Blue Jasmine Villa

Allegation investigated: Staff installed a blue light in the resident's room that is interfering with the resident's sleep. Staff did not seek consent from resident's POA or medical team to install a blue light in the resident's room.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Kaveh Chavoshpour. It was alleged that staff installed a blue light in the resident's room that is interfering with the resident's sleep. Per documentation review, LPA observed that resident 1 (R1) did have a blue light installed in the room, however upon LPA conducting an interview with R1, R1 stated "I like it" and when asked about sleep interference, R1 stated "I sleep very good" and denied of any interference with sleep. It was alleged that staff did not seek consent from resident's POA or medical team to install a blue light in the resident's room. Per documentation review and observation, it was observed that R1 had a blue light in the room but the color of the light was randomly chosen due to R1 having a light in the room that had multiple colors. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Chavoshpour. A copy of this report was provided and explained. R1's POA then expressed concerns regarding the light, therefore, R1's nurse suggested for the facility to not utilize a blue light to which then the facility changed the light to a different color instead, and did not continue to use the blue light. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Chavoshpour. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 22-AS-20230804130842

Allegation investigated: Resident is being denied medical services

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Soheila Amirmakky. Facility administrator (AD) Zahrabigom "Zahra" Fakim was unable to be present during time of visit, however provided consent for S1 to receive and sign report. It was alleged that resident is being denied medical services. LPA De Perio conducted a total of 4 interviews that consisted of staff and residents, of which the 4 interviews did not corroborate with the allegation by stating that the facility does assist residents with medical services and does not deny a resident from obtaining medical services. Per record review, on 8/16/23, resident 1 (R1) was given an order for wheelchair due to R1 being a fall risk, however the order did not specify when to use the wheelchair. LPA De Perio interviewed R1 who verified that staff offer R1 to use the wheelchair, but R1 denies in wanting to use it. R1 stated "I don't need it, so why would I use it. I walk just fine". Unsubstantiated During the tour of the facility, LPA De Perio observed that the wheelchair was located in R1's room and also observed that that R1 was ambulating independently around the facility. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with S1 Amirmakky and AD Fakim via phone call. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 22-AS-20230815123016

Allegation investigated: Staff did not assist resident with prescribed medications.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by staff on duty (S1) Soheila Amirmakky. Facility administrator (AD) Zahrabigom "Zahra" Fakim was unable to be present during time of visit, however provided consent for S1 to receive and sign report. It was alleged that staff did not assist resident with prescribed medications. LPA De Perio conducted a total of 4 interviews that consisted of staff and residents, of which the 4 interviews did not corroborate with the allegation by stating that the facility staff does assist residents with prescribed medications. 2 of the interviews conducted with residents stated that staff help "all the time". Per record review, LPA observed that facility documents when medications are given to a resident, along with updating the residents medication chart when the residents doctor prescribes new medication. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with S1 Amirmakky and AD Fakim via phone call. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 22-AS-20230816091158

Allegation investigated: Staff did not provide proper toileting assistance to resident in care

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Parinaz "Naz" Safari. It was alleged that staff did not provide proper toileting assistance to resident in care. LPA conducted interviews, and 2 of the interviews conducted with residents on 08/29/23, did not corroborate with the allegation by verifying that staff do provide toileting assistance to residents in care. LPA reviewed facility documentation that verified that nightly room checks were conducted. It was observed that per documentation, at 4:30AM, resident (R1) woke up and had an accident, therefore, staff on duty gave R1 a shower and after being cleaned, R1 went back to sleep at 5:37AM. Unsubstantiated During the tour of the physical plant of the facility, LPA observed that the facility has an adequate supply regarding toileting needs such as diapers and wipes. Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today's visit, no citations were issued. An exit interview was conducted with AD Safari. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Sep 7, 2023 · control 22-AS-20230829084614

Allegation investigated: Facility is playing music at high volume to disturb resident.

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Naz Safari. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that facility is playing music at high volume to disturb resident. During the tour, LPA De Perio observed that the facility has a small radio, and during this visit, the radio was off. LPA De Perio conducted interviews, and 2 of the interviews conducted with residents did not corroborate with the allegation by both residents denying of being disturbed when the facility plays music. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with AD Safari. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Aug 29, 2023 · control 22-AS-20230825083402

Allegation investigated: Staff did not follow home health orders for resident in care

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to deliver the findings for the complaint received on 7/10/23. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Naz Safari. It was alleged that staff did not follow home health orders for resident in care. During the course of the investigation, an interview was conducted with the reporting party (RP) who provided a direct admission stating that it was the home health agency that had made an error regarding the order for the resident (R1) and not the facility. RP confirmed that the facilty had no fault or involvement regarding this allegation. Unfounded Based on LPA’s interviews which were conducted, review of documents obtained, and observations, this allegation was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Safari. A copy of this report was explained and provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 22-AS-20230710131634

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20230726155846 . LPA was greeted and granted entry into the facility by Administrator Naz Safari and explained the reason for the visit. During the course of complaint investigation 22-AS-20230726155846, LPA reviewed a recorded video provided by facility. LPA observed there is audio recording on the video. While facility is allowed to record in common areas, audio recording are not allowed in licensed facilities. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights. Facility representative declined to sign the report or deficiency page.the state’s words, verbatim · CDSS document, Aug 10, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Aug 23, 2023

... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To have a reasonable level of personal privacy in... communications... resident and family groups This req is not being met as evidenced by:. Based on observation, Licensee failed to ensure residents are afforded privacy in communications with family or residents. Facility audio recorded with the ring device. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 10, 2023

Plan of correction: Licensee to submit a statement of understanding to LPA by POC due date.

