Commonwealth Royale Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual visit at the facility using the CARE inspection tool. Upon arrival, LPA met with the Administrator/Director of Operations, Zara Poghosyan. The reason for the visit was explained. The facility is licensed to serve 106 residents and 14 non-ambulatory residents, ages 60 and above. Non-ambulatory residents may reside in rooms #101,102,103,104,105,106,107,122 on the first floor’s bedrooms only. Hospice Waiver approved 15 residents. Dementia Plan is in place. The facility has two floors. The first floor consists of 22 residents’ rooms, a lobby, two dining rooms, commercial kitchen, TV/ activity room, laundry room, staff break room, and common areas. The second floor consists of 31 resident rooms, business office, storages and medication room. The following CARE tool domains were reviewed during this visit: Infection Control: Sufficient PPE supplies and an Infection Control Plan maintained at the facility were observed and in compliance. Physical Plant & Environment Safety: Physical plant tour was conducted. Residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The backyard, outdoor and passageways were free of obstruction and debris/hazards. Storage areas for cleaning solutions, toxins, knives, and hazardous items were kept in a locked cabinet and were inaccessible to residents. (-Continued on the LIC809-C) Water temperature was tested and the temperatures were between 109.8 to 115 degrees F., which is in compliance with regulations. Smoke detectors and carbon monoxide detectors were tested on both floors and were operable. Fire extinguishers were observed and fully charged. Operational Requirements and Disaster Preparedness: Facility has an activity area furnished for outdoor use. Fire drills were conducted monthly. The last fire drill was on 6/25/26. Call system was tested. The staff’s responding time was from 2 minutes to 5 minutes, which was in compliance. Staffing and Personnel Records- Training: There appears to be sufficient staffing at all times in the facility. Staff files were reviewed and in compliance. Administrator certificate is current with the expiration date on 4/23/2027. Resident Rights-Information and resident Records-Incident Reports: Facility provided telephone landline and internet for the residents. Resident rights posters and reporting posters were displayed within the facility. Food Service: The kitchen was observed to be clean. Two (2) days of perishables and one-week (7) days of non-perishables food supply were observed. Health Related Service: Medication was properly labeled, centrally stored, and in their original containers. Incidental Medical & Dental and Emergency Intervention: Staff designated to administer medication have the proper training on file. Staff maintain a CPI Certificate in the case of use. Exit: Deficiencies were noted during this visit per California Code of Regulations, Title 22, Division 6. Exit interview was conducted with Administrator Zara. Copies of LIC 809s and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 22, 2026

Allegation investigated: Staff did not notify authorized representatives of incident Staff do not ensure the residents’ toileting needs are met Staff do not ensure resident is administered medication Due to staff neglect resident left the facility unattended

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 06/02/2026 to deliver findings related to the above allegations. LPA was greeted by facility staff and Administrator Zara Poghosyan and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1's face sheet, R1's Physician's Reports, Special Incident Report (SIR), Admission Agreement, and Medication Administration Records (MARs) for May and June. In addition, the LPA conducted interviews with four (4) staff members (S1–S4), ten (10) residents (R1–R10), and three (3) witnesses (W1-W3). (continued on 9099C) Unsubstantiated Allegation: Staff did not notify authorized representatives of incident It was alleged that staff failed to notify an authorized representative of an incident. Record review of R1's Admission Agreement and Assisted Living Waiver (ALW) documentation revealed that R1 is his own responsible party. No authorized representative was identified in the resident's records; therefore, there was no designated authorized representative for the facility to notify regarding the incident. Additionally, staff interviews revealed that although R1 is their own responsible party, the facility routinely notifies R1's sister and physician when concerns arise regarding R1's health, safety, or well-being. Allegation: Due to staff neglect resident left the facility unattended It was alleged that due to staff neglect, R1 left the facility unattended and staff failed to take appropriate action to locate or report him missing. During an interview, S1 reported that R1 frequently leaves the facility independently to visit his wife and typically returns on his own. Staff further indicated that procedures are in place to notify appropriate parties and law enforcement if a resident remains missing for an extended period. During record review, the LPA observed that R1's Physician's Report dated 1/7/2026 indicated that R1 may not leave the facility unattended. However, previous Physician's Reports dated from 2023 through 2025 consistently reflected that R1 was permitted to leave the facility unattended. To clarify, LPA contacted R1's physician during the investigation. The physician confirmed that the restriction noted on the 1/7/2026 Physician's Report was entered in error and stated that an updated report would be completed to reflect that R1 is permitted to leave the facility unattended. Allegation: Staff do not ensure the residents’ toileting needs are met It was alleged that staff failed to ensure R1's toileting and incontinence care needs were met. During staff interviews, staff consistently reported that R1 is able to use the restroom independently and generally does not require assistance with toileting. Staff stated that R1 wears pull-ups and frequently refuses personal care, including changing and incontinence care. Staff reported that assistance is routinely offered and provided when accepted by R1. During an interview, R1 expressed no concerns regarding assistance with toileting, incontinence care and stated that staff are supportive and assist him when needed. During interviews, residents R2 through R10 did not express any concerns regarding toileting or incontinence care provided by facility staff. Residents consistently reported that staff are supportive of their needs, provide assistance when requested, and treat residents with dignity and respect. (continued on 9099C) Allegation: Staff do not ensure resident is administered medication It was alleged that staff failed to ensure R1 received prescribed medications and that medication needs were not adequately monitored or addressed. During staff interviews, staff reported that medications are routinely offered and administered to R1. Staff stated that R1 frequently refuses his medications and that refusals are documented and reported to the physician. During an interview, R1 reported that staff assist with their medications and stated that they take their medications. R1 did not express any concerns regarding medication administration or delayed medications. During interviews, W1 and W2 did not express any concerns regarding the facility's medication administration practices and did not report concerns that R1 was being denied or not offered prescribed medications. Record review revealed multiple documented medication refusals by R1 on the Medication Administration Records (MARs). Record reviews also revealed documentation of communication between facility staff and R1's physician regarding the medication refusals. Based on the investigation conducted, which included interviews with staff, witnesses and residents, as well as a review of relevant records, there was insufficient evidence to support 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 was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 28-AS-20260528091630

Allegation investigated: Facility does not have sufficient staff to meet the resident's care needs Resident was not afforded dignity

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced 10-day complaint visit to this facility.Upon arriving at the facility, LPA met with Administrator, Zara Poghosyan. LPA explained the purpose of today’s visit is to investigate the allegations above. The investigation consisted of : LPA obtained resident roster and staff roster. File of Resident R1 was reviewed and Physician's Report, Face Sheet and Emergency Info, and Resident Assessment was submitted. Interviews were conducted with the Administrator and Staff S1 and Staff S2. Interviews were conducted with Resident's R1- Resident's R13. The investigation revealed the following: In regards to the allegation Facility does not have sufficient staff to meet the resident's care needs, based on interviews conducted and and information gathered Resident's R2-R13 all stated that there is sufficient staff to assist the residents. Unsubstantiated All stated that staff respond quickly and carry out their job duties professionally and efficiently. Resident R2 stated that they are always hiring and enough staff to help all residents. Resident R3 stated that staff even responded quickly when he hit the buzzer for assistance at 3AM. Resident R6 stated that there are new residents and staff are more than sufficient. Resident R10 stated that staff gives perfect care. Administrator and Staff S1 and Staff S2 all stated that there is always sufficient staff for each shift. Also stated that there was miscommunication with Resident R1. Stated that staff is always here to provide care and supervision and they would do it when R1 came back from surgery. All stated that R1 had said that what was needed was an escort back and forth from surgery which would leave the facility short staffed and that afterwards R1 said what was needed was care at facility after surgery and not an escort. All stated that if R1 was assured that if pulling the cord staff would help with care and also walk by R1's room and check on R1. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. In regards to the allegation Resident was not afforded dignity, based on interviews conducted and information gathered Resident's R2-R13 all stated that staff treat them kindly with dignity and respect. Resident R1 stated that staff had always treated R1 with respect and dignity for 7 years prior to this situation. Resident's R2-R13 all stated they are treated kindly. All said they have never been mistreated. Resident R2 stated that staff are very kind in helping him connect with mom. Resident's R2-R13 all stated that they never observed staff ever acting inappropriately to the residents. Resident R6 stated that staff never retaliate when residents get unruly with them and still treat residents with respect. Administrator and Staff S1 and Staff S2 all stated that there was mis- communication with R1, but R1-R13 have always been treated with respect and dignity. All said that staff never lied to R1 and was somehow a misunderstanding. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Zara Poghosyan. The findings were discussed and copies of the report were provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 28-AS-20260527115353

