarding the allegation and she stated they do not have visitors except for doctors, nurses and licensing. She stated when visitors sign they check their temperatures. Administrator also stated they do not screen visitors and do not ask screening questions. On 2/17/22, LPA conducted interviewed staff #2-4 and they stated do not ask screening questions and have not observed other staff asking questions. LPA interviewed residents #1-7, they stated staff doesn't take there temperatures when they enter from outside the facility. When LPA and LPM arrived at the facility, they did check our temperature but did not observe any hand sanitizer , mask or screen log in place and there is not designated staff in charge of screening visitors. Based on LPAs observation the facility failed to comply with covid-19 procedure as identified Pin 21-38-ASC. and Pin 22-07-ASC. Regarding allegation: Facility is in disrepair. On 2/17/22, LPA conducted interview the Administrator, she stated the elevator has not been in operation since 8/2021 due to not having a part. She stated Non-Ambulatory residents have been moved to the first floor for accommodations. She stated the elevator will be working on 2/21/22. LPA conducted interviews with staff #2-4. Staff stated the elevator has been down for a while. Staff also stated they have not noticed any residents on the 2nd floor having difficulty going down the stairs due to the elevator not working. on 2/17/22, LPA interview residents #1-7 and they stated the elevator has not been working since 08/2021. Resident #7 stated they heard someone had fell down the stairs a few months ago. On 2/17/22, LPA obtained elevator repair receipts. Based on LPAs observation the facility failed to comply with the operations of the elevator. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. It is alleged that facility is not clean. On 2/17/22, LPA interviewed the administrator and she stated facility is deep clean once a week and spot cleaned daily. She stated no residents had any concerns. LPA interview staff #2-4, all residents stated the facility is deep clean once a week and spot cleaned daily. LPA Interview residents #1-7 and all residents stated the facility is deep clean once a week and spot cleaned daily. LPA/LPM walked through the facility and there was no trash left out and the facility was clean. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a hard copy was provided via email for signature.the state’s words, verbatim · CDSS document, Feb 17, 2022 · control 11-AS-20220211093906

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: Feb 25, 2022

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on LPA/LPM's observation, screening but did not observe any hand sanitizer, mask or screen log in place and there is not designated staff in charge of screening visitors. LPA did not observe a screening log in place. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Feb 17, 2022

Plan of correction: Administrator will review Covid-19 provider pins information notice and implement Covid-19 proper screen procedure and review their Mitigation Plan. Administrator will also come up with a plan on how they will maintain proper screening of visitors and staff to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 24, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation and interviews conducted, Licensee did not ensure elevator was accessible to residents in care. Elevator has been in not operating since 08/2021. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Feb 17, 2022

Plan of correction: Administrator will make sure elevator is in good condition and working at all times. Administrator will submit a plan on how they will ensure that the residents health and safety are met in the event if the elevator is down. Administrator will provide proof that the elevator is working to LPA by POC due date.

Allegation investigated: Facility is in disrepair.

On 11/8/2021, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Torres, the facilities Supervisor and the purpose of the visit was explained. The investigation consisted of the following: on 9/23/21, LPA Brown toured the physical plants. LPA observed on the 1st floor elevator southside of the building was not working. LPA interviewed Supervisor Clifford Johnson, he stated the elevator has been down since 8/18/21. LPA requested and obtained the following documents: Resident/Staff Roster, Incident report and elevator company contract/invoice completion. The investigation revealed the following: Regarding allegation: Facility is in disrepair. LIC9099-C is on the next page. Substantiated On 9/23/21, LPA conducted interview with supervisor Johnson. He stated the elevator has not been in operation since 8/18/21. He stated the original elevator company was no longer in services and had to locate a new company. He stated they have a contract with a new elevator company that will come out tomorrow to start work. LPA reviewed the contract which was a “Monthly Service Contract”. Contract did not indicate any invoice or notice on when elevator will be repaired. On 11/4/21, LPA interviewed Administrator Ella Nayqas and she stated the elevator has been down for 2 months. She stated the elevator company is waiting on a part and there is a problem with the shipping. She did not know when the elevator will be working but stated she has been contacting them every day. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit Interview Conducted, appeal rights were explained and a copy of this report was provided to Torresthe state’s words, verbatim · CDSS document, Nov 8, 2021 · control 11-AS-20210917125609

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 9, 2021

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation and interviews conducted, Licensee did not ensure elevator was accessible to residents in care. Administrator did not notify LPA that elevators was not in operations. This an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: Administrator will make sure elevator is in good condition and working at all times. Administrator will submit a plan on how they will ensure that the residents health and safety are met in the event if the elevator is down. Administrator will provide documenataion from the elevator company on when the elevator will be fixed to LPA by POC due date 11/9/2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 15, 2021

87211 Reporting Requirement (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days.. This requirement was not met as evedience by: Based on observation and interview conducted on 9/23/21, supervisor Johnson did not notify CCLD that the elevator not working. This poses an immediate/Potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: Supervisor provided to LPA incident report at the time of visi and did not notify CCLD. Administrator will review the regulation section and will send a statement that they read and understood the reporting requirements to LPA by POC date 11/15/21.

Type of visit: Case Management - Incident

On 11/8/21. Licensee Program Analyst (LPA) Martessa Brown conducted an unannounced Health and Safety visit to the above facility. LPA met with Torres, the Supervisor and disclosed the purpose of today’s visit. · On 11/4/21 LPA interviewed the administrator Ella Nayas, she stated the elevator was still not working. LPA asked for a resident roster and to indicate the non-ambulatory resident. She stated did not have known where the information was and stated Johnson was in charge but he wasn’t at the facility. During today’s visit LPA issued deficiency an plan of corrections and due date. Deficiencies cited on California code of regulations title 22, division 6, chapter 8. An exit interview was conducted and a copy the report and the appeal rights were discussed and provided to Torresthe state’s words, verbatim · CDSS document, Nov 8, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 15, 2021

87405 Administrator-Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management. This requirement was not met as evidence by. Based on observation and interview conducted on 11/4/21 Administrator did not know where the client roster and could not provide request information to LPA. This is a potential risk to residents in care.the state’s words, verbatim · CDSS document, Nov 8, 2021

Plan of correction: Administrator will review the regulation section and will send a statement that she read and understood the Administrator Qualifications & Duties to LPA by POC date 11/15/2021