Allegation investigated: Staff restricted ombudsman representative's right to conduct a proper facility visit

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility by Administrator Naz Safari and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff, resident, and witnesses. Regarding the allegation that staff restricted ombudsman representative's right to conduct a proper facility visit, the investigation revealed the following: On 07/25/2023, witness attempted to visit at the facility. Facility staff informed verbally that the visit would be recorded. LPA observed a sign at the entrance gate stating that visitors are on camera. Visitor did not want to be recorded and declined to come in the facility. Facility staff deny restricting the visit stating they only advised of recording. Therefore the allegations are deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility Unfoundedthe state’s words, verbatim · CDSS document, Aug 9, 2023 · control 22-AS-20230726155846

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

Allegation investigated: Resident sustained an unexplained injury while in care.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to deliver findings into the investigation of the allegation listed above. LPA was greeted and granted entry by administrator Parinaz Safari after introducing himself and stating the purpose of the visit. Administrator Kaveh Chavoshpour was notified of the findings via telephone. An initial complaint investigation visit was led on June 19, 2023. LPA accompanied by caregiver conducted a tour of the physical plant. Resident records for the three residents in care requested, obtained and reviewed during the visit. Hospital records requested and obtained from Hoag Hospital Irvine. It is alleged that resident R1 sustained a head injury due to a fall at the facility on June 14, 2023. Paramedics were called to the facility and transferred the resident to the Emergency Department at Hoag Hospital in Irvine for evaluation. Resident received a CT scan and was discharged to the facility later the same evening. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Hospital discharge notes reviewed indicate: "6/14/2023 11:51 PM PDT The patient's condition did not warrant admission to the hospital. Patient is clinically stable, the emergency department evaluation does not indicate that they are in danger of imminent deterioration, and deemed safe for outpatient management." No mention is made of a concussion diagnosis at that time. An incident report submitted by the facility indicates that the injury was sustained while the resident was attending an adult day care program. Declarations gathered at bedside in the Emergency Department are inconsistent and place the incident both at the residential care facility and at the adult day care program. Video footage from the morning of the day the incident occurred do not allow to corroborate the presence of facial bruising upon departure from Blue Jasmine Villa that morning. As a result, the allegation listed above is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 21, 2023 · control 22-AS-20230614135946

Allegation investigated: Licensee/Administrator is harassing the resident about paying more money for rent. Licensee/Administrator is entering the residents room without permission requesting the resident pay more rent money.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility for the complaint received on 3/8/2023 to deliver the findings. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Kaveh Chavoshpour. It was alleged that licensee/administrator is harassing the resident about paying more money for rent. LPA De Perio conducted a total of 3 interviews that consisted on staff and residents. LPA was unable to conduct an additional 3 interviews due to unavailability. 3 out of the 3 interviews conducted did not corroborate with the allegation. 1 out of the 3 interviews conducted also denied of ever witnessing or hearing any forms of harassment take place. Per record review, it was found that resident (R1) is behind on the monthly fees due, and gets upset when the topic of needing to pay is brought up. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. It was alleged that licensee/administrator is entering the resident’s room without permission requesting the resident pay more rent money. LPA De Perio conducted a total of 3 interviews that consisted on staff and residents. LPA was unable to conduct an additional 3 interviews due to unavailability. 3 out of the 3 interviews conducted did not corroborate with the allegation. 1 out of the 3 interviews conducted, shares a room with R1, who stated that staff "are respectful of our space”. LPA De Perio conducted record reviews of regarding R1. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. For today's visit, no citations were issued. An exit interview was conducted with AD Chavoshpour and a copy of this report was explained and provided to the facility.the state’s words, verbatim · CDSS document, May 4, 2023 · control 22-AS-20230308160812

Allegation investigated: Facility has not provided POA with requested documentation.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced 10-day visit to this facility for the complaint received on 4/14/2023 and to deliver the findings. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Zahrabigom Fakhim. For today's visit, there are a total of 4 residents in care of which 1 is on hospice and 2 staff members on duty. On today’s visit, LPA De Perio conducted file reviews, obtained pertinent documents, and conducted interviews. This department has investigated the complaint alleging that facility has not provided POA with requested documentation. Unfounded LPA conducted an interview and reviewed documents which consisted of the following but not limited to: the facility admission agreement, and email exchanges directly from the reporting party (RP) and staff. On 4/14/23, RP requested for invoices copies from the facility, of which AD did not deny in providing, and stated that documents requested will be sent to RP on 4/17/23. On 4/17/23, AD provided RP with the invoices, payment receipts and itemized lists dated from 7/26/22-4/30/23 per RP request, of which RP acknowledged and confirmed on 4/19/23. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. For today's visit, no citations were issued. An exit interview was conducted with AD Fakhim and AD Chavoshpour (via phone call) and a copy of this report was explained and provided to the facility.the state’s words, verbatim · CDSS document, Apr 24, 2023 · control 22-AS-20230414151941

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to follow-up on an incident report that was received on 4/20/23. LPA explained reason for visit, and was greeted by facility administrator (AD) Zahrabigom Fakhim, who also informed AD Kaveh Chavoshpour about visit. On 4/20/23, the facility reported that a resident (R1), did not arrive to the facility after first day of day program. LPA De Perio conducted an interview with AD Chavoshpour via phone call, who informed LPA about the incident. It was stated that R1 was scheduled to be dropped off at the facility by the OCTA bus by 2:30 PM on 4/19/23, however at around 4:00PM, R1 had not arrived to the facility, to which AD Chavoshpour contacted the day program social worker, who contacted R1's responsible party about the incident. Day program social worker, then contacted R1's responsible party and 911, and both responsible party and police arrived to the facility prior to looking for the R1. At 6:20PM, R1 returned to the facility and it was found that the OCTA bus dropped R1 off at the wrong location. Staff assessed R1 for any injuries and no injuries were noted. LPA De Perio also reviewed the video footage obtained from the facility Ring camera, and observed R1 returning to facility at 6:20PM, with R1's responsible party and police present. For today's visit, no citation issued. An exit interview was conducted with AD Fakhim, and AD Chavoshpour (via phone call) and a copy of this report was explained and provided to the facility.the state’s words, verbatim · CDSS document, Apr 24, 2023

