California Mission Inn - Rose Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Dwight Dunagan and assisted LPA with the visit. The facility is licensed to RCFE/Dementia for age range 60 and over. Approved for 85 non-ambulatory, of which 9 may be bedridden, approved hospice waiver for 20. Currently, there's two residents on home health, six residents on hospice but no bed ridden residents. On today's date, LPA inspected the following domains which include: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Record-Training, Resident Records/Incident Reports, Resident's Right, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness and Resident with Special Health Needs 1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents; of which 9 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant/Environmental Safety: The facility is consisted of a 5 floor building. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floor. LPA inspected Room#106, #116, #212, #205, #303, #301, #412, #414 and the rooms are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room. (See LIC 809C for continuation) Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature were tested between 105 and 112.6 degrees F which is within the Title 22 regulation. LPA also inspected the carbon monoxide detectors in the facility and they are working properly. The facility has a telephone service on the premises. 4. Staffing: The facility has sufficient staffing to provide care and supervision to residents 5. Personnel Record-Training : All the staff are over 18 years old and they are fingerprint cleared and associated with the facility. LPA inspected four staff files and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Dwight Dunagan and his administrator certificate expiration date 7/11/2024. 6. Resident Record-Incident Reports: LPA inspected 4 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. 7. Resident's Right: LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for the facility. The facility does not have a resident council but regular town hall meeting. 9. Food Service: Currently the facility has 3 resident is on a modified diet with physician order in file. The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room. Sanitation practices and kitchen cleanliness was observed. 10. Incidental Medical and Dental: LPA inspected four (4) residents medication and the medication are centrally stored and locked in the Wellness Center room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide transportation to residents' medical and dental appointments. 11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 10/20/22. The last fire drill was conducted on 9/22/23 and the last disaster drill was conducted on 6/28/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are six resident on hospice and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. No deficiencies were observed during the visit. Exit Interview Conducted and a copy of the report was provided to Administrator Dwight Dunagan.the state’s words, verbatim · CDSS document, Oct 31, 2023

