Brookdale Monrovia

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by the Wellness Director, Ken Patrick Padilla, and explained the purpose of the visit. The facility is licensed to serve (41) ambulatory and (34) non ambulatory residents age 60 and over, hospice waiver approved for ten (10) residents and non-ambulatory to be housed on the second floor only. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan in place. Operational Requirements: A Fire Clearance is in place. Valid Liability Insurance is in place. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (10) is approved, no bedridden allowed. There are 17 fire extinguishers in the facility which was serviced on 04/09/2026. LPA reviewed that the Liability insurance is in place. Fire and disaster drills were last conducted on 05/11/2026. Physical Plant/Environment Safety: The facility is a 3-story building located in a residential/commercial community. The facility consists of: First floor: Lobby, Administrative offices, (1) Elevator, Dining room, Kitchen, Pantry areas, Employee break room, Storage rooms, Covered parking area, Activity room, Boiler room and Electrical room. Second floor: (31) resident rooms, Activity room, Exercise room, Medication room, Business Office Manager's office, Wellness/Health Center, Beauty salon, Courtyard and Laundry room. [Continue to LIC809-C] Physical Plant/Environment Safety [Cont.]: Third floor: (34) resident rooms and Laundry room. The interior and exterior physical plant was inspected. LPA inspected eight (8) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed Emergency Chairs at the stairways. Carbon Monoxide and Smoke detectors are interconnected and were tested annually and working properly. The living room had a covered fireplace that is inaccessible to residents. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random rooms (#106, #109, #114, #134, 204, 218, 228, and 229) and the readings vary between 110.3 deg F to 131.5 deg F which did not meet the required 105 - 120 deg F stated in Title 22 regulations. Staffing: A total of (45) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records-Training: LPA reviewed six (6) staff files which include: Personnel Record/Job Application, health screening, TB test results, Employee Rights, valid First Aid/CPR/AED Training, Valid Food Handling Certificate, staff training. Executive Director’s Administrator’s certificate is valid and expires on 11/19/2027. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted in the 1st floor hallway. Facility provides internet services to all residents and they have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly & weekly activity calendar is distributed to the residents and posted in the elevator. Daily activity schedule is posted near the dining area. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: LPA toured the kitchen which appeared clean and the appliances and fixtures functional. The facility kitchen was observed to be clean at the time of inspection. Plates, cups and utensils are kept clean and stored properly. Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Incident Medical and Dental: A total of five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses e-MAR (Point Click Care) system to properly document medications. Medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. The first Aid kit was observed and has all required items. Resident Records/Incident Reports: LPA reviewed five (5) resident files that include the Face Sheet, Identification and Emergency Information form, Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Personal Service Assessment, Physician's Orders, Ambulatory Status, and Personal Rights. Disaster Preparedness: Updated Emergency and Disaster Plan LIC 610E is in place with contact numbers and at least two (2) relocation sites. LPA observed the evacuation chairs at each stairway is in place. Residents with Special Health Needs: Four (4) residents are receiving home health services. Two (2) residents receive hospice care. Three (3) residents are using oxygen and have "No smoking/oxygen in use" signs posted on the residents’ doors. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview was conducted and an appeals rights and a copy of this report were provided to the Executive Director, Ken Patrick Padilla.the state’s words, verbatim · CDSS document, Jun 12, 2026