Allegation investigated: Staff do not provide care and supervision to resident(s) during the night. Staff are not ensuring that resident's toileting needs are being met while in care.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility for the complaint received on 2/22/2023 to deliver the findings. LPA De Perio explained reason for visit and met with facility administrator (AD) Parinaz "Naz" Safari. For today's visit, there are a total of 4 residents in care of which 1 is on hospice. (SEE LIC9099-C) Unfounded This department has investigated the complaint alleging that staff do not provide care and supervision to resident(s) during the night. LPA conducted record reviews and interviews which consisted of 2 staff and 4 residents. LPA reviewed the following documents such as but not limited to: the resident roster, staff roster, staff schedule, the facility admission agreement, the resident’s physician report, and further documents regarding supervision at night such as the nightly bathroom log. LPA also conducted a total of 6 interviews of which 1 interview was unable to be conducted due to unavailability, and the remainder of the 5 interviews did not corroborate with the allegations due to reporting that the facility staff provides each resident with a call button to utilize to notify staff if assistance is needed. 1 of the interviews also added that the staff present at night will check on residents a minimum of twice a night. When LPA conducted a tour of the facility, LPA tested all the resident call buttons and observed that all buttons were functional and operational, and that once the button was pressed, an alarm will sound throughout the facility to notify staff. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This department has investigated the complaint alleging that staff are not ensuring that resident's toileting needs are being met while in care. LPA conducted record reviews and interviews which consisted of 2 staff and 4 residents. LPA conducted a total of 6 interviews, of which 1 interview was unable to be conducted due to unavailability, and 5 of the remaining interviews did not corroborate with the allegation. LPA reviewed the following documents such as but not limited to: the resident roster, staff roster, staff schedule, the facility admission agreement, receipts of toiletry supplies, bathroom log from August 2022-February 2022, and the resident’s physician report. LPA also conducted a tour of the interior portion of the facility and observed that the facility had an adequate supply of toiletry supplies (such as: diapers and pads), which is located inside the facility and in the garage. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. For this visit, no citations were issued. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 10, 2023 · control 22-AS-20230222123029

Allegation investigated: Facility failed to provide responsible party with information requested for resident's medical appointment.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility for the complaint received on 3/7/2023 to deliver the findings. LPA De Perio explained reason for visit and met with facility administrator (AD) Kaveh Chavoshpour. For today's visit, there are a total of 4 residents in care of which 1 is on hospice. (SEE LIC9099-C) Unfounded This department has investigated the complaint alleging that facility failed to provide responsible party with information requested for resident's medical appointment. LPA conducted record reviews and interviews which consisted of residents and staff. A total of 5 interviews were conducted, of which 2 of the interviews did not corroborate with the allegation, and 3 of the interviews were unable to be conducted due to unavailability. LPA reviewed the following documents but not limited to: the staff roster, the resident roster, the facility admission agreement, resident’s physician report, and additional forms of communication (via email) between the facility and responsible party. Per record review, on March 3, 2023, the facility provided resident’s responsible party with the following information: meal report, medication record and administration report, and sleep report. On March 6, 2023, the responsible party responded to the email and confirmed that the information provided was received. In the responsible party’s response, there were inquiries regarding meal times, to which the facility responded within an hour. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Chavoshpour and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 27, 2023 · control 22-AS-20230307083958

Allegation investigated: Resident was overmedicated while in care resulting in overdose. Facility obtained medications for resident without authorization.

Licensing Program Analyst (LPA) Michelle Reed met with Staff Parinaz Safari to discuss the complaint findings for the above allegations. Administrator Kevin Chavoshpour was not able to come to the facility. The investigation consisted of interviews with staff, Resident #1(R1), Administrator as well as witnesses. Records from the facility and the hospital were also reviewed. The following was determined: The Department received a complaint regarding allegations that Resident #1 (R1) was overmedicated while in care resulting in overdose and that the facility obtained medications for resident without authorization. (R1) was admitted into the facility on November 4, 2020. R1 had chronic pain and was prescribed multiple opiate pain medications. On February 2, 2021 at approximately 11:15 am, R1 became lethargic and 911 was contacted by facility staff. R1 presented at the ER with an altered mental status and sepsis due to an acute UTI with fecal impaction. Narcan was given. Unsubstantiated According to hospital records dated February 2, 2021, page 92 of Hospital History and Physical, the cause of R1’s altered mental status involved a number of factors. “The first was likely due to polypharmacy, however, it was also aggravated by the UTI and fecal impaction. It was unclear how much medication R1 actually had been getting from the board/care facility.” Records and interviews disclosed that R1 was getting prescriptions from two different Doctor’s. According to text messages provided between the responsible party and the Licensee, the responsible party was aware of the doctor’s and pharmacy used by the facility. Based upon interviews and a review of R1's records, these allegations are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Parinaz Safari and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2023 · control 22-AS-20210205142629

Allegation investigated: Resident's medication was changed without authorization Facility failed to seek medical attention Unlawful eviction