Allegation investigated: Staff yelled at a resident in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Administrative Assistant Diana Rios. Executive Director Zara Poghosyan arrived shortly after. The investigation consisted of: On 3/5/2026, LPA interviewed 3 staff and resident (R1), reviewed 5 resident Medication Administration Records (MARs) and reviewed/collected resident face sheets, physician reports, MARs, resident appraisals, and resident/staff rosters. During today's visit, LPA toured the physical plant, interviewed 7 staff and 14 residents and reviewed R1's March & April 2026 MAR records, and collected S1's disciplinary action "Counseling Record" and In-service training sheet (3/19/26). *Narrative continues next page. Substantiated Allegation: Staff yelled at a resident in care. It is alleged that a medication technician (med-tech) staff has a bad attitude because they are rude, argue, and yell at resident (R1). According to information obtained, staff (S1) speaks in an aggressive manner. A total of 15 mentally disabled residents were interviewed. Resident interviews revealed that sometimes S1 responds in an aggressive manner and yells at residents when they ask staff for medications. One resident stated that S1 has called them "crazy". Resident (R1) stated that med-tech/S1, Wellness Director, and Administrative Assistant yell at the resident. A total of 10 staff were interviewed, of which 7 confirmed the allegation. Staff interviews revealed that med-tech/S1 sometimes speaks to residents with an aggressive, strong tone of voice and has been observed being confrontational and scolding residents and resident (R1). Staff (S1) stated they sometimes lose their patience when residents are rude toward them. Per record review, staff (S1) did not have any disciplinary record on file at the time of the initial complaint visit. However, on 3/12/2026, S1 received a written counseling warning regarding the use of abusive language. There is sufficient information to support the allegation. Based on observation and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited. An exit interview conducted, copy of the report and appeal rights was provided to Executive Director. Allegation: Staff did not administer medications to a resident in care. The complaint alleges that med-tech staff (S1) refuses to administer PRN medications and give them to the resident "when they want, and "not when I need it." It is also alleged that sometimes medications are given 2 hours late. A total of 15 residents were interviewed, of which 14 stated their medications are administered on time and have no issues with medication management. Staff interviews revealed that R1 asked the night shift med-tech staff to give them their morning medications, but the day shift med-techs had already clocked in and had begun passing out AM medications. Staff stated that R1 sometimes refused their psychiatric medications, but requests pain medications and Alprazolam. Resident (R1) has a PRN order for Alprazolam because the doctor wants to ensure the medication is administered in case the facility runs out of the routine Alprazolam medication. Therefore, when R1 asked for the PRN medication they were told they could not administer the medication because it is only to be given if they run out during the cycle change. The cycle begins on the 21st of each month, and there are 2 pharmacies that handle resident medications. Per Medication Administration Record review, no discrepancies were observed in medication administration. There is insufficient information to prove the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 28-AS-20260225171826

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(2) · Plan of correction due date: Apr 28, 2026

Personnel - Operations. In each facility: Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement was not met evidenced by: Based on interviews, the findings indicate that S1 yells at residents and resident (R1), and can also be confrontational with staff. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 14, 2026

Plan of correction: Executive Director agreed to submit: 1/. A written plan of correction addressing verbal abuse, facility procedures, and disciplinary action. 2. Proof of staff in-service training on Personal RIghts and Personnel Operations.

Allegation investigated: Staff are not treating resident with dignity and respect. Staff are not meeting resident's needs.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Executive Director, Zara Poghosyan. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to Director. The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster, staff training records and resident's facility files. The investigation revealed the following: In regards of facility staff are not treating resident with dignity and respect, it was alleged that a resident felt staff gave attitude and not showing respect when providing care to resident. (-continued on LIC 9099C-) Unsubstantiated Per the resident interviews, ten (10) out of ten (10) residents interviewed could not corroborate the allegation. It revealed residents were treated with respect and residents received care from staff with dignity. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation which indicated staff would treat residents with respect and dignity. During the facility tour, LPA observed staff were nice to residents and had smiles on their faces when assisting residents. Therefore, residents are treated with dignity and respect. In regards of facility staff are not meeting resident's needs, it was alleged that staff did not provide proper incontinence care, prolong changing residents’ diapers and dismiss diaper change requests when called. LPA interviewed residents, three (3) out of ten (10) residents interviewed stated staff did not change their diapers often enough and did not provide immediate response to their requests when called. Seven (7) out of ten (10) residents interviewed revealed staff would change their diapers and pull ups throughout the day and as needed. Staff would check on residents when called. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. During the visit, residents were observed to be clean and there was no foul odor in residents’ rooms. Per the record review, in-service training was provided to staff related to incontinence care. Besides, facility kept an incontinence log to show incontinence care was provided and residents were checked every two hours. In addition, LPA tested the call button, and staff came to residents’ room checking on residents within five (5) minutes. Therefore, staff provide care to meet the care needs of residents. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Program Director Zara Poghosyan. The findings were discussed and a copy this report LIC 9099s was provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 28-AS-20260127131137

Allegation investigated: Staff do not ensure the facility is at a comfortable temperature for residents.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 01/05/2026 regarding the above allegation. During today’s visit LPA Ramirez was greeted by Administrator Zara Poghosyan and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 3 interviews (S1 – S3), Interview with facility general contractor, Resident#1-9 (R1- R9), copy of repair and restoration letter from general contractor, and physical plant tour. SEE 9099-C for continued report Substantiated The investigation revealed the following: regarding the allegation “Staff do not ensure the facility is at a comfortable temperature for residents.” It is alleged staff do not ensure the facility is heated to a comfortable temperature for residents. Five (5) out of the nine (9) residents interviewed corroborated this allegation. Two (2) out of the three (3) staff interviewed corroborated this allegation. Resident interviews revealed that most common areas and resident rooms are not being heated, and residents have to put on extra layers of clothing and blankets to keep warm. Staff interviews revealed that on or around December 20th, 2025, the facility’s thermostat was not properly functioning, and some areas of the facility were not maintaining proper heating. Staff interviews revealed that some residents have complained about their rooms being too cold and needing more blankets to stay warm. Staff interviews revealed the facility has at least twelve (12) extra portable heaters that residents will be provided upon their request. During facility tour, LPA Ramirez common areas and seven (7) resident rooms. LPA Ramirez did not observe thermostats in resident rooms; however, one (1) thermostat located on the 1st floor hallway located near the dining room read 67-degree F at 10am. According to weather forecast for 01/05/2026, it shows a high of 61-degree F daytime and a low of 52 -degree F in the evening. During record review, LPA Ramirez observed a letter from the facility general contractor that indicated the facility was professionally serviced on December 20th, 2025, and all repair and restoration work is currently in progress and is scheduled to be fully completed by January 12, 2026. Phone interview with the facility general contractor revealed that some thermostats in the facility are not functioning properly and some areas of the facility are not reaching desired set temperature, and all facility thermostats will be replaced as a result. During tour of facility, LPA Ramirez observed several residents throughout the facility, layered with clothing and layered with several blankets to keep warm. One (1) out of the seven (7) rooms toured was equipped with a portable heater. Based on interviews, observations and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) deficiency was issued during this complaint investigation. Exit interview was conducted and a copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Jan 5, 2026 · control 28-AS-20251229085146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(1) · Plan of correction due date: Jan 7, 2026

(b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement was not met as evidenced by: One of the facility’s thermostats read 67 degree F at 10am and 5 out of 9 residents interviewed corroborated that the facility does not maintain a comfortable temperature. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jan 5, 2026

Plan of correction: Licensee will create and execute a plan to ensure rooms occupied by residents are maintained at a minimum of 68 degree F and email plan to LPA Ramirez by 01/07/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sakinah Madyun conducted an unannounced Case Management visit to facility to check the health and safety of residents in care. LPA met with Director Zara Poghosyan and Administrative Assistant Diana Rios and explained the reason for today's visit. At 9:45am LPA discussed incident in question regarding medication error in which Wellness Director Ambresa Bree Thomas was contacted via phone to assist with information. At 10:00am - 1:15pm LPA reviewed Residents (R1 and R2) Electronic Medication Administration Records (EMAR). Director, Administrative Assistant, and Wellness Director assisted during review. Based on record review and interviews the following errors were found: R1 was given the prescription medication on September 25, 2025 by MedTech. R1 was given medication that was prescribed for R2 by MedTech. Medication error was not discovered until a week later. Upon distribution R2's scheduled prescription medication was discover missing. Medication is listed on residents Face Sheet and Emergency Information Sheet (Info) and EMAR system. The medication for both (R1) and (R2) are alike but have different milogram dosages. The requirement was not met by Title 22 Regulation and resulted in a medication given in error. Deficiency is cited per California Title 22, Division 6 Chapter 8. See LIC 809D. Exit interview was conducted with Director Zara Poghosyan. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Oct 31, 2025