Allegation investigated: Staff does not adhere to posted food menus. Facility has inadequate food service. Staff do not serve nutritious meals. Facility meals are served more than fifteen (15) hours apart.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Dwight Dunagan and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Administrator Dwight Dunagan, Staff 1-3 (S1-3) and Resident 1-5 (R1-5). LPA collected copies of Staff and Resident Rosters, Facility Food Menus for June - September 2023 and a copy of Bistro Menu. LPA also conducted a tour of facility kitchen, dining room, and observed facility food supply. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff does not adhere to posted food menus, it is alleged that facility is not providing facility residents the requested or posted meals. Interviews with Administrator Dunagan and facility staff revealed that staff adhere to posted menus at all times. They stated that residents also have the option of requesting an alternate meal from the bistro menu. Staff stated that the facility serves three full meals and provides two snacks on a daily basis. Staff also stated that residents can also request additional servings of any meal if they wish. Interviews conducted with 3 out of 5 residents revealed that facility adheres to the food menus. They also stated that they are given a copy of the weekly menu the week before so that they can make their own choices and turn it in to the front desk. LPA observed residents being served lunch during tour and verified that residents were served what was listed on the menu. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility has inadequate food service, it is alleged that the facility residents are not receiving an adequate amount of protein and the servings are not enough for someone of a certain height. Protein servings are allegedly 1.5 ounces of chicken. Interviews with Administrator Dunagan and facility staff revealed that the facility provides adequate food service for all residents. They stated that the facility follows menus approved and developed by a registered dietician and the menus meet the residents nutritional needs. They stated that residents also have the option of requesting an alternate meal from the bistro menu and additional servings for any meal that they have. Staff stated that the facility serves three full meals and provides two snacks on a daily basis. Staff also stated that residents also have the option of requesting a half serving which will have a smaller serving of protein. Interviews conducted with 3 out of 5 residents revealed that facility food service is adequate. They stated that they are served an adequate amount of food including protein. They also stated that they are given two snacks a day. LPA observed residents being served lunch during tour and verified that residents were served what was listed on the menu. LPA observed that residents were served an appropriate amount of protein. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff do not serve nutritious meals, it is alleged that residents are not being given nutritious options such as broccoli. Staff have allegedly stated that they are unable to provide the meal items due to the facility not having them. Interviews with Administrator Dunagan and facility staff revealed that the facility provides nutritious meals for all residents. They stated that the facility serves well balanced and nutritious meals that include servings of protein, carbohydrates, fruits and vegetables. They also stated that the facility follows menus approved by a registered dietician. They also stated that residents can request certain foods or different meal options on the weekly menu and that is collected at the front desk and is followed by kitchen staff according to resident's preferences. Residents also have the option of requesting an alternate meal from the bistro menu and additional servings for any meal that they have. Staff stated that the facility serves three full meals and provides two snacks on a daily basis. Interviews conducted with 3 out of 5 residents revealed that facility food service is adequate. They stated that they are served nutritious and well balanced meals. They also stated that they are given two snacks a day. LPA observed residents being served lunch during tour. LPA observed that residents were served protein, fruits and vegetables. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility meals are served more than fifteen (15) hours apart, it is alleged that dinner is served too early. Dinner is scheduled for 3:30pm and residents are not given snacks. It is also alleged that residents do not receive their next meal until the following morning at approximately 9-9:30am. Interviews with Administrator Dunagan and facility staff revealed that the facility does not serve meals more than 15 hours apart. They stated that dinner is served from 4:30pm to 6:00pm and breakfast is served from 7:30am to 9:00am. They also stated that residents can also request food from the Bistro Menu when they want and residents are given 2 snacks per day. Interviews conducted with 3 out of 5 residents revealed that meals are not served more than 15 hours apart. They stated that they are satisfied with the food service and do not have any concerns regarding the times that the meals are serve. They also stated that they are given two snacks a day. LPA observed lunch service at approximately 12:00pm. LPA additionally toured the facility kitchen and observed an ample amount of food. There was enough food for 7 days non perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. 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. A copy of the report was provided to Administrator Dwight Dunagan.the state’s words, verbatim · CDSS document, Jul 24, 2023 · control 28-AS-20230718162329