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 12/6/22 against this facility. For today’s visit, there are a total of 4 residents in care of which 1 is on hospice. (SEE LIC9099-C) Substantiated The Department has investigated the complaint alleging that resident’s medication was changed without authorization. During the course of the investigation, LPA De Perio conducted interviews with staff, residents as well as record reviews such as, but not limited to: resident’s physician report, medication log dated from November 2022-Janruary 2022, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers. Initially, it appeared that that the facility staff were following the prescribed medications per physician orders, as was indicated on the resident’s centrally stored medication log. However, upon further review, it was determined that on one occasion, the resident’s responsible party and facility administrator were in communication, and the facility administrator informed the responsible party that the medication (Depakote) was being decreased, but there were no official orders for this change from the prescribing physician. LPA conducted a total of 6 interviews of which 3 of the interviews did not corroborate with the allegation due to the individuals not having any knowledge about medication changes and authorizations. 1 interview was unable to be conducted due to unavailability, and 1 interview corroborate with the allegation. Based on the LPA’s investigation, which consisted of interviews and record reviews the Department has found that the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. The Department has investigated the complaint alleging that the facility failed to seek medical attention for resident #1 (R1). LPA De Perio conducted interviews with facility staff and residents. LPA conducted a total of 6 interviews, of which 4 out of the 6 interviews stated that the facility does contact 911 if medical attention is needed, and the 2 remaining interviews did not corroborate with the allegation due unavailability and having no knowledge in relation to the allegation. In this particular case, however, R1’s responsible party observed an injury on R1’s head and proceeded to inquire why the facility staff did not seek medical attention for R1. The facility administrator replied to R1’s responsible party that 911 was not contacted due to the injury being “just a scratch”. LPA reviewed the picture of R1’s injury and observed a raised, bruised bump on R1’s forehead above R1’s left eye with a scratch, which required medical attention. Based on the information gathered through the course of the investigation, the Department has found that the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The Department has investigated the complaint alleging that facility failed to report incidents to R1’s responsible party. LPA De Perio conducted record reviews such as, but not limited to: resident’s physician report, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers, and interviews with staff, residents, and residents’ responsible parties, and found that the facility keeps in contact with responsible parties via text message and verbal conversation and will notify the resident’s responsible party with changes of condition, behaviors and incidents. LPA conducted interviews with residents’ responsible parties, it was stated that the facility staff will inform them of any incidents either verbally or via text message. LPA conducted a total of 8 interviews which consisted of staff, residents and responsible parties. 1 out of the 8 interviews were unable to be conducted due unavailability, 4 out of the 8 interviews did not corroborate with the allegation, and 3 out of the 8 interviews verified that facility does report incidents to the responsible party. to One responsible party stated, “every time there was an update, they told me right away". The reporting party is stating that incidents were not reported to the responsible party, however, according to emails between the facility and responsible party, incidents were reported via email, text message and in person. Based on interviews and review of records obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has investigated the complaint alleging that facility falsified documents. During a visit initiated on 12/12/22, LPA De Perio conducted record reviews such as, but not limited to: resident’s physician report, medication log, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers, and interviews with staff and residents, and any other individual specified on the indicated incident reports. LPA conducted a total of 6 interviews of which 1 interview was unable to be conducted due to unavailability, 3 out of the 8 did not corroborate with the allegation, and 2 out of the 8 interviews did corroborate. 1 of the interviews that corroborated with the allegation described the incident that occurred as reported on the incident reports the facility provided Community Care Licensing. Per record review, the facility has submitted incident reports regarding altercations that have occurred in the facility involving R1. The interviews conducted stated that R1 has behaviors and provided information regarding how staff handle the situation and de-escalate. During this visit, LPA De Perio also observed R1 having an allegation, yelling and getting close to resident 2’s (R2) face. R1 was quickly redirected by staff. Facility has also submitted incident reports to the Department between the time frames of 12/1/22-1/25/23. If there was another resident involved, LPA conducted interviews that corroborated with the reports that were submitted to the Department. Based on interviews and review of records obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted a copy of this report and Appeal Rights were provided to the facility. The Department has investigated the complaint alleging that facility issued an unlawful eviction. LPA conducted record reviews, such as, but not limited to incident reports, communication between the facility and responsible party, medical documents, eviction notices and interviews with staff, resident’s responsible party, and Ombudsman. On 12/6/22, the facility administrator (AD) issued resident and resident’s responsible party a 3-day eviction prior to notifying Licensing agency. On 12/7/22, AD rescinded the 3-day eviction notice and provided the resident and resident’s responsible party an official 30-day eviction notice on 12/28/22. On 2/3/23, the facility issued a 60-day eviction. Based on the LPA’s investigation, which consisted of interviews and record reviews the Department has found that the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. For today's visit, citations were issued per Title 22 California Code of Regulations. An exit interview was conducted with both AD's and a copy of this report, annd Appeal Rights were provided to the facility. The Department has investigated the complaint alleging that facility is not following physician orders. LPA De Perio conducted record reviews such as, but not limited to resident’s physician report, medication log facility admission agreement, incident reports, communication between the facility, responsible party, medical providers and interviews with staff and residents. LPA conducted 6 interviews of which 2 of the interviews stated that the facility does follow physician orders, and the remaining 4 interviews did not provide any further information due to difficulty understanding or unable to answer. According to the allegation, the facility is not following physician orders as the facility was not ensuring that the wrist brace given to the resident, was worn at all times. Per record review of the doctor’s order, on 12/2/22, the resident attended an appointment for a wrist exam. On 12/5/22, the responsible party informed the facility via text message that the wrist brace must be kept on the resident. Per doctors note received on 12/28/22, it stated that the wrist brace was advised to use if the resident was experiencing any pain. LPA De Perio conducted an interview with the resident on 12/12/22, who freely moved her wrist and stated, “this feels good” and also reported that there was a wrist brace, but “did not need it”. LPA De Perio also conducted a tour of the resident’s room and observed a wrist brace in the room. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED An exit interview was conducted a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20221206134752