87465(a)(1)- (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met as evidenced by: Based on record review and interviews R1 was given the prescription medication on September 25, 2025 by MedTech. R1 was given medication that was prescribed for R2 by MedTech. Medication error was not discovered until a week later. Upon distribution R2's scheduled prescription medication was discovered missing. Medication is listed on residents Face Sheet and Emergency Information Sheet (Info) and EMAR system. The medication for both (R1) and (R2) are alike but have different milogram dosages.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: The Administrator is to have an in service training on medication protocol to ensure future medication errors do not occur. The training shall include a plan that illustrates steps the facility will take to prevent future errors.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA met with Zara Poghosyan, Director of Operations. and discussed the purpose of today’s visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility uses appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (85) ambulatory and (14) non-ambulatory residents aged 60 and above. Non-ambulatory residents in first floor bedrooms only. Hospice Waiver approved 15 residents. Last Fire Drill was conducted 07/30/2025 Staff are adhering to operational requirements. Staffing: There is sufficient staffing at the facility. Administrator Certificate for Anna Rempel on file has an expiration date of 06/11/26. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff 1-5 (S1) - (S5). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained in Abuse Reporting and Resident Rights. Staff have on-going training. Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility as well as LTCO poster. Per Facility Administrator, facility provides wi-fi services for facility residents. (See LIC809C for the continuation of this report) Resident Records-Incident Reports: LPA reviewed Resident files for R#1 - R#8. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place but needs to be updated. Physical Plant & Environment Safety: LPA conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards, and that facility follows Title 22 Regulations. The physical plant tour was conducted with the assistance of Zara Poghosyan, Director of Operations. The physical plant consists of a two-story building with 52 rooms with bathrooms in each room, offices, lobby, TV Room/ Activity Room, 2 dining rooms, kitchen, storage, laundry and outside patio. Resident rooms were randomly chosen for inspection and LPA observed that resident bedrooms have the required furniture, bed linens, sufficient lighting and closet/drawer space to accommodate each resident comfortably. Private resident bathrooms in rooms were inspected. Restrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures and have secure grab bars, showers were free of mold/ mildew and most had non-skid mats or strips in place. Hygiene supplies are provided. Water temperature was measured in random resident’s rooms and temperatures ranged from 109.4 to 113.5 degrees F. which is within range of 105.0 – 120.0 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. The fire alarm system requires maintenance as it could not be heard in the entire building. Some rooms had smoke alarms that were not operable at the time of visit. One room has a missing door on the bathroom vanity and the bathroom shelf was uncleaned. Planned Activities: Calendars and supplies for activities were observed in the activity room. (Continued on 809C) (Continued from 809C) Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. Additional food supply was also observed. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly. The dining room has adequate seating. Posted menu observed. Health Related Services/Incidental Medical Services: The medications are centrally stored in the office/ medication room and in bubble packs and/or original containers. LPA reviewed medication for R1-R5. The facility uses the Medication Administration Records (MARs) to document medications given to residents. Medications are administered as prescribed by the Physician. The facility provides incidental medical services. Per Title 22 Regulations, there were deficiencies observed during the visit. Technical Advisory issued. An Exit interview and a copy of this report were provided to Zara Poghosyan, Director of Operations along with appeal rights.the state’s words, verbatim · CDSS document, Aug 18, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst(LPA) Sakinah Madyun and Out Of Class-Licensing Program Manager(LPM) Mary Flores conducted a Case Management visit to follow-up on corrections needed that were observed during previous case management visit conducted on 5/22/25. LPA and LPM met with Diana Rios and explained the reason for the visit. During today's visit LPA and LPM conducted a tour with Assistant Administrator Diana Rios and Executive Director Zara Poghosyan and observed the following: Room #218 is clear and ready for residents to move in. Sufficient lighting in rooms #204,210,215,218. Shower curtain observed in room #210. Additional grab bar observed in room #215's shower. Proper privacy means observed for resident R1 in shared bedroom #119. Repaired dining room floor was observed. A sketch of the facility which notes non-ambulatory rooms was submitted to the Department on 6/6/25. Physical plan observed ready to provide care for additional residents per capacity increase request. Capacity increase is as follow: Fire Clearance was granted for (92) Ambulatory and (14) Non-Ambulatory residents age 60 and above. Non-Ambulatory residents in first floor only in rooms #101, #102, #103, #104, #105, #106, #107, and #122. Exit interview was conducted with Executive Director Zara Poghosyan.the state’s words, verbatim · CDSS document, Jun 27, 2025

Type of visit: Case Management - Other

LIcensing Program Analyst (LPA)s Mary Flores and Blanca Gonzalez conducted an unannounced case management visit to follow up on capacity increase request submitted to the department on 8/21/24. LPAs met with Zara Poghosyan and explained the reason for the visit. The facility is currently licensed to serve 99 non-ambulatory residents over the age of 60, of which 14 may be non-ambulatory in rooms #101,102,103,104,105,106,107,122 (rooms #101 and 122 are allowed only 1 non-ambulatory resident). The facility is located in a residential area and consist of a two level building with two dining rooms, a lobby area, a commercial kitchen, a courtyard, an activity room, several rooms, front patios, and a garage area in the back. No changes have been done to the building. The capacity increase will take place by changing current bedrooms into shared resident bedrooms. The Fire Clearance was granted on 4/17/25 for 92 ambulatory residents and 14 non-ambulatory residents over the age of 60. The facility does not serve dementia residents and does not have a memory care unit. LPA toured the facility with Zara Poghosyan and observed common areas, kitchen, and the following resident rooms: #103,105, 111,115,119, 204, 210, 215,218 which were randomly chosen. Room #218 was observed currently being used as storage for linens. Rooms #204, 210, 215,218 have lighting. However, bulbs were very dim and do not light up the entire room. Additional lighting is required. Shower curtain in room #210 was observed ripped. Room #215 was missing side grab bar near the shower. Resident #1(R1)'s bed was observed with half bed rails on one side of the bed and a large box per the residents initiative to obtain privacy in room #119. Dining room floor by the entrance has a rise of about a 2ft by 3ft with a height of about 4 inches from ground level. Facility has a camera system to allow entry to the facility to residents and staff by facial recognition. (CONTINUED ON LIC 809C) Guest and visitors may call the receptionist to gain entry into the facility using the same system. Residents have signed a surveillance acknowledgment and may refused to participate. The main door does not open from the outside but opens from inside to allow exit of the facility. Passageways exit doors have a code which the staff are trained and have access to exit in case of an emergency. Codes and facial recognition have been place due to security reasons. Administrator will make the following corrections and will submit pictures to the department within 10 days: Will remove the items and ensure room #218 is ready for residents to move in. Will provide sufficient lighting to rooms #204,210,215,218. Will provide shower curtain in room #210. Will provide additional grab bar in room #215's shower. Will provide proper privacy means for resident R1 in share bedroom #119. Will fix the dining room floor. Will submit a sketch of the facility which notes non-ambulatory rooms. LPA was provided an updated LIC 200 during this visit. LPA will return at a different time to follow up on the items above. Exit interview was conducted and a copy of this review was provided.the state’s words, verbatim · CDSS document, May 22, 2025