Allegation investigated: Staff had inappropriate interaction with the resident. Facility does not have activities. Food Service inadequate. Staff share personal information of resident. Residents are forced to stay in their rooms.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Wellness DIrector Ruby Magao. The investigation consisted of the following: On 1/22/2021, a virtual physical plant tour of kitchen area/food preparation station was conducted at 4:25 pm via FaceTime, and staff (S1-S3) were interviewed. The following documents were obtained: COVID Plan of Action [ Letters to family/visitors (4/8/20 & 4/25/20) regarding visitation restrictions and infection control], incident reports RE: COVID-19 positive case dated 1/3/2021 & incident dated 1/13/2, Food Menu [Dec. 2020 – Jan.2021], Alternative Food Menu, (R1's) MD food order, staff compliance training - HIPAA training, Compliance and Code of Conduct proof of completion by receptionist staff, and LIC 500 Personnel Report. On 10/22/2022, residents (R1-R3) and staff (S4) were interviewed. During today's visit, residents (R4- R9) were interviewed. See LIC 9099C for report continuation. Unsubstantiated Allegation: Staff had inappropriate interaction with the resident. It is alleged that on 1/13/2021, two staff were antagonistic and yelled at resident (R1) and it's visitor for questioning COVID-19 visitation policies and for not wearing a mask. The resident went to the front entrance to pick up the food delivery packages that were dropped off by the visitor. Staff explained to the visitor that they were not allowed to enter the building due to pandemic visitation restrictions. Based on interviews conducted, R1's visitor argued with receptionist staff for not allowing R1 to exit the building to get the food delivery. According to staff interviews, R1 and it's visitor were not wearing a required face mask. As a result, staff brought it to their attention and explained that masks are required due to active COVID-19 cases in the building. All staff interviewed denied yelling at R1 and it's visitor. They stated that in the beginning of January 2021 the facility had a COVID-19 outbreak and visitation was prohibited due to the state and public health order. At that time, all residents were quarantined in their rooms, but resident (R1) occasionally sneaked out of the room to see visitors. Resident (R1) denied that both staff involved in the incident yelled at the resident, but stated that the receptionist staff shouted at the visitor when explaining the visitation policies. Staff (S3) was nearby and stated that receptionist staff (S5) did not yell at R1 or the visitor. Staff (S5) was not interviewed due to scheduling conflict, as they only worked at the facility once a week at that time. Staff (S5) is no longer employed at the facility. A total of nine (9) residents were interviewed; all denied the allegation. Allegation: Facility does not have activities. It is alleged that the facility did not have any scheduled activities for residents during COVID-19 quarantine in 2020 and early 2021. According to record review and staff interviews, the findings indicate the facility had a large COVID-19 outbreak in the building in late December 2020 and January 2021. Due to state and public health directives, residents were to quarantine in their rooms and all communal activities were suspended. All staff stated there were no activities for residents at that time, with the exception of Zoom doctor and family communication. A total of nine (9) residents were interviewed, all stated activities were suspended due to the pandemic. Residents understood the public health directive the facility enforced. Allegation: Food Service inadequate. It is alleged that the food that was delivered to residents in their rooms in 2020 and early 2021 was poor quality and were given less food selection. Resident (R1) requires a special diet and was not being given variety of foods. Staff interviews revealed that the food was cooked at the sister facility in the same campus and then brought over to this facility. It was transported in carts in disposable food containers in order to prevent virus contagion. Staff stated that the food may have been at times served cold because of staffing shortages experienced during that time; in which caregivers were expected to deliver the food and feed the residents as well. Two (2) out of nine (9) residents stated the food was served lukewarm and the food was not of good quality. According to staff interviews, residents were provided special diet meals as directed. There is insufficient evidence to corroborate the allegation. Allegation: Staff share personal information of resident. It is alleged that facility staff were revealing personal resident information to other residents and family members about a resident that passed away from the COVID-19 virus. All staff stated denied the allegation and stated that staff are trained not to share any resident personal information with anyone. Staff stated that R1's nearby neighbor was transported to the hospital during the COVID-19 January 2021 outbreak, and residents may have observed through their windows emergency personnel take the resident. Resident (R1) state that they felt the facility did not provide any information about what was happening. Eight (8) residents denied the allegation. Front desk staff or Activities staff handle all resident memorials and place flowers in the lobby with a "in loving memory" message, for other residents to see. According to staff, R1 often asked staff about what was happening in the facility, especially after hearing ambulances. Staff denied sharing any information with residents. Allegation: Residents are forced to stay in their rooms. It is alleged residents were forced to stay in their rooms beginning November 2020 because the other Assisted Living facility in the front area of the campus had large COVID-19 outbreaks. All staff confirmed that residents were quarantined in their rooms due to COVID-19 outbreak public health orders, and in effort to mitigate the spread of the virus in this building. Staff stated that on several occasions R1 sneaked in family visitors when front desk staff were not present. According to staff interviews, some residents were allowed to go out of their rooms if they were experiencing a lot of anxiety, and that R1 was allowed to walk downstairs to see family visitor. Resident (R1) stated residents were asked to stay in their rooms during COVID-19 pandemic. All residents interviewed stated they were directed to quarantine in their rooms during COVID-19 pandemic outbreaks. Therefore, the allegation cannot be supported because the facility was following public health and Licensing directives. Based on interviews conducted and record review, there is insufficient information to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Wellness Director. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 16, 2023 · control 28-AS-20210115160840