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(c) · Plan of correction due date: Mar 16, 2023

87224 Eviction Procedures (c) The licensee shall...seeking approval from the Department... This requirement was not met as evidence by: Licensee issued a 3-day eviction to the resident and rseponsible party on 12/6/22, and recinded it on 12/7/23. Threat reduced. This can pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: As POC, licensee will send assigned LPA proof of understanding regarding the regulation cited on or by 3/20/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Mar 16, 2023

87465 Incidental Medical and Dental Care (e) For every prescription... there shall be a signed, dated written order from a physician... This requirement is not met as evidence by: Based on LPAs observations, record reviews and interviews, licensee failed to obtain a dated, written order from a physican. This can pose an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: As POC, licensee will provide assigned LPA with proof of understanding of the regulation cited on or by 3/20/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a) · Plan of correction due date: Mar 16, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Based on LPAs observations, record reviews and interviews, licensee failed to report resident's injury to licesning agency. This can pose an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2023

Plan of correction: As POC, licensee will provide assigned LPA with proof of understanding of the regulation cited on or by 3/20/23.

Allegation investigated: Facility is unsanitary.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 12/13/22 against this facility. For today’s visit, there are a total of 4 residents in care of which 1 is on hospice. Unfounded The Department has investigated the complaint alleging that facility is unsanitary. LPA De Perio conducted record reviews and interviews, of which all interviews conducted reported that facility is clean, and 1 interview specifically shared “they are cleaning all the time”. LPA conducted a total of 7 interviews with staff, residents, and the Ombudsman, of which 7 out of the 7 interviews conducted reported that the facility is clean. LPA De Perio also conducted a tour of interior portion of the facility and observed that all bedrooms had furniture in good condition and no odors. On 12/11/22, a welfare check was conducted by Irvine Police department, and per police report, it indicated that the resident was clean and happy. During the visit conducted on 12/20/22, LPA De Perio was also notified by staff that when a resident has an accident, one staff member will clean the resident, and the other staff member will clean the area where the accident took place. On 2/9/23, the assigned care coordinator from the Assisted Living Waiver program was instructed to check on the resident, of which the care coordinator stated that the resident was also observed to be clean and happy. Based on interviews and review of records obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to the facility. The Department has investigated the complaint alleging that facility is not allowing residents to have visitors. LPA conducted record reviews and interviews with staff, residents, resident’s responsible party and Ombudsman. LPA conducted a total of 7 interviews with staff and residents, and 5 out of the 7 interviews stated that facility has not actually denied visitors, and the 2 remaining interviews did not corroborate with the allegation due unavailability and having no knowledge in relation to the allegation. On 12/9/22, facility administrator issued reporting party a “Visiting Notice” stating that reporting party was not allowed to visit due to violating the facility’s visiting policy through interactions and behaviors with residents and staff, which was described as “harassment”. Upon administrator consulting with the Department after visitation notice was issued, the Department disclosed that the facility is unable to deny visitation, therefore, facility administrator issued a revised notice on 12/28/22 stating that facility staff is able to request for a visitor to leave the premises if the facility visitation policies are being violated. During the time frame of 12/9/22-12/28/22, facility verified that visitors were not denied, and per reporting party, it was also stated that the facility did not actually deny visitation, despite visitation notice being issued. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. The Department has investigated the complaint alleging that resident missed medical appointments. LPA De Perio conducted file reviews and interviews with residents, and staff, and it was reported that residents have their family take them to their appointments or are able to independently attend appointments on their own. On 12/20/22, per facility, the responsible party had scheduled an appointment on behalf of the resident, however, did not show up to pick the resident up. On 12/27/22, the reporting party stated that the facility is still “denying” taking the resident to appointments, of which on 1/23/22, the facility reiterated to responsible party that they are unable to do so due to the residents behaviors. In addition, per facility admission agreement, it states that the facility will take measures to ensure that the resident will keep all medical and dental appointments. LPA conducted a total of 6 interviews, and 3 out of the 6 interviews conducted denied that any appointments were missed, and the 3 remaining interviews did not corroborate with the allegation due unavailability and having no knowledge in relation to the allegation. In addition, the facility agreement also states that the facility will assist in arranging outside transportation to ensure that appointments are kept, and the remaining 3 interviews did not with the allegation due to either not having knowledge in relation to the allegation, or due to unavailability. The facility also expressed that if a resident is exhibiting physical behaviors that are “dangerous” (such as: kicking, punching, pushing), then the facility will inform the resident’s responsible party in order to coordinate ways and agree on a plan, to ensure that the resident is able to attend the appointment. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED An exit interview was conducted and a copy of this reported was provided to the facility.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20221213143447

Allegation investigated: Staff are not refilling resident’s prescriptions in a timely manner.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 1/17/23 against this facility. For today’s visit, there are a total of 4 residents in care of which 1 is on hospice. Unsubstantiated The Department has investigated the complaint alleging that staff are not refilling resident’s prescriptions in a timely manner. LPA conducted a total of 6 interviews with staff and residents, and 5 out of the 6 interviews conducted stated that resident’s prescriptions are refilled in a timely manner and that residents do get their medications, and 1 interview was unable to be conducted due to unavailability. LPA conducted record reviews and found that upon admission of the resident (R1), the responsible party verbally consented to utilize the facility doctor on behalf of R1. Per interview, if a resident is utilizing the services of the facility doctor, and if medications are prescribed, the partnering pharmacy (Brightside Pharmacy) will conduct automatic refills on medications. However, on 1/8/23, it was stated that due to the responsible party switching R1’s doctors, the second/current doctor provided a notice stating that R1 is only under the care of the current doctor, the facility doctor did not submit a request for refills for the R1 due to the change in medical providers. It was noted that the second doctor did not submit a request for the R1’s medication. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20230117150233