Allegation investigated: Staff do not assist resident with obtaining medical care Staff do not observe resident for change in condition Staff do not provide resident with a safe and comfortable environmen Staff do not ensure that facility is maintained sanitary Staff do not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Anna Rempel and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 04/29/2025, LPA interviewed Administrator, Staff #1- Staff #6, Residents #1 -Residents #8. LPA obtained copies of the following documents: Staff roster, Resident roster, R1-R2 preplacement appraisal information, Physicians reports, Identification and emergency information, and R1’s order summary report. LPA also toured facility and did random room check. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff do not assist resident with obtaining medical care”, it is alleged that R1 had a rash, and staff will not assist with care. During interviews with residents six (6) out of eight (8) residents stated that staff helps them with medical care. R6 stated “I always get what I need”. During interviews with Administrator and staff it was revealed that residents’ medical needs are taken care of staff helps with any and all medical needs. Administrator stated they have a Care Coordinator who is charge of making appointments. In regard to the allegation “Staff do not observe resident for change in condition”, it is alleged that residents are not being assessed for behavior changes. During interviews with staff, it was revealed that there is a LVN at the facility and that if a staff member notices anything different with residents the LVN will observe and contact physician if needed for new evaluation. S3 stated that if he/she sees a difference with the resident they will notify the med-tech. In regard to the allegation “Staff do not provide resident with a safe and comfortable environment”, it is alleged that R1 is afraid of roommate and staff will not change rooms. During interviews with residents six (6) out of seven (7) residents all felt the facility was safe and comfortable. R8 stated “It can be overwhelming because some residents have behavioral issues and cuss staff out”. During interviews with staff, it was revealed that R1 wants a private room but because of ambulatory status it has been a challenge. Staff stated they have not heard that residents do not feel safe here. During todays visit LPA was informed that R1 had been moved rooms. In regard to the allegation “Staff do not ensure that facility is maintained sanitary”, it is alleged that bathrooms in residents’ bathrooms are not cleaned. During interviews with residents seven (7) out of eight (8) all stated that bathrooms are cleaned daily, and that facility is clean. During interviews with staff seven (7) out of seven (7) stated the facility is cleaned daily. S5 stated they have rooms that need to be cleaned three times a day. SEE 9099C In regard to the allegation “Staff do not safeguard resident's personal belongings”, it is alleged that R1’s money and cigarettes have been stolen from bedroom. During interviews with residents five (5) out of eight (8) have never had anything stolen from there bedrooms. R4 stated that mail has been taken from room. During interviews with staff all stated that residents have said clothes like socks, or t-shirts have been missing but that they are usually found when looked for. Administrator stated that when items are said to be missing, she asks for proof that they had it, but residents can’t provide that. Administrator stated that she can’t accuse anyone without proof. 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 conducted, a copy of the Appeal Rights and this report was provided.the state’s words, verbatim · CDSS document, May 3, 2025 · control 28-AS-20250421082449

Allegation investigated: Staff are not administering resident's medications as prescribed. Staff are falsifying medication documentation. Staff did not reorder resident's medications timely.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial visit to investigate the above allegations. LPA met with Anna Rempel (Administrator) and Zara Poghosyan (Director) and discussed the purpose of today’s visit. During this visit, LPA obtained a copy of the resident and staff rosters, interviewed Resident #1 (R-1) through Resident #8 (R-8), interviewed Staff #1 (S-1) through Staff #4 (S-4), reviewed R-1’s file and obtained relevant documentation and conducted tour of medication room. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Staff are not administering resident's medications as prescribed. It has been alleged that staff are not administering residents’ medications as prescribed. Resident interviews revealed that staff provide them with their prescribed medications daily. Interviewed residents indicated they have not had any issues/concerns regarding this matter. Interviewed residents indicated they have not heard other residents complaining about their medication not being administered. Interviewed staff indicated that they provide residents with their medication as prescribed. Interviewed staff indicated that R-1 tends to refuse to take R-1’s ointment medication which is documented on the back of the Medication Administration Record (MAR). Interviewed staff indicated that R-1 takes R-1’s Ativan and Citalopram daily and has not refused to take these medications. Interviewed staff indicated that C-1’s pharmacy sent extra medication bubble packs (for January 2025) with Ativan and Citalopram and staff were awaiting for the end of the cycle to return them back to the pharmacy. Interviewed staff indicated that R-1 has not complained about not receiving their medication. Interviews do not corroborate this allegation. Staff are falsifying medication documentation. It has been alleged that R-1’s Medication Administration Record (MAR) had been signed by staff as medication being administered to R-1 when medication was not administered to R-1. Based on record review and interviews conducted with residents and staff, there is no evidence to corroborate this allegation. Staff did not reorder resident's medications timely: It has been alleged that R-1’s PRN (as needed) and routine medications were all empty and refills had not been requested at the time. Based on record review and interviews conducted with residents and staff, there is no evidence to corroborate this 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 conducted, a copy of the Appeal Rights and this report was provided to Anna Rempel (Administrator).the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 28-AS-20250129153136

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial complaint investigation visit and met with Ana Rempel (Administrator) and Zara Poghosyan (Director). During this complaint visit, it was discovered that R-1’s records were incomplete. LPA discovered multiple staff initials missing on R-1’s Medication Administration Record (MAR) for the January 2025 log. The MAR was missing initials for the following medications: Triamcinolone, Aripiprazole, Lorazapam/Avitan, Fluocinonide, Ammonium Lactate, Citalopram, Lisinopril, Atorvastatin, Metformin HCI, Eliquis, Carvedilol and Clotrimazole. Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 809D. Exit interview, appeal rights and a copy of this report was provided to Anna Rempel (Administrator).the state’s words, verbatim · CDSS document, Feb 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 14, 2025

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This standard is not met as evidence by: R-1’s records were incomplete. LPA discovered multiple staff initials missing on R-1’s Medication Administration Record (MAR) for the January 2025 log.the state’s words, verbatim · CDSS document, Feb 4, 2025

Plan of correction: Administrator to provide in-service training to staff pertaining to medication administration documentation and provide proof of training to LPA Irra by POC due date.

Allegation investigated: Licensee did not provide adequate notice of fee increase to residents. Licensee did not abide by the terms and conditions of resident's admission agreement.

**This is a corrected version of previously dated report 10/10/2024. LPA Ramirez corrected verbiage on 9099-D page. Violation 87507(4) was corrected to 87507(g)(4). No changes to findings.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/10/2024 regarding the above allegations. LPA Ramirez was greeted by Assistant Administrator- Tannya Quezada and Director- Zara Poghosyan. LPA Ramirez explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 - 2 interviews (S1 – S2), Interview of Resident#1 (R1), copies of R1's Admission Agreement, Emgernecy and Identification Information, Physician's Report, Notice of adjustments to rates dated 10/01/2024, Recind notice of adjustments to rates dated 10/10/2024, and physical plant tour. See 9099-C for continuation. Substantiated The investigation revealed the following. Regarding Allegation: Licensee did not provide adequate notice of fee increase to residents – It is alleged the licensee did not provide R1 with adequate notice of fee increase. On 10/01/2024, R1 was given a notice of rate increase based on level of care required and would be effective 11/01/2024. According to the notice, staff will be conducting assessments the week of 10/21/2024, and R1’s new rate will be based on new assessment conducted. Per Title 22, Division 6, Chapter 8, Article 09. Resident Records- 87507(4) Admission Agreement- Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. Licensee did not provide R1 with adequate notice of rate increase. One (1) out of one (1) resident interviewed collaborate this allegation. Two (2) out of the two (2) staff interviewed collaborate this allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Licensee did not abide by the terms and conditions of resident's admission agreement - It is alleged the licensee did not abide by R1’s admission agreement. During records review, LPA Ramirez observed R1’s original admission agreement signed by R1 and a facility representative, on 11/03/2021. Per the facility admission agreement, page 4- Section 8. Rate Change- A. “The Agreement must inform the resident of the conditions under which rates may be increased and provide no less than 60 days prior written notice to the resident or the resident’s responsible person.” On 10/01/2024, Licensee issued a notice of rate increase to R1, which did not adhere to R1’s admission agreement. One (1) out of one (1) resident interviewed collaborate this allegation. Two (2) out of the two (2) staff interviewed collaborate this allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) violation was cited during this investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 28-AS-20241003113403