Allegation investigated: Staff are not following reporting requirements

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with Danny Vera, Exedutive Director and Ken Patrick Padilla Wellness Director and explained the purpose of the visit. Executive Director, Danny Vera arrived shortly after and LPA explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of Resident #1 (R1’s) file documents such as Face Sheet. LPA reviewed and requested copies of Resident #2 (R2’s) file documents such as Face Sheet, Physician's Report, Personal Rights, and Resident Personal Property and Valuables document. LPA interviewed the Executive Director, Wellness Director, Staff #1 (S1) to Staff # 6 (S6), Resident #1 (R1), and Resident #3 (R3) to Resident #8 (R8). LPA attempted to interview R2. However, R2 is currently at a Skilled Nursing Facility (SNF) and LPA attempted to call SNF but LPA was unable to speak with R2. LPA also obtained the staff and resident rosters. LPA also obtained Staff In-service training on Elderly and Dependent Adult Abuse: Resident to Resident. [Continue to LIC-9099-C] Substantiated LPA also obtained copies of Staff #7 (S7) and Staff #8 (S8’s) file documents such as Staff Training, Residents’ Rights Associate Acknowledgement Form, Elder Abuse Reporting Requirements, and Mandated Reporting Requirements. The investigation revealed the following: In regards to the allegation that: "Staff are not following reporting requirements," it is alleged that the facility staff are not properly reporting an incident of a physical altercation that occurred on 09/08/2025 involving R1 and Resident #3 (R3) was reported by another resident to staff on 09/15/2025. LPA interviewed the Executive Director and Wellness Director denied the allegation stating that the facility reported the incident that occurred of the physical altercation between R1 and R3 on 09/08/2025 was reported to staff on 09/15/2025. Five (5) out of six (6) staff could not confirm nor deny the allegations since they were not aware nor witness that incident. LPA interviewed one (1) out of six (6) staff which stated that the incident of the physical altercation between R1 and R3 that occurred on 09/08/2025 was reported to the Health and Wellness Director on 09/08/2025. LPA also obtained facility Progress Notes dated 09/08/25 which indicate that the staff had knowledge of the physical altercation between R1 and R3 on 09/08/2025 as the incident was reported on the notes. LPA reviewed the Special Incident Report for the incident that occurred on 09/08/2025 which was not submitted by the facility to licensing until 09/18/2025 and not submitted within seven (7) days of the occurrence. There is enough evidence to substantiate. Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D. An exit interview was held with the Executive Director, Danny Vera and a copy of this report and appeal rights were provided. LPA also obtained copies of Staff #7 (S7) and Staff #8 (S8’s) file documents such as Staff Training, Residents’ Rights Associate Acknowledgement Form, Elder Abuse Reporting Requirements, and Mandated Reporting Requirements . The investigation revealed the following: In regards to the allegation that: “Staff did not safeguard client's personal belongings,” it is alleged that resident #2 (R2’s) couch was taken by staff while R2 was out of the facility at a skilled nursing facility (SNF) and that R2 received a replacement couch from the facility trash area. Wellness Director and one (1) out of six (6) staff interviewed denied the allegation stating that R2’s couch was never taken away or replaced. Executive Director interviewed could not confirm nor deny the allegation. Five (5) out of six (6) staff interviewed corroborated with the allegation stating that R2’s couch was replaced with a couch but could not specify where the prior couch went. One (1) out six (6) staff interviewed stated that the current couch in R2’s room was taken from the trash area. However, Executive Director, Wellness Director, and two (2) out of six (6) staff stated that the current couch in R2’s room was not from the trash area. Three (3) out of six (6) residents could not confirm nor deny that the current couch in R2’s room was from the trash area. LPA toured the facility with the Wellness Director and observed a couch in R2’s bedroom. However, LPA is unable to verify if R2’s couch in the room is the same couch while R2 was living at the facility prior to being transferred to the Skilled Nursing Facility due to conflicting statements obtained during staff interviews. Seven (7) out of seven (7) residents interviewed denied the allegation stating that their belongings are safeguarded and that staff have not taken any of their belongings from them without permission. LPA reviewed R2’s Resident Personal Property and Valuables form and it did not list a couch as part of R2’s property/valuables upon moving into the facility. Per Executive Director and Wellness Director, R2 was first admitted to the facility without any valuables except a bed and a TV. Per Executive Director and Wellness Director, the prior and current couch was given to R2 by the facility that belonged to a former resident that moved out of the facility. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and a copy of this report was provided to the Executive Director, Danny Vera.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 28-AS-20250925083433