Allegation investigated: Facility did not provide requested medical information to resident's responsible party in a timely manner.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 1/25/23 against this facility. For today’s visit, there are a total of 4 residents in care of which 1 is on hospice. Unfounded The Department has investigated the complaint alleging that facility did not provide requested medical information to resident's responsible party in a timely manner. LPA conducted record reviews such as, but not limited to resident’s physician report, medication log, facility admission agreement, incident reports, communication between the facility, responsible party and medical providers, and interviews with staff, residents, responsible parties and Ombudsman. LPA conducted a total of 8 interviews of which 1 was unable to be interviewed due to unavailability, 3 out of the 8 interviews corroborated with the allegation, 4 out of the 8 did not provide further information regarding the allegation. On 1/8/23, the facility administrator sent the responsible party the requested documentation specifically regarding the resident’s medication record and medical information. In addition, the administrator provided the requested documentation to the responsible party in person, via text, faxed it to the resident’s preferred doctor twice and gave copies to the Ombudsman. On 12/16/22 facility’s Ring camera recorded via video footage that both the Ombudsman and responsible party obtained copies of the requested medical information from the administrator. On 1/23/23, the responsible party requested that the administrator send the same resident’s medical information by 1/25/23 by 10 AM. On 1/25/23, the administrator reminded the responsible party via email that the requested information and documents were emailed on 1/12/23; nonetheless, he provided the requested documentation again for the responsible party’s reference. On 1/1/23 and 1/24/23, the administrator also sent the responsible party the resident’s weekly report and medication log, per request of responsible party. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20230125162114

Allegation investigated: Facility has not provided POA with requested documentation Facility does not communicate with POA Facility not billing properly Resident bedrooms doors have a lock that required a code

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to this facility. LPA De Perio met with Facility Administrators, Kaveh Chavoshpour and Parinaz “Naz” Safari and stated the purpose of this visit which was to deliver the final findings for the complaint received on 12/16/22 against this facility. For today’s visit, there are a total of 4 residents in care of which 1 is on hospice. Unfounded The Department has investigated the complaint alleging that facility has not provided Power of Attorney (POA) with requested documentation. Per documentation reviews and interviews conducted by LPA, it was found that facility did provide POA with the requested documentation on 1/8/23 and 1/12/23, specifically, regarding the resident’s medication record for November 2022-December 2022. The information was sent via text message, and the medication record for December 2022 was provided in person to the POA, Ombudsman, and faxed to the POA’s preferred doctor. Based on interviews and review of records obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has investigated the complaint alleging that facility does not communicate with POA. LPA conducted interviews and documentation reviews and found that facility and POA communicate in person, through verbal conversation, through text messages, and email. LPA also conducted additional interviews with responsible parties of current residents and of residents who have previously lived at the facility, all of which stated that the facility does communicate with the POA either via verbal conversation or via text message. LPA conducted a total of 8 interviews and 6 out of the 8 interviews conducted all reported that facility communicates with POA via verbal conversation, via phone call or text, or email and the 2 remainder of interviews did not corroborate with the allegation due to unavailability, and unable to provide further information regarding this allegation. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has investigated the complaint alleging that facility is not billing properly. LPA conducted interviews and documentation reviews and found that the facility is in partnership with the Assisted Living Waiver (ALW) Program, of which part of the financial aspect of the resident paying for a facility goes through ALW. On 11/8/22 and 12/15/22, the facility sent a notice that the responsible party is withholding the payment for the month of December 2022 due to feeling as if there was an overcharge. It was verified by the ALW Director on 1/4/23, that the facility had not been overcharging the resident and that the amount the resident has been charged in December 2022, is correct. On 12/23/23, the facility verified with responsible party that the payment amount was correct and on 1/26/23, an itemized list was issued to show for the breakdown of expenses, and in January 2023, the resident still had an unpaid balance that was owed. Per review of the documents provided by the ALW Director, and confirmation that the amount was correct, the responsible party owed a total of $1,365.77 for the month of December. In addition, it was found that in the facility admission agreement, the facility will provide incontinence supplies which would cost and extra $150.00, and upon the resident being admitted to the facility, the responsible party denied incontinence supplies and instead, would provide it to the facility. However, as resident started to progress in condition, and began to need incontinence supplies, the responsible party did not pay for it. It was stated that per facility admission agreement, if a resident needed incontinence supplies, the responsible party had the option to either accept the terms, meaning that the facility will pay for the supplies, of which that fee will be included in the monthly statement, or deny the terms, of which the responsible party will separately pay and supply the facility and resident with the incontinence. On 2/6/23, ALW director verified the amount again and stated that the fees were correct. Per LPA’s review of the signed admission agreement, it was determined that the responsible party denied this portion of the facility admission agreement. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has investigated the complaint alleging that resident bedroom doors have a lock that required a code. LPA conducted interviews, record reviews and toured the facility and it was found that there are only three locks in the following locations of the facility: the door leading to the garage, the caregiver room, and one resident room. Per interviews with the residents residing in the room with the lock, both residents requested for the lock to be in place. LPA conducted a total of 6 interviews of which 4 corroborated with the allegation, 1 was unavailable for an interview, and 1 was unable to continue with the interview. LPA reviewed charts of both residents whose door has a lock, and found that both residents do not have any cognitive impairment. The code to the lock is also labeled on the lock, and residents are able to open the door without a lock from the inside of their room. LPA also verified that there is no lock from inside the resident’s bedroom, only on the outside door. Based on the interviews conducted and documentation obtained, the Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20221216090339