Allegation investigated: Licensee did not provide adequate notice of fee increase to residents. Licensee did not abide by the terms and conditions of resident's admission agreement.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/10/2024 regarding the above allegations. LPA Ramirez was greeted by Assistant Administrator- Tannya Quezada and Director- Zara Poghosyan. LPA Ramirez explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff#1 - 2 interviews (S1 – S2), Interview of Resident#1 (R1), copies of R1's Admission Agreement, Emgernecy and Identification Information, Physician's Report, Notice of adjustments to rates dated 10/01/2024, Recind notice of adjustments to rates dated 10/10/2024, and physical plant tour. See 9099-C for continuation. Substantiated The investigation revealed the following. Regarding Allegation: Licensee did not provide adequate notice of fee increase to residents – It is alleged the licensee did not provide R1 with adequate notice of fee increase. On 10/01/2024, R1 was given a notice of rate increase based on level of care required and would be effective 11/01/2024. According to the notice, staff will be conducting assessments the week of 10/21/2024, and R1’s new rate will be based on new assessment conducted. Per Title 22, Division 6, Chapter 8, Article 09. Resident Records- 87507(4) Admission Agreement- Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. Licensee did not provide R1 with adequate notice of rate increase. One (1) out of one (1) resident interviewed collaborate this allegation. Two (2) out of the two (2) staff interviewed collaborate this allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Licensee did not abide by the terms and conditions of resident's admission agreement - It is alleged the licensee did not abide by R1’s admission agreement. During records review, LPA Ramirez observed R1’s original admission agreement signed by R1 and a facility representative, on 11/03/2021. Per the facility admission agreement, page 4- Section 8. Rate Change- A. “The Agreement must inform the resident of the conditions under which rates may be increased and provide no less than 60 days prior written notice to the resident or the resident’s responsible person.” On 10/01/2024, Licensee issued a notice of rate increase to R1, which did not adhere to R1’s admission agreement. One (1) out of one (1) resident interviewed collaborate this allegation. Two (2) out of the two (2) staff interviewed collaborate this allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) violation was cited during this investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 28-AS-20241003113403

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4) · Plan of correction due date: Oct 17, 2024

87507 Admission Agreements (g) Admission agreements shall specify the following:(4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. This requirement was not met as evidenced by: Licensee issued notice of rate increase to R1 that was to take effect 11/01/2024. Notice was issued to R1 0n 10/01/24.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee will recind prior notice dated 10/01/24 and retrain staff on regulation 87507(4). During visit, Licensee drafted notice to recind. This will clear part of POC. Retraining of staff will be due by 10/17/24. Proof of retraining must be sent via email.

Allegation investigated: Staff are not distributing resident's medications as prescribed Staff did not ensure that a resident's medication was centrally stored

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Zara Poghosyan and explained the reason for the visit. The investigation consisted of the following: On 7/13/24 LPA had obtained copies of staff/resident roster and reviewed medication for 5 residents during an annual visit. On 7/15/24 LPA Flores conducted interviews with 8 residents and 5 staff. LPA reviewed 3 additional residents' medication and collected the following copies: Physician's report dated: 7/3/24, admission agreement dated: 10/28/21, appraisal needs and services plan dated: 10/27/21, identification and emergency information dated 10/28/21, and medication sheets for June and July 2024 for resident #1 (R1). On 8/1/24 LPA obtained copies of Med-Tech training and delivered findings for complaint. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff are not distributing resident's medications as prescribed. It is alleged resident’s prescribed medications were not given to resident as prescribed. Interviews conducted with residents revealed 6 out of 8 residents stated their medication is provide for each dose as prescribed and have not missed any doses of their medications, 2 out of 8 residents stated they have either missed a dose or their dose was switched from the night dosage to the morning dosage by staff. Interviews with staff revealed medication is provided as prescribed and given to the residents by Med-Techs during each mealtime. Per staff the only time a resident misses a dose of their medication is when the residents refuse to take their medication. During medication review which was conducted on 7/13/24 and 7/15/24, LPA observed medications prescribed available for at least 30 days, the medication matched the medication sheets, and was noted by the Med-Tech on the medication sheet after each dose was provided. File review revealed no additional prescribed medications others than the listed ones in medication sheet for R1. 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. Regarding allegation: Staff did not ensure that a resident's medication was centrally stored. It is alleged resident’s medication was "tossed inside of a trash can" and not stored properly. Interviews with residents revealed their medication has not been missing at any time and residents stated the facility staff stored their medication for them and it is available for them. Interviews with staff revealed the medication is stored in the medication room, medication has not been disposed or found in the trash can for any of the residents. R1’s injectable medication was observed stored in the refrigerator during medication review. Per med-techs R1 recently started this medication. Usually, this medication is provided by a resident’s program nurse which is brought by them. However, the pharmacy delivered the medication for R1 to the facility, and it is being stored and provided when the nurse asks. During facility’s tour which was conducted on 7/13/24 LPA did not observed medications in common areas or resident rooms. Med-Techs last training was provided on 7/20/24. 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 was conducted with and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 28-AS-20240710143743

Allegation investigated: Resident sustained multiple wounds (unstageable) while in the facilities care Staff did not adequately manage resident's glucose

Licensing Program Analyst (LPA) Alma Gonzalez conducted unannounced subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of: During the initial visit conducted on 07/26/22, LPA Gonzalez collected copies of Staff and Resident rosters, reviewed Resident 1's file (R1), and collected copies of documents pertinent to the investigation. LPA conducted an interview with Assistant Administrator Anna Rempel and collected contact information for R1's Home Health Agency - Supportive Homecare. LPA additionally conducted a tour of entire facility inside and out with Assistant Administrator Anna Rempel and did not observe any immediate Health & Safety concerns during the visit. On 08/02/22, LPA requested and received home health records (See LIC9099C for continuation) Unsubstantiated dated 06/11/22 – 07/01/22 for R1 via email from Supportive Home Health. On 03/08/23, LPA mailed/ emailed Investigative Subpoena Duces Tecum to hospital requesting hospital records. On 10/11/23, LPA re-emailed subpoena and sent an email inquiring on status of subpoena and didn't receive a response. On 11/14/23, LPA completed an Investigations Branch Service Request requesting assistance with obtaining hospital records. On 12/27/23, LPA received R1's hospital records from Special Investigator Eliza Jackson. On 01/31/24, LPA called home health agency to request additional documents for dates 07/02/22 – 07/18/22. On 02/02/24, LPA followed up with home health agency regarding request for additional documents. On 02/07/24, LPA submitted a Clinical Consult Referral with hospital records and partial home health records for review by department Program Clinical Consultant (PCC). On 02/08/24, LPA received additional documents from home health agency dated 07/02/22 – 07/18/22 and forwarded the records on 02/14/24 to the department PCC for review. On 04/23/24, LPA conducted a telephone interview with Administrator Rempel and a telephone interview with Supportive Home Health Care Director of Patient Care Services. LPA emailed additional information to PCC. On 06/11/24, LPA conducted a Subsequent Visit and collected copies of Staff and Resident rosters, conducted interviews with Administrator Anna Rempel, S1-4 and R2-8. LPA conducted a tour of the facility and observed residents in care. LPA toured and inspected a total of 8 resident rooms and also tested the facility signal system. On 06/21/24, LPA Gonzalez revised and resubmitted Clinical Consult Referral for PCC review with hospital records and home health records. On 07/03/24, LPA requested and received facility shower schedules for January – July 2022 and Medication Administration Records (MARs) for June and July 2022 from the facility. LPA forwarded the records and resident/ staff interviews to PCC for review. On 07/19/24, LPA received completed PCC referral. The investigation revealed the following: Regarding allegation of, Resident sustained multiple wounds (unstageable) while in the facilities care, it is alleged that R1 was neglected by the facility. R1 was hospitalized on 07/18/22 and had several wounds that appeared to be unattended, and the facility Administrator allegedly stated that R1’s wound had just started over the weekend before R1 was hospitalized and were treated with heel protectors and lotion. However, when R1 was hospitalized, they had some wounds that were reported as unstageable. Interviews conducted with facility staff revealed that R1 did not have any pressure injuries before being hospitalized. Staff stated that the resident was seen by home health twice a day and they were not instructed that resident needed to be repositioned or given any other instructions regarding caring for any wounds. Staff stated that R1 was able to shift around in their bed as well as get off the bed. They stated that R1 did have very dry skin, so they often had to moisturize their skin with lotion. Staff also stated that they check on all residents every two hours and immediately if a resident uses their call button requesting assistance. Staff stated that incontinence care is provided every two hours and as needed, if a resident uses the call button requesting assistance. Administrator stated that R1 was seen twice a day by home health and that facility staff cared for R1's needs as needed and always followed the doctors orders as well as home health nurse orders. She stated that facility staff are trained in providing adequate care and supervision, as well as the importance of providing assistance with Activities of Daily Living (ADLs) for any resident that requires assistance with ADL's. She stated that staff were providing R1 with shower assistance twice a week and staff had not reported that they had observed any changes with R1's skin. Per medical records review, the home health agency indicated that R1's skin condition did not vary from 06/11/22 - 07/17/22 indicating that their skin was cool, dry, clammy and also stated that the nurse performed a comprehensive nursing assessment of all body systems, blood sugar was checked via fingerstick, diabetic foot exams were performed with no abnormal findings noted. The nurse also noted that they prepared and gave the insulin subcutaneously and skin was intact. On 07/18/22, records indicate that the home health nurse documented that R1's skin was cool, dry, clammy, pallor and wounds were observed. The nurse documented the wound care per physician's orders. The nurse also noted weakness and poor fluid intake at which time the nurse decided to call the physician who ordered that R1 be taken to the hospital. Interviews conducted with 7 out of 7 residents revealed that the facility staff are helpful, check on them often and respond to the call system right away. One resident was bed bound at the time of LPA visit, and they stated that they do not have any concerns, staff check on them every 2 hours or sooner and when they need assistance, they use the signal system, and staff respond quickly. This resident stated that they can shift around without assistance. Residents requiring shower assistance stated that staff give them their showers as scheduled and they do not have any complaints. LPA observed staff tending to residents and observed that residents appeared clean. LPA also tested the signal system in 8 resident rooms and verified that the signal system is working, and staff responded in less than two minutes. Based on statements gathered from interviews conducted with staff, facility residents, LPA observations and record review, there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff did not adequately manage resident's glucose, it is alleged that R1's A1c level was at 17 when they were hospitalized on 07/18/22. Administrator stated that R1's glucose was checked daily and insulin was administered as well and staff know to call the doctor if R1's glucose is very high. Interview conducted with facility administrator revealed that R1 was provided adequate and timely care at all times. She stated that R1 was seen twice a day by home health and that facility staff cared for R1's needs as needed and always followed the doctors orders as well as home health nurse orders. Per medical records review, Supportive Home Health Care Re-Certification Form dated 06/07/22, indicated the continuance of skilled nursing visits for R1 and also indicated the physician ordered Home Health Care to monitor blood glucose twice a day and administer insulin by subcutaneous injection in the morning and in the evening. Home Health Care records also reported blood sugars that did not match the blood sugars at the hospital emergency department. A complaint against Supportive Home Health Care by California Department of Public Health (CDPH) was investigated regarding R1's blood sugars recorded from 06/11/22 - 07/18/22 and the hospital emergency department's blood sugar results. The records revealed that R1's blood sugar were taken twice a day by home health and they did not ever measure over 300mg/dL, and there was no evidence of the home health nurses reporting any sings or symptoms of high blood sugar to R1's primary care physician. CDPH report dated 04/17/24 was unsubstantiated based on interviews and record review. Based on interviews conducted with facility staff and record review, 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 Anna Rempel.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 28-AS-20220722163041