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 16, 2025

(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 of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and records review, the facility staff sent the LIC624 Unusual Incident Report to Licensing on 09/18/2025 for a physical altercation between Resident #1 (R1) and Resident #3 (R3) that occurred on 09/08/2025. LPA obtained facility Progress Notes which indicated that the staff had knowledge of the physical altercation between R1 and R3 on 09/08/2025. The facility failed to not report to licensing within seven days, per Title 22 reporting requirements. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2025

Plan of correction: Executive Director will ensure that Special Incident Reports and Reportable Incidents are sent to Licensing as required. Executive Director will ensure that all staff are re-trained in Reporting Requirements and provide all training materials and training signup sheets to the LPA by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by the Wellness Director, Ken Patrick Padilla, and explained the purpose of the visit. The facility is licensed to serve (41) ambulatory and (34) non ambulatory residents age 60 and over, hospice waiver approved for ten (10) residents and non-ambulatory to be housed on the second floor only. There are currently (69) residents residing in the facility, of which five (5) are under hospice care and (0) bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan in place. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (10) is approved, no bedridden allowed. There are 17 fire extinguishers in the facility which was serviced on 04/04/2025. LPA reviewed that the Liability insurance is in place. Fire and disaster drills were last conducted on 08/19/2025. Physical Plant/Environment Safety: The facility is a 3-story building located in a residential/commercial community. The facility consists of: First floor: Lobby, Administrative offices, (1) Elevator, Dining room, Kitchen, Pantry areas, Employee break room, Storage rooms, Covered parking area, Activity room, Boiler room and Electrical room. Physical Plant/Environment Safety [Cont.]: Second floor: (31) resident rooms, Activity room, Exercise room, Medication room, Business Office Manager's office, Wellness/Health Center, Beauty salon, Courtyard and Laundry room. Third floor: (34) resident rooms and Laundry room. The interior and exterior physical plant was inspected. LPA inspected eight (8) residents' rooms and each resident bedroom has the required furniture such as the bed, bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. The bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, skid matt/strips and shower chair. Exit doors are free of any obstruction and there are no pools or large bodies of water. LPA observed Emergency Chairs at the stairways. Carbon Monoxide and Smoke detectors are interconnected and were tested annually and working properly. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in eight (8) random resident rooms (Rooms: 103, 113, 115, 120, 201, 205, 207 and 219) in the 2nd & 3rd floors. Water temperature readings measured between 111.3 degrees F to 119.1 degrees F within the required 105 - 120 degrees Fahrenheit. Staffing: A total of (44) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records-Training: Seven (7) staff files were reviewed which include: Personnel Record, health screening, TB test results, Employee Rights, valid First Aid / CPR/AED Training, staff training. Executive Director’s Administrator’s certificate is valid and expires on 02/18/2027. However, based on record review, the Executive Director, Staff #2 (S2), Staff #5 (S5), and Staff #6 (S6’s) file did not have the Health Screening and TB. Test. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted in the 1st floor hallway. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly & weekly activity calendar is distributed to the residents and posted in the elevator. Daily activity schedule is posted near the dining area. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly. Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Incident Medical and Dental: A total of eight (8) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses e-MAR (Point Click Care) system to properly document medications. Medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. The first Aid kit was observed and has all required items. Resident Records/Incident Reports: LPA reviewed seven (7) resident files that include the Face Sheet, Identification and Emergency Information form, Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Personal Service Assessment, Physician's Orders, Ambulatory Status, and Personal Rights. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was last updated 06/07/2024 is in place with contact numbers and at least two (2) relocation sites. LPA observed the evacuation chairs at each stairway is in place. Residents with Special Health Needs: Four (4) residents are receiving home health services. Five (5) residents receive hospice care. Seven (7) residents are using oxygen and have "No smoking/oxygen in use" signs posted on the residents’ doors. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit interview, appeals rights and a copy of this report were provided to the as provided to the Wellness Director, Ken Patrick Padilla.the state’s words, verbatim · CDSS document, Aug 19, 2025