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cynthia Chan and Kimberly Ramirez conducted the unannounced annual inspection with the focus of the infection control domain. LPAs met with Wellness Director, Ruby Racca-Magao, who assisted with the visit. The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which 9 may be bedridden. The hospice waiver is approved for 20 residents. LPAs toured the facility and observed the following: * The building consists of 5 floors. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floor. * Covid-19 signage are posted throughout the facility. Hand washing signs are posted in the bathrooms. * Extra PPE supplies of at least 30 days are observed. * The facility has a digital Covid-19 screening form for all staff and visitors. * LPAs inspected rooms #107, #117, #212, #215, #308, #314, #404, and #405. The rooms are clean and have the required furnishings. * Food supplies of 2 day perishable and a week of non-perishable are observed. * Medications are centrally stored in the Wellness Office. LPAs reviewed 4 residents' medications and medications are being administered as prescribed. These 4 residents' files also have updated emergency contact information forms. * 3 Staff and 4 Residents were interviewed. * Staff were observed wearing a face mask. * Staff are cleaning and disinfecting on each shift and more often for high touched surfaces. * Per the Wellness Director, they have backup staff when needed and are following the strictest covid-19 guidance. There are no deficiencies issued today. The exit interview was held. A copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Nov 4, 2022

Allegation investigated: Staff is overcharging resident while in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Wellness DIrector Ruby Magao. The investigation consisted of: On 4/21/2020, due to Coronavirus Disease 2019 (COVID-19) LPA Elizabeth Irra initiated a telephonic complaint investigation with former Administrator Lori Waters. The following documents were requested, but NOTobtained on 4/21/2020: Resident and staff rosters including contact information, a list of Residents that have receive an eviction notice in the past 3 months. R-1's: Face Sheet with contact information, Admission Agreement including any addendums, Appraisal Needs and Services Plan (most current), Daily Notes (if applicable) and Physician Report (most current). Staff records-schedule for March 2020 and April 2020, Staff contact numbers, Staff training on Mandating Reporting and Resident Rights. During today’s visit, some of the requested documents (financial/transaction records) and other pertinent documents were obtained. NOTE: Facility file was found incomplete in storage. Staff (S2 – S6) and family member (F1) were interviewed. Substantiated Allegation: Staff is overcharging resident while in care. It is alleged that resident (R1) was overcharged monthly rent fees after moving from sister facility "California Mission Inn #198603161" located in the same property campus. The resident moved in to the sister facility on 10/29/2019. R1 required more assistance and was charged an additional $1,600 in care level fees. Per "Basic Provisions -Resident Admission Agreement" Schedule A, the basic room and board rate total was $2,400, with an additional $1,600 rate fee for level 5 care fees; totaling $4,000 per month. On 2/29/2020, resident (R1) moved in to this facility and was no longer provided care assistance. Therefore, R1 was no longer supposed to pay $1,600 in care fees. The new monthly rent fee was $2,400, effective 2/29/2020. However, the facility continued to charge R1 care fees and the resident paid $4,180 (March 2020) and $4,000 (April 2020), but should have only paid the basic monthly fee of $2,400. Per document review, the resident's Admission Agreement was not amended to reflect the facility move or rate fee changes. Former Administrator Laura Waters, stated she spoke to the resident and was going to review the file to determine if there was a discrepancy in rent charges. However, rent fee clarification was never provided. Staff interviews confirmed that when the resident moved to this facility it no longer received care assistance, and the care fees would not be applicable. Per PCC Point Clique Care System Transaction Report it was confirmed that the resident was overcharged. Resident (R1) moved out of the facility on 6/1/2020. The total refund amount due to resident (R1) is $3,306.80. Based on record review, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 05. An exit interview was conducted with Wellness Director Ruby Magao. A copy of the report an appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 28-AS-20200415133935

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Nov 24, 2022

Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met evidenced by: Based on record review the findings indicate R1 was overcharged for months March 2020 and April 2020, after moving to this facility from Massey Hall. The resident continued to be billed and paid for care fees that it was no longer receiving.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee shall reimburse R1 the overcharged rent amount totaling $3,306.80. Administration staff shall certify mail a check to R1 and provide proof that the money has been reimbursed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(d) · Plan of correction due date: Nov 24, 2022

Admission Agreements. The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This requirement was not met evidenced by: Based on observation of file/record review, the facility failed to issue a new admission agreement and/or modify the original admission agreement when R1 moved to this facility from the sister facility in the same campus. There is no record of changes in the rent fees.the state’s words, verbatim · CDSS document, Oct 27, 2022

Plan of correction: Licensee shall ensure all former resident records are stored intact /complete. In addition, if a resident is moved from one facility to another, the resident and/or responsible party must be re-issued a new Admission Agreement. Submit a written statement of protocols that will be implemented, and proof of staff training.