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual continuation - case management visit at the facility. LPA met with Zara Poghosyan and Tanya Quezada Administrator and explained the reason for the visit. On 7/13/24 LPA Flores conducted an initial annual visit. During today's visit LPA Flores reviewed the following CARE inspection tool domains: Infection Control, Staffing, Personnel Records/Staff Training, and Residents with Special Health Needs. LPA reviewed 5 staff files. Administrator certificate was observed for Tanya Quezada #6056570740 expiration date: 7/8/24. Per staff documents were submitted to the department for renewal on 6/10/24. LPA reviewed Infection Control Plan was last reviewed on 5/11/22. During the visit of 7/13/24 LPA observed resident #1(R1) on room #227 had half bed rails on the bed. R1 does not have a bed rail request on file. During medication review conducted on 7/13/24 LPA Flores observed Resident #2(R2) had medication prescribed. However, the medication was not found during the review of medication. Med-Tech search for the medication but it was not found. LPA interviewed 8 residents and 4 staff during this visit. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Zara Poghosyan and Tanya Quezada and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 15, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Zara Pghosyan and explained the reason for the visit. The facility is licensed to served 85 ambulatory and 14 non-ambulatory residents ages 60 and above. Non-ambulatory residents in first floor only. Hospice waiver approved for 15 residents. The facility is located in a residential area and consist of a large two story building. First floor has a commercial kitchen, two dining rooms, a courtyard, a lobby, office space, resident rooms, and a front patio. Second floor has resident rooms, medication room. Storage spaces are throughout the facility. LPA conducted a tour of the facility with Zara Pghosyan and observed the following: Facility is in good repair indoor and outdoor. Commercial kitchen is clean, and food supplies were stored sufficient for at least two days of perishables and 7 days of non-perishables. Common areas are clean and in good repair. All the required postage was observed throughout the first floor. LPA observed 8 randomly chosen resident rooms which have sufficient lighting, the required furniture, and bedding supplies. Water temperature was tested in each bathroom and tested between 97.7 - 117.2 degrees F. which is not within the required 105-120 degrees F. Bathrooms were observed to have the required grab bars and skid strips on showers. Call system was tested in 4 rooms and receptionist responded to each call immediately. No large bodies of water were observed. Facility has a fire sprinkler system throughout. Smoke/Carbon monoxide detectors were tested in each room and are in working condition. LPA reviewed medication and files for 5 residents and Emergency Disaster Plan LIC 610E (10/03) dated 9/19/23. Last emergency drill was conducted 5/26/24. During this visit LPA conducted the following CARE tool domains:Operational Requirements, Physical Plant/Environmental Safety, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness. Due to time LPA will return at a later time to finish the remaining domains. Deficiency was noted on LIC 809D, and technical violations were noted. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 13, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff neglect led to serious hospitalization of resident. Staff did not seek timely medical attention for resident.

Licensing Program Analyst (LPA) Alma Gonzalez conducted unannounced subsequent complaint visit to deliver investigation findings for the above stated allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of: During the initial visit conducted on 07/17/23, LPA Gonzalez collected copies of Staff and Resident rosters, conducted a tour of entire facility inside and out with Administrator Anna Rempel and observed residents in the facility at the time of the visit. LPA observed the residents to identify any signs of neglect, abuse or other immediate Health and Safety threats. LPA did not observe any immediate Health & Safety concerns during the visit. The investigation for this complaint was conducted by Investigator Christine Ferris. (See LIC9099C for continuation) Unsubstantiated During the course of the investigation, Investigator Ferris obtained copies of the following documents pertaining to Resident 1 (R1): Physician’s Report For Residential Care Facilities for the Elderly (RCFE) (LIC602A) dated 06/20/23 and 08/09/22, two (2) Unusual Incident/ Injury Reports (LIC624) dated 07/10/23 and 04/21/23, Resident Appraisal (LIC603A), Preplacement Appraisal Information (LIC603), Facility Communication Notes, Identification and Emergency Information, Appraisal/ Needs and Services Plan (LIC625) dated 05/01/19, Kaiser Permanente Hospital Records, and Los Angeles Fire Department Care Report dated 07/07/24. Investigator Ferris interviewed Facility Administrator Anna Rempel, facility staff (S1-5), facility Residents 1-2 (R1-2), R1 Family Member (R1 FM1) and Gateways Conditional Release Program (ConRep) Clinical Director (W1). The investigation revealed the following: Regarding allegation of, Staff neglect led to serious hospitalization of resident, during this investigation, the Department of Social Services Investigation Bureau, Investigator Ferris, reviewed hospital records which revealed that R1 was hospitalized due to an ongoing medical diagnosis and complications that resulted from it. Hospital Records revealed that R1’s hospitalization was not a result of neglect/ lack of supervision. Investigator Ferris stated that there was insufficient evidence to support the allegation of Neglect/ Lack of Supervision led to R1’s hospitalization. Based on the investigation and supporting information obtained, this allegation is not corroborated. For allegation, Staff did not seek timely medical attention for resident, during this investigation, the Department of Social Services Investigation Bureau, Investigator Ferris, interviewed facility administrator and S1-5 and their statements revealed that R1 was provided adequate and timely care and they were unaware that R1 had recently fell. Administrator stated that R1 had one fall on 04/20/23 while they were outside of the facility and that there were no reports of R1 falling since then. Administrator stated that R1 will let staff know when they need to see or speak to their doctors and had not requested to go to the hospital. Administrator stated that R1 was hospitalized on 07/07/23 due to observation of resident being weak. Interview with R2 who is R1’s roommate revealed that they did not see R1 fall or see R1 on the floor and only heard a noise that sounded as if R1 had fallen. R2 stated that R1 did not mention they had fallen, and that staff checked on R1 and then sent R1 to the hospital. R1 stated that they did not recall what happened prior to their hospitalization and did not recall falling off the toilet or anywhere else. R1 stated that R1 FM1 told them that they had fallen. R1 stated that they like the facility but that R1 FM1 does not like the facility as they believe that R1 is not getting adequate care. R1 stated that R1 FM1 has not visited them at the facility as they live out of state. R1 stated that staff would send them to the hospital if they had a fall. R1 stated that they do not have any concerns with the facility and that staff provided a good level of care and supervision. R1 additionally stated that they were treated well at the facility, they were never mistreated or neglected by facility staff. R1 stated that staff had never denied them medical attention when needed or requested. R1 stated that they would return to the facility when possible and felt that the facility was safe for them and other residents. Based on interviews conducted with facility staff and R1-2 there is insufficient evidence to support the allegation, this allegation is not corroborated. 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 Anna Rempel.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20230713121244