Allegation investigated: Staff speaks inappropriately to resident in care Staff does not ensure that residents' incontinence needs are being met Staff does not assist residents, when responding to call button

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with Logan Harrison, Executive Director for the facility, and explained the purpose of the visit. The investigation consisted of the following: LPA interviewed Staff #1 - 5 (S1 - S5), Residents #1 - 7 (R1 - R7), conducted a tour of the facility, and also obtained the staff and resident rosters, tested a call light pendant of a resident, obtained the police report number for the investigation conducted by the Monrovia Police Department, and also reviewed the staff file of Staff #6 (S6). LPA attempted to interview Staff #6 however they had recently resigned. The investigation revealed the following: In regards to the allegation that "Staff speaks inappropriately to resident in care," it is alleged that S6 had been making inappropriate and belittling remarks towards R1. Unsubstantiated During interviews with the residents, six (6) out of seven (7) did not corroborate the allegation. One resident interviewed stated that staff are respectful towards them and everyone else in the facility. Another resident interviewed stated that they have never heard of staff making inappropriate or rude remarks towards anyone else in the facility. During interviews with staff, five (5) out of six (6) interviewed did not corroborate the allegation. One staff interviewed that the Monrovia Police Department conducted their own investigation into the matter and determined that they would be closing the case, and provided LPA with the investigating officer's name and report number. Another staff member stated that they have never witnessed S6 make any inappropriate remarks towards any of the residents of the facility in the past. During record review of S6's file it was revealed that they were suspended pending investigation on 2/13/2025 due to the allegation that she had been treating residents disrespectfully. The executive director of the facility explained that following the facility's investigation into the allegations, they determined that there was no evidence for them and allowed S6 to return to work. S6 however voluntarily resigned today 2/25/2025. In regards to the allegation that "Staff does not ensure that residents' incontinence needs are being met," it is alleged that staff, particularly S6, and been intentionally refusing to provide incontinence care to the residents including R1. During interviews with the residents, none of them corroborated the allegation. One of the residents explained that they are receiving all of the services that they require at the facility. Another resident interviewed stated that all their needs are met and that staff are always very pleasant when assisting them. During interviews with staff, five (5) out of six (6) did not corroborate the allegation. One of the staff member stated that they have never witnessed S6 or any other staff refuse to provide care to any of the residents. Another staff member interviewed stated that no staff members have ever denied care to any of the residents. In regards to the allegation that "Staff does not assist residents, when responding to call button," it is alleged that S6 had been intentionally going into R1's room to deactivate their call light pendant and leave their room without assisting them. During interviews with residents, none of them corroborated the allegation. One residents stated that they always receive assistance when they use their pendant. Another resident interviewed stated that it sometimes takes time to receive assistance when it is busy for caregivers, but they ultimately always receive assistance. During interviews with staff, five (5) out of six (6) interviewed did not corroborate the allegation. One of the staff members stated that they have never witnessed S6 or any other staff intentionally turning off or ignoring the call lights. Another staff member stated that they were not aware of any staff members refusing to respond to call lights or turning them off when residents use them to request assistance. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 28-AS-20250221115902