Allegation investigated: Facility failed to advise primary care physician of change in medications

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit on January 6, 2023 to investigate the complaint allegation listed above. During the initial visit LPA Haley conducted interviews with the facility Licensee/Administrator, House Manager/Caregiver Staff 1 (S1), Staff 2 (S2), Resident 1 (R1), and Resident 2 (R2). LPA Halley conducted a second unannounced visit to compete resident interviews and gather additional information. During the second visit, LPA Haley interviewed, the Licensee/Administrator for a second time, Resident 3 (R3) and Resident 4 (R4). Further, LPA Haley conducted a telephone interview with Resident 4's (R4) responsible party. Regarding the allegation, Facility failed to advise primary care physician of change in medications During the investigation, LPA Haley discovered R4 was seeing multiple medical professionals/primary care physicians Continued on LIC9099C Unsubstantiated LPA Haley received copies of text messages sent October 23, 2022 that confirm R4’s responsible party was made aware of an increase in R4’s medication. Additionally, LPA Haley received a screen shot of a message that was sent from R4’s responsible party to the licensee regarding a decrease in one of R4’s medications. Further, after reviewing numerous text exchanges between R4’s Responsible Party and the Licensee, it was determined that R4’s responsible party provided instructions and attempted to provide direction/coordination regarding prescriptions/dosages between R4’s psychiatrists, neurologist, and physician who were all treating R4 as evidenced by text messages sent October 23, 2022 and November 10, 2022. Based on the information gathered during the investigation, review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20221228143511

Allegation investigated: Facility failed to respect resident's personal right to chose physician Facility is retaliating against resident for complaining

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit on January 6, 2023 to investigate the complaint allegations listed above. During the initial visit LPA Haley conducted interviews with the facility Licensee/Administrator, House Manager/Caregiver Staff 1 (S1), Staff 2 (S2), Resident 1 (R1), and Resident 2 (R2). LPA Halley conducted a second unannounced visit to compete resident interviews and gather additional information. During the second visit, LPA Haley interviewed, the Licensee/Administrator for a second time, Resident 3 (R3) and Resident 4 (R4). Further, LPA Haley conducted a telephone interview with Resident 4's (R4) Responsible Party. Regarding the allegation, Facility failed to respect resident's personal right to choose physician During the initial unannounced visit LPA Haley conducted five interviews (3 Staff, 2 residents) and no staff or resident could corroborate the allegations above. Continued on LIC9099C Unfounded Further, LPA Haley was provided with text message documentation between the Licensee and R4’s Responsible Party regarding R4’s physician. With the change in physician in question, it was clear from the text messages dated August 15, 2022, August 23, 2022, and August 31, 2022 the responsible party was in agreement to allow R4 to be seen and treated by Blue Jasmine Villa’s facility physician. It is unclear if Blue Jasmin Villa’s in-house physician was ever designated as the only physician to see R4; however, it was clear R4’s responsible party was aware R4 was being seen by the in-house physician, in communication with the facility in-house physician, and asked if the in-house physician could treat R4 for what appeared to be a “foot fungus on R4’s foot.” It is unclear from the text messages provided if R4 was treated for the foot fungus or not. Per the licensee, the in-house physician sent a nurse out to the facility and the “fungus” was treated with a cream. Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Facility failed to respect resident's personal right to choose physician, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Regarding the allegation, Facility is retaliating against resident for complaining During the investigation, six interviews were conducted with Staff and Residents (3 Staff, 3 Residents) and 1 more attempted resident interview with R4, all of which did not or could not corroborate the allegation above. LPA Haley discovered R4 has not been retaliated on in anyway. Furthermore, R4 has not made a single complaint against Blue Jasmine Villa. Based on the information gathered during the investigation, observation, and review of all documents obtained, the following allegation: Facility is retaliating against resident for complaining, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 22-AS-20221228143511

Allegation investigated: Facility staff refused to give resident medication as prescribed by resident's physician.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced 10-day visit to this facility for the complaint received on 2/1/2023 and to deliver the findings. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Kaveh Chavoshpour. For today's visit, there are a total of 3 residents in care of which none are on hospice and 2 staff members on duty. On today’s visit, LPA De Perio conducted file reviews, obtained pertinent documents, and conducted interviews. (SEE LIC9099-C) Unfounded This agency has investigated the complaint alleging that facility staff refused to give resident medication as prescribed by resident's physician. Per documentation reviews and interviews, reporting party provided an email to AD stating that the resident's medication dosage was increased, however, in response, AD requested for a written note from the prescribing physician to confirm the medication increase prior to giving the resident the new dosage amount. On 2/1/23, AD contacted the doctor to verify the increased dosage as stated by RP, and received confirmation from the doctor stating that the resident's medication was not changed as of 1/30/23. Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Chavoshpour and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 6, 2023 · control 22-AS-20230201090603