Allegation investigated: Staff are not keeping accurate records of medication distribution

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Anna Rempel and explained the reason for the visit. The Investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-5 (S1-5) and Residents 1-7 (R1-7). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-7's facility files, R1-7's medications and Medication Administration Records (MARs), S1-5 files and collected copies of R1-7 MARs for May 2024 and June 2024 and other documents pertinent to the complaint investigation. LPA additionally conducted a tour of the facility including medication room. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff are not maintaining a complete record for resident, it is alleged that facility medication technician is properly completing and updating resident medication logs and the medication log for R1 for the month of June 2024 had not been properly completed so staff are not properly tracking the date and time of medication distribution so there is no way of knowing if resident(s) are receiving their medications. Interviews conducted with Administrator Anna Rempel and S5 revealed that when medications are given to residents, staff initial each resident MARs for each medication and for each dosage. They stated that if a resident refuses to take their medications or are not at the facility due to being out or in the hospital the MARs are completed to indicate why the resident did not take their medications and proper reporting is done to any applicable agencies such as CCLD and other programs. Staff stated that the medications are given to residents as prescribed by the doctor. They stated that if a medication has to be taken with food they ensure that the medications are given to them with their meals. Interviews conducted 7 out of 7 facility residents revealed that they do not have any concerns regarding medication management and indicated that they receive their medications at the appropriate times that they have to take them as prescribed by their doctor. LPA reviewed R1-7's MARs and observed that MARs were properly completed by facility staff after medication administration at the time of LPA visit. LPA reviewed 5 staff files and observed that staff who assist with medication had the required medication administration training documented in their personnel files. LPA observed staff as they were administering medications to facility residents during the lunch hour and did not observe anything of concern. LPA review of R1's records revealed that R1 was being given only the medication that was prescribed to them and MARs was properly completed at the time of the visit. LPA also reviewed R1-7's Centrally Stored Medication and Destruction Records and observed the forms to be properly completed. LPA toured medication room and did not observe anything of concern. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, 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. A copy of the report was provided to Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20240613083638

Allegation investigated: Staff speak to residents inappropriately while in care. Staff do not treat residents with dignity and respect.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-5 (S1-5) and Residents 1-7 (R1-7). S6 was not interviewed as they were not working at the time of LPA visit. LPA obtained copies of Staff and Resident Rosters. LPA reviewed S1-6 files. LPA collected copies of documents pertinent to the complaint investigation. LPA conducted a tour of the facility inside and out which consisted of inspection and observations of the lobby, dining room, medication room, patio and (5) five resident rooms. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff speak to residents inappropriately while in care, it is alleged that facility staff yell at residents when they are having their meals. Interview with Administrator revealed that facility staff do not yell at residents when they are having their meals or at any other time. Interviews conducted with 1 out of 5 staff revealed that there is one staff (S6) that has been observed yelling at residents when they are having their meals. 4 out of 5 staff stated that staff do not yell at residents or speak to residents inappropriately at any time. S6 was not interviewed as they were not working at the time of LPA visit. Interviews conducted with 7 out of 7 residents revealed that staff do not yell at them when they are having their meals and also stated that staff speak to them appropriately at all times. During the visit, LPA observed staff interacting with residents during the lunch hour and throughout the facility and did not observe anything of concern. The interactions between staff and residents were observed to be respectful. LPA additionally reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA record review and observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff do not treat residents with dignity and respect, it is alleged that facility staff do not treat residents with respect. Interview conducted with Administrator Rempel revealed that all facility residents are treated with dignity and respect at all times, staff do not speak to any resident inappropriately or yell at any resident. Interviews conducted with 1 out of 5 staff revealed that there is one staff (S6) that does not treat residents with dignity and respect. 4 out of 5 staff stated that staff treat residents with dignity and respect at all times. S6 was not interviewed as they were not working at the time of LPA visit. Interviews conducted with 7 out of 7 residents revealed that they are satisfied with the services, staff treat them with dignity and respect, staff do not yell at residents and staff do not speak inappropriately to residents. During the visit, LPA observed staff interacting with residents and did not observe anything of concern. The interactions between staff and residents were observed to be respectful. LPA additionally reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA record review and 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 Anna Rempel.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20240613160701

Allegation investigated: Staff did not follow proper reporting requirements Staff did not safeguard residents' personal property

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-4 (S1-4) and Residents 2-8 (R2-8). R1 is not a resident of the facility. R1 passed away on 03/30/24. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-3's facility files and collected copies of documents pertinent to the complaint investigation. LPA conducted a tour of the facility inside and out which consisted of inspection and observations of the lobby, dining room, medication room, patio and (5) five resident rooms. LPA additionally conducted a telephone interview with Veterans Affairs (VA) Placement Coordinator Mona LeDuc. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff did not follow proper reporting requirements, it is alleged that R1 did not return to the facility on 03/27/24 and that facility administrator filed a missing person report with local law enforcement but did not report the incident to Community Care Licensing Division (CCLD). Administrator allegedly stated that the incident was not reported to CCLD because R1 did not sign an admission agreement and was not considered a resident due to that. Interview conducted with Administrator Rempel revealed that R1 was admitted to the facility on 02/13/24. She denied ever saying that R1 was not a resident of the facility. She stated that R1 would go out for daily morning walks. She stated that R1 went out on 03/17/24, and did not return to the facility. On 03/18/24, Administrator filed a missing person report with Los Angeles Police Department (LAPD) and also created and sent in an unusual incident report to CCLD within 7 days per regulation. She stated that she also called and made a report to Veterans Affairs (VA) Placement Coordinator. Interview conducted with facility administrator revealed that she always makes appropriate reports to all applicable agencies when needed. She stated that she is aware of reporting requirements for all government and local state and county agencies that the facility is affiliated with. Interviews conducted with facility staff revealed that they are properly trained on how to properly report incidents to all applicable agencies when needed. Interviews conducted with facility staff revealed that facility staff create and submit unusual incident reports to CCL within 7 days, and facility staff keep family members, responsible parties and conservators (if any) notified of any incidents involving residents. LPA review of documents revealed that the facility completed and submitted an incident report to CCLD in a timely manner as well as notified responsible party of incident(s) involving R1. Unusual Incident/ Injury Report reviewed was dated 03/18/24. R1's admission agreement was signed and dated on 02/13/24. LPA also observed/ reviewed LAPD Missing Person report dated 03/18/24. LPA additionally spoke with VA Placement Coordinator Mona LeDuc who stated that the facility did call her to report that R1 was missing from the facility. She stated that the facility is very good at keeping the VA informed of any incidents involving resident's receiving services from the VA that are residing at the facility. Interviews with 6 out of 7 residents revealed that facility maintains documentation and when necessary family or responsible parties are notified of incidents and they do not have any concerns regarding facility's documentation. Based on statements gathered from interviews conducted with staff, VA Placement Coordinator, residents and LPA review of records there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff did not safeguard residents' personal property, it is alleged that on 04/30/24, R2 reported that two gold coins were stolen from their room and that R2 suspects that S4 took them as the staff goes into R2’s room without permission. Additional personal items that were stored in the facility garage were also reported missing by R2. It is also alleged that on 04/29/24, R3 reported that their California Identification Card and their Veteran ID card were stolen from their bedroom dresser the week of 04/22/24. Administrator stated that if a resident reports that they have any missing belongings including any money they will document and investigate all alleged theft and loss of personal property. Staff will be responsible for searching for missing items and if items cannot be found, an estimate of the value will be assessed. If the theft amount exceeds $100.00, a report will be filed with appropriate law enforcement agency. Interview with Administrator Rempel and facility staff revealed that facility staff do not take any resident belongings. She stated that staff do not go in to resident rooms and take their belongings even when they are hospitalized or out of their rooms. Administrator stated that R2 did report that they were missing three gold coins and that S4 took them as S4 goes into their room. She stated that S4 is a housekeeper and does go into resident rooms to clean. Administrator stated that gold coins are not listed on R2's Personal Property and Clothing Record and that staff did attempt to help R2 locate their missing items but none were found. Administrator stated that R2 showed her a picture of the coins but she never physically saw them. Staff stated that R2 can be aggressive and repeatedly makes false allegations about staff. S1-4 deny ever taking any items from resident rooms. S3-4 stated that they do go into resident rooms but only conduct housekeeping services and they do not touch resident's personal items or open their personal drawers. Administrator stated that R2 could not indicate what items were missing from the garage and only reported the coins missing. Administrator stated that she was not aware that R3 reported that their CA ID or VA ID were missing. Staff interviewed denied ever taking any residents personal items such as money, coins or IDs. S3 stated that they pick up any loose change found on the floor while they are cleaning and will place on top of resident's drawers. Interviews conducted with 6 out of 7 residents revealed that facility staff respect their belongings and have never taken any of their belongings. 6 out of 7 residents stated that staff always knock before coming into their rooms. 6 out of 7 residents stated that they are satisfied with all the services they get at the facility and stated that they do not have any concerns, and staff are very helpful and always assist them when they need assistance. R2 stated that they could not recall what was missing from the property they have stored in the garage but that they know stuff is missing as they heard a resident talk about a 2011 concert that they attended. R3 stated that they located their CA and VA IDs and that they had just misplaced them in their room. LPA observed staff knocking and announcing themselves before going into resident rooms. LPA reviewed R2's Personal Property and Clothing Record and did not observe that gold coins were listed. LPA also observed R3's CA and VA IDs in their possession. Based on LPAs observations, review of records and statements gathered from interviews conducted with staff and residents 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 Anna Rempel.the state’s words, verbatim · CDSS document, May 7, 2024 · control 28-AS-20240501151245