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Executive Director/Administrator Logan Harrison and explained the purposed of the visit. The facility is licensed to serve (41) ambulatory and (34) non ambulatory residents age 60 and over. There are currently (67) residents residing in the facility, of which (4) are under hospice care and (0) bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (10) is approved, no bedridden allowed. There are 17 fire extinguishers in the facility which was serviced on 04/12/2024. Liability insurance in the amount of ($2,250,000) per occurrence and ($20,000,000) in total annual aggregate is in place and expires 12/21/2024. Fire and disaster drills were last conducted on 06/12/2024. Physical Plant/Environment Safety: The facility is a 3-story building located in a residential/commercial community. The facility consists of: First floor: Lobby, Administrative offices, (1) Elevator, Dining room, Kitchen, Pantry areas, Employee break room, Storage rooms, Covered parking area, Activity room, Boiler room and Electrical room. Second floor: (31) resident rooms, Activity room, Exercise room, Medication room, Business Office Manager's office, Wellness/Health Center, Beauty salon, Courtyard and Laundry room. Third floor: (34) resident rooms and Laundry room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Between 10:30am-11:30am, LPA tested hot water temperature in eight (8) random resident rooms (Rooms: #115, #119, #128, #134, #213, #216, #221 and #231) in the 2nd & 3rd floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. *****CONTINUED ON LIC809-C***** Staffing: A total of (44) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed a total of (6) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. However, (5) out of (6) files reviewed did not have a valid/current First aid/CPR training certificates on file. Administrator stated that first aid/CPR training will be conducted next week. Personnel Records-Training: Six (6) staff files were reviewed. Proof of staff training, health clearance, and TB test/vaccinations are current. Administrator's certificate is valid and expires on 11/19/2025. Resident Rights-Information: Resident personal rights, complaint hot line information and visitors policy posters are posted in the 1st floor hallway. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly & weekly activity calendar is distributed to the residents and posted in the elevator. Daily activity schedule is posted near the dining area. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: A total of eight (8) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses e-MAR (Point Click Care) system to properly document medications. Medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of six (6) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, and Medication Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Four (4) residents are receiving home health services. Four (4) residents receive hospice care. Five (5) residents are using oxygen and have "No smoking/oxygen in use" signs posted on the residents doors. LPA did not observe bed rails for mobility assistance in residents' beds. Per California Code of Regulations, Title 22, deficiency was cited. Exit interview conducted and a copy of the report and appeal rights were provided to Logan Harrison, Executive Director/Administrator.the state’s words, verbatim · CDSS document, Aug 6, 2024

Allegation investigated: Facility failed to adhere the admission agreement.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced initial 10-day complaint visit and met with Executive Director Logan Harrison. The purpose of today’s visit was explained. The investigation consisted of the following: Interview with Executive Director Logan Harrison (person assigned to handle admissions, discharge and refunds, and interviews with 4 residents. LPA obtained resident roster, staff roster, and Resident #1’s (R1) facility files, admission agreement, Preplacement Appraisal Information, ID and Emergency Information, and R1’s 30-day notice to vacate. (Continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility failed to adhere the admission agreement. It is alleged that the facility failed to credit the correct amount of R1’s refundable community fee ($2,000), resident was due a 80% credit on the fee but was provided with a 60% credit instead. Per the admission agreement under section “III. Rates, A Community Fee, 3. Once you enter the Community, if this agreement terminates and you leave for any reason within the second month of residency, you are entitled to a refund of sixty percent (60%) of the refundable amount.” R1 was admitted to the facility on 8/24/23 (date granted access to apartment and given keys, resident fully moved in days after), R1 provided facility with 30-day notice to vacate apartment on 9/17/23 and vacated facility with all belongings on 9/18/23. Per R1 account history report, R1 was issued a credit in the amount of $1,200 which is 60% of the refundable amount. The 80% refundable amount would be for a resident “who terminates upon arrival to the facility and leaves for any reason within the first month of residency” or “decides after the completion of pre-admission appraisal (personal service assessment) not to enter the Community.” Due to R1 providing the 30-day notice on 9/17/23 would give them a vacate date of 10/17/23, which would be within the 2nd month of residency, granting R1 the 60% credit of the refundable amount which the $1,200 that was credited. LPA interviewed 4 residents during todays visit and 4 out of 4 residents stated that they feel the bookkeeping/administrative team are proactive and responsive when it comes to questions regarding fees and credits. R2 stated they have been in a situation when a credit was needed and the facility was responsive, took action and were “more than fair” with the credit that was given back to resident. LPA interviewed Executive Director Logan Harrison and he explained the credits issued that were listed on the account history report of R1 along with the admission agreement percentages for the Community Fee, since R1 was within their second month of residency the 60% is what was credited. Based on statements and interviews conducted with staff/residents, review of R1 files and facility file records, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided to Executive Director Logan Harrison.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 28-AS-20231107160807