Allegation investigated: Facility is not transporting resident to medical appointments.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced 10-day visit to this facility for the complaint received on 2/3/2023 and to deliver the findings. LPA De Perio explained reason for visit and met with facility administrator (AD) Parinaz "Naz" Safari. For today's visit, there are a total of 3 residents in care of which none are on hospice and 2 staff members on duty. On today’s visit, LPA De Perio conducted file reviews, obtained pertinent documents, and conducted interviews. (SEE LIC9099-C) Unfounded This agency has investigated the complaint alleging that facility is not transporting resident to medical appointments. Per facility admission agreement, on page 2 under the section titled "Basic Services" it states "assistance in meeting necessary medication and dental needs as follows: assuring appointments are kept, arranging for transportation when necessary" . On page 7, section titled "Transportation" it states "Transportation arrangements to meet the health and dental needs of the resident. Resident financial responsibility. Facility will assist in arranging for transportation needs, facility will call for emergency vehicle when need arises, a planned activity program and transportation to participate in community events/activities, and listed transportation options such as OCTA ACCESS, TRIPS, Age Well Transportation", of which facility obtained a signature from the responsible party upon resident's admission acknowledging and consenting to this section. In addition, confirmation was received from the Assisted Living Waiver program director confirming that it was relayed to the resident's responsible party "that the facility is only responsible for ensuring that the resident gets to their appointments" reporting party also stated "I understand that it is not the facility's responsibility". Based on observations and review of documents obtained, we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with AD Safari, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 6, 2023 · control 22-AS-20230203171639

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine De Perio made an unannounced case management visit at facility to follow up on Special Incident Report (SIR) regarding an incident that occurred on 11/4/22 between two residents. LPA De Perio was greeted and granted entry by facility administrator (AD) Parinaz "Naz" Safari who checked prior to entering facility. For this visit, there were a total of 4 residents in care, of which 0 are on hospice, and 1 staff on duty. Per SIR, resident #1 (R1) got into an altercation with resident #2 (R2), when R1 grabbed R2's playing cards. R2 asked R1 to "nicely" leave her alone, and R1 responded with "shut up, don't tell me what to do". Upon staff attempting to de-escalate situation, R1 attempted to punch AD Safari. A total of 3 staff members were able to redirect R1, and no one was hurt. LPA De Perio conducted file reviews on both residents and interviewed both residents. LPA De Perio observed R1 in the living room watching television, and upon LPA De Perio inquiring how R1 was doing, R1 stated that she was doing "good". R1 was unable to continue with interview due to difficulty communicating. LPA De Perio observed R2 was playing puzzles on the kitchen table. Upon inquiring to R2 about what occurred during incident, R2 stated "she (R1) was just having one of her behaviors again", but informed LPA De Perio that no one was hurt, and that there were no safety concerns. LPA De Perio inquired to R2 about the measures staff took to redirect R1, and R2 stated "they're good, they tell her to go to her room and she listens to them. They're always there to step in". For today's visit, no deficiencies were issued, and no citations issued. LPA De Perio conducted an exit interview with AD Safari and a copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Nov 23, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty/facility administrator Parinaz "Naz" Safari who checked temperature prior to entering facility. During the visit, 1 staff was on duty, who also contacted facility administrator (AD) Kaveh Chavoshpour about visit. As of 10/21/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the main entrance. LPA De Perio observed the Administrator's Certificate for Kaveh Chavoshpour, which expires on 3/6/23, Parinaz Safari, which expires on 1/20/24 and Zahrabigom Fakhim which expires on 11/6/23. LPA De Perio toured the interior and exterior portions of the facility with AD Safari. The facility is a single level structure and is licensed for 6 non-ambulatory residents 60 years and over, of which 6 may be bedridden and there is a hospice waiver for 4. For this visit, there are a total of 3 residents in care, 0 on hospice, and 0 bedridden. There are a total of 4 bedrooms, of which 1 is a private resident room, and 2 shared resident room and 1 room for staff. Per interview with AD Chavoshpour, although facility is licensed for 6, facility only plans on accepting a maximum of 5 residents. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms of which 1 is for staff and 1 is for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 108.3 degrees Fahrenheit and hand washing signs were also posted in each restroom. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care, and is located in a kitchen cabinet. Fire extinguisher was charged, mounted and located in the garage. LPA De Perio observed the emergency disaster and evacuation plan, which is posted at the entrance of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components, and is mounted on the living room wall. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in the garage and is inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents in care and is located in the garage. Garage is also locked at all times. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates on one side of the facility, which were observed to self-closing and self-latching. No bodies of water were observed. LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Chavoshpour. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA De Perio discussed with AD Chavoshpour to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov. LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Chavoshpour. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA De Perio advised AD Chavoshpour to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA De Perio conducted an exit interview with AD Chavoshpour and a copy of this report and copies of the regulations discussed were provided to the facility.the state’s words, verbatim · CDSS document, Oct 21, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced Case Management visit to facility. LPA De Perio was greeted by facility administrator (AD) Parinaz "Naz" Safari who took temperature prior to entering facility and verified that there are no active COVID cases as of 8/1/22. AD Safari also contacted AD Kaveh Chavoshpour to notify him about visit and communicated with LPA De Perio via phone call. Currently, there are a total of 2 residents in care, of which none are on hospice. LPA De Perio observed AD certificate for Parinaz Safari which expires on 1/20/24 and Kaveh Chavoshpour which expires on 3/6/23. The purpose of this Case Management visit was to follow up on a call LPA De Perio received from Ombudsman Lynette Fugitani in regards to a concern of a locked gate blocking the main entrance front door of the facility and not being able to access the main doorbell. Upon arrival, LPA De Perio observed a gate with a numerical code lock, and a Ring doorbell with a camera which was operational and functional. LPA De Perio was informed by AD Safari that the main facility door is not locked due to residents wanting to walk outside, and that instead, the gate is used as the "main door". Based on LPA De Perio's observation, this incident has been cleared and resolved, For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA De Perio advised AD Safari and AD Chavoshpour to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA De Perio conducted an exit interview with AD Safari and AD Chavoshpour via phone and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 1, 2022