Allegation investigated: Facility staff pushed resident Facility staff speaks inappropriately to residents Facility staff yells at residents

***This report serves as an amendment and supersedes the complaint investigation report created on 03/20/24. The reason for amendment is the initial report contained errors on the second and third page of the report. No other changes have been made to the report and findings remain the same.*** Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-3 (S1-3) and Residents 2-9 (R2-9). R1 was not at the facilty during the visit. LPA obtained copies of Staff (See LIC9099C for continuation) Unsubstantiated and Resident Rosters. LPA reviewed R1-9's facility files, and S1-3 files. LPA collected copies of documents pertinent to the complaint investigation. LPA conducted a tour of the facility inside and out which consisted of inspection and observations of the lobby, dining room, medication room, patio and (5) five resident rooms. Investigation revealed the following: Regarding allegation, Facility staff pushed resident, it is alleged that a facility staff (S3) pushed a facility resident (R1) approximately 3 weeks ago and the incident was witnessed by another facility resident (R2). The alleged incident occurred in the courtyard/ patio area. R1 did not sustain any injuries. Interviews with facility staff revealed that facility staff have not pushed any resident. Staff stated that all residents are always treated with dignity and respect. Staff stated that R1 is very aggressive and does not follow house rules. They stated that R1 is the one that invades staff's personal space and screams and yells at staff and residents. LPA interviewed a total of 8 residents, and 7 residents stated that staff do not push residents. They stated that hey like the facility, they feel safe, staff treat them with respect and they do not have any concerns. 1 out of the 8 residents stated that they did witness S3 push R1 that R1 did not do anything in return and only walked away. 7 residents stated that they did not witness any staff push or chase any resident. R1 was not at the facility at the time of visit. LPA toured the facility and observed residents in the front patio, courtyard and throughout the facility and residents appeared comfortable. LPA did not observe any bruising on any resident and did not observe anything of concern. Based on statements gathered from interviews conducted with staff, residents and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegations, Facility staff speaks inappropriately to residents and Facility staff yells at residents, it is alleged that on 03/11/24, a facility staff (S3) yelled at R1 and used profanity towards the same resident. This alleged incident was witnessed by a facility resident (R2) who stated that they heard S3 yell and chase R1. It was additionally reported that S3 yells at other residents and at facility staff. R1 has been served an eviction notice by facility. Interviews conducted with facility staff revealed that all facility residents are treated with dignity and respect at all times, staff do not speak to any resident inappropriately or yell at any resident and/ or staff. Staff also stated that staff have not chased any resident. S3 denied ever speaking inappropriately to R1, yelling at R1 or any other resident and also denied chasing R1. S3 denied ever yelling at any staff. Administrator stated that R1 is very aggressive and continuously does not follow house rules and refuses to pay their rent. She stated that R1 has been served with a 60 day eviction notice on 02/15/24. Staff also stated there is a zero-tolerance policy on abuse and will make a report if they observe any staff verbally abusing a resident. Interviews conducted with 7 out of 8 residents revealed that they are satisfied with the services, staff treat them with dignity and respect, staff do not yell at residents and staff do not speak inappropriately to residents. 7 residents stated that they have never seen a staff chase a resident, 1 resident stated that they did hear S3 speak inappropriately to R1, yell at R1 and stated that they did not see the incident but only heard it. 1 resident stated that they did not see S3 chase R1 but has seen S3 push R1 before. R1 was not at the facility at the time of the visit. During the visit, LPA observed staff interacting with residents and did not observe anything of concern. The interactions between staff and residents were observed to be respectful. LPA reviewed R1's file and did observe an eviction letter dated 02/15/24. LPA Gonzalez reviewed all eviction documents, warning notices, and notes regarding R1's behavior and found the eviction notice to be legal. A copy of the eviction notice was provided to R1's placement agency. LPA additionally reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA record review and 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 Anna Rempel.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240318151857

Allegation investigated: Staff mismanaged resident’s medication. Staff does not meet resident’s dietary needs.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-3 (S1-3) and Residents 1-9 (R1-9). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-9's facility files, R1-9's medications and Medication Administration Records (MARs), and S1-3 files. LPA collected copies of R1's MARs for February 2024 and March 2024 and other documents pertinent to the complaint investigation including facility menus. LPA conducted a tour of the facility inside and out, the tour included the observations and inspection of the lobby, dining room, medication room, kitchen and food storage. LPA additionally conducted a phone call with R1's Home Health Agency. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Staff mismanaged resident’s medication, it is alleged that on 03/14/24, R1 was injected with another resident's medication. R1 allegedly receives medication from a blue pen and was given medication from an orange pen, which belongs to another resident. R1 did not realize until the injection was administered that it was the incorrect colored pen. R1 reported the incident to their nurse but was told by nurse that there was not an orange pen. R1 did not exhibit any side effects and refused to get checked. Interview conducted with Administrator Anna Rempel revealed that facility staff do not administer any injections to facility residents. She stated that facility staff properly administer resident medications at their appropriate prescribed times on a daily basis as well as properly document on resident medication administrator on each resident's MARs. Administrator stated that R1 is seen by a Home Health nurse who comes in once a day to administer their medication. She stated that R1 did report the incident to her and that she spoke to the nurse who stated that a mistake was not made. She stated that R1's vitals were immediately taken and there was no concern noted as well as R1 was observed and no side effects were noted. Interviews conducted with S1-3 revealed that they administer and give residents their medications daily as prescribed by the doctor. They stated that facility staff do not administer injections to any resident and stated that home health nurses come in to administer injections for certain residents. Interviews with 8 out of 9 clients revealed that they get their medications on time everyday and that staff make sure that they take their medications. 4 residents stated that a home health agency comes in to see them either once or twice a day to administer injections. They stated that facility staff do not administer injections to them. LPA interviewed Home Health nurse who denied that R1 was given another resident's medication. Home Health Agency nurse stated that R1 is the only resident at the facility seen by the nurse and that there were no mistakes made with the resident's medication on 03/14/24 or any other day. Home Health Agency nurse stated that R1 is seen once a day for medication administration. LPA review of R1-9s MARs revealed that medications are appropriately administered to residents. R1 stated that the incident only occurred once and that it was a home health nurse who made the alleged mistake and not a staff at the facility. R1 stated that they did not feel any unusual side effects after the alleged medication mistake occurred. Based on interviews conducted with facility staff, facility residents, and LPA review of documents there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff do not ensure special diet plans are followed for residents in care, it is alleged that the facility does not serve food to meet resident's dietary needs. Interviews conducted with facility staff revealed that the food that is served to residents does meets all residents dietary needs and stated that all servings include grains, protein, fruits and vegetables. Administrator stated that the menu is reviewed and approved by a registered dietician every month. The dietician reviews the menus to ensure that the meals that the facility is serving to residents that follow a special diet are meeting their daily dietary needs as well as the needs of all residents in care. Administrator stated that food is