Allegation investigated: Staff threatens resident with eviction while in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate and deliver findings on the above allegations. The purpose of the visit was discussed with Wellness DIrector Ruby Magao. The investigation consisted of: On 4/21/2020, due to Coronavirus Disease 2019 (COVID-19) LPA Elizabeth Irra initiated a telephonic complaint investigation with former Administrator Lori Waters. The following documents were requested, but not obtained: Resident and staff rosters including contact information, a list of Residents that have receive an eviction notice in the past 3 months. R-1's: Face Sheet with contact information, Admission Agreement including any addendums, Appraisal Needs and Services Plan (most current), Daily Notes (if applicable) and Physician Report (most current). Staff records-schedule for March 2020 and April 2020, Staff contact numbers, Staff training on Mandating Reporting and Resident Rights. During today’s visit, additional documents (financial/transaction records) and other pertinent documents were obtained. Staff (S2 – S6) and family member (F1) were interviewed. Unsubstantiated Allegation: Staff threatens resident with eviction while in care. It is alleged resident (R1) was threatened by former Administrator Laura "Lori" Waters with an eviction due to disagreements and arguments about rent billing and overcharges. Former Administrator stated that resident (R1) was belligerent with everyone after consuming alcohol. According to former Administrator, the resident was told it has the right to consume alcohol, but if it continued to drink excessively and break house rules then an eviction notice may have to be issued. Ms. Waters denied threatening the resident or issuing an eviction notice. A total of six (6) staff were interviewed, one staff (1) staff stated that former Administrator threatened R1 with an eviction in a passive aggressive manner, but never issued an eviction. Family (F1) was interviewed and stated that R1 often addressed staff aggressively when spoken to about it's alcohol use. There is insufficient evidence to corroborate the allegation. Based upon interviews conducted and record review, the findings indicate that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Wellness Director Ruby Magao. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 28-AS-20200415133935

Allegation investigated: Staff are failing to address a resident's needs while in care.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Ruby Racca-Magao, Wellness Director); as current Administrator (A2: Scott Ambrose) was unavailable at the time of this visit. LPA/RA Ceniceros spoke to S1 prior to entering the facility to conduct a risk assessment. A1 informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 12/16/20 (via telephone) with (former) Administrator (A1: Lorie Waters) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed two (2) staff members (between 12:30 p.m. - 1:00 p.m. and four (4) residents (between 1:00 p.m. - 2:00 p.m.); reviewed Resident #1's records (between 12:15 p.m. - 12:30 p.m.) and requested copies of pertinent documents: Admissions Agreement, Physician’s Report, Emergency I.D. & Information, Pre-Placement Appraisal, Resident Appraisal, Needs & Services Plan, Staff & Resident Rosters. Unsubstantiated Regarding Allegation #1: this investigation revealed that Resident #1 has a private caregiver that tends to its activities of daily living in addition to facility staff meeting Resident #1's care needs. Resident #1 feels that whenever its done with its meals (breakfast, lunch, and dinner) and would like for its plate to be removed from its room, Resident #1 summons the caregiver to its room following meal time. Resident #1 feels that it takes the caregiver awhile to respond to the resident's room. Resident #1 is satisfied with the overall service from staff providing adequate care and meeting its needs of activities of daily living. The majority of interviews conducted with residents were consistent with their response that the facility is providing adequate care to meet the needs of the residents; and, facility staff respond to the residents calls in a timely manner. Interviews that were conducted of facility staff, the majority indicated that they had not received a complaint from a resident that facility staff is not providing adequate care to a resident. LPA/RA Ceniceros attempted interviews with Reporting Party and Witness #1, but to no avail. A review of Resident #1's records (dated 09/13/17) documented the resident is ambulatory and capacity for self-care: needs assistance with bathing. Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF CARE: Staff are failing to address a resident's needs while in care is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1: Ruby Racca-Magao, Wellness Director.the state’s words, verbatim · CDSS document, Aug 9, 2022 · control 28-AS-20201207134150

Allegation investigated: Facility caused injury to resident.

Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Administrator Tyler Cheney. The investigation consisted of the following: A physical plant tour of the facility, record review, and interviews with residents (R2- R7) and staff (S1- S5). Former resident (R1's) Power of Attorney was interviewed. Resident (R1) is deceased and was not interviewed. Resident (R1's) file was reviewed and documents [Identification And Emergency Informatio, Face Sheet, Preplacement Appraisal Information, Resident Appraisal, Physician Reports (7/18/2017, 3/20/2019, 2/25/2020), Medication Review Reports (6/19/2019, 1/28/2020, 7/31/2020), Rx MD orders, LIC 500 Personnel Report, and resident roster] were reviewed and obtained. No health and safety issues were observed during the visit. See LIC 9099C for report continuation. Unsubstantiated Allegation: "Facility caused injury to resident." Based on record review and interviews conducted the findings indicate that former resident (R1) had pre-existing Glaucoma disease prior to moving in to the facility on 7/21/2017. Resident (R1) was admitted to the facility with Glaucoma medications [Brimonidine Tartrate Solution, Dorzolamide HCI solution, Theratears Solutions, and Latanoprost Solution. Per Physician's Reports the resident was not diagnosed with Dementia and was not taking anti-psychotic medications during the time it resided at the facility. Resident (R1) had various health issues that were managed with medications ordered by Physician; which were administered as directed. No major combative behaviors by resident (R1) or administration of behavioral medications were reported by staff. Staff denied over-medicating R1. Staff interviews revealed that resident (R1) was ambulatory and did not appear to have major eye disease issues while it lived at the facility. Staff stated that resident (R1's) daughter/Power of Attorney [POA] took the resident to medical appointments. The resident was discharged from the facility on 8/1/2020, and went to live at another Assisted Living facility closer to family. All staff interviewed denied causing injury to resident (R1) or over-medicating resident (R1). Six (6) out of six (6) residents interviewed denied that facility staff have caused any injuries to residents. Resident (R1's) Power of Attorney was interviewed and denied the allegation by confirming that R1 had Glaucoma eye disease prior to moving into the facility, and went blind on the left eye because at the beginning of the COVID-19 Pandemic R1 was scheduled to receive laser eye surgery at the Veteran's Affairs Hospital, but due to COVID-19 health setting guidelines the resident's surgery got cancelled, and caused the resident to lose sight in the left eye. Therefore, the facility is not at fault. Record review did not corroborate neglect of care, or injury to resident (R1) during the length of time it resided at the facility. Based on interviews conducted, records reviewed, and LPA observations there is insufficient information to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Administrator Tyler Cheney. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 9, 2021 · control 28-AS-20211206090603

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Galarza and Jewel Baptiste conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Administrator Tyler Cheney and Wellness Director Ruby Magao and explained the purpose of the visit. The facility is a 5 story story building located in a residential neighborhood that is licensed for 85 adults 60 and over approved for 85 non-ambulatory, of which 9 may be bedridden. The facility has a hospice waiver for 20. The facility consists of 69 rooms, activity room, dining room, kitchen, Wellness office, laundry room, and an outdoor water fountain. The last fire drill was conducted on 9/3/2021. The following were observed/inspected: The interior and exterior physical plant was inspected. Twenty nine (29) rooms were inspected. COVID-19 Infection Control Practices and signs were observed in the entrance, some common areas hallways, but not in the public bathrooms and resident bathrooms. Signs are not posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Furniture was observed to be at least 6 feet apart. Each client's room is designated as a COVID-19 solation room if needed. All staff were observed wearing mask. Six (6) centrally stored resident medication records were reviewed. Medication errors were observed. The residents were observed wearing masks. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. A posted Emergency Disaster Plan was observed. Facility has sufficient supply of Personal Protective Equipment (PPEs). Resident's physician reports were reviewed during today's visit. Deficiencies were cited. See LIC 809D. Exit interview was conducted with Administrator Tyler Cheney and Wellness Director Ruby Magao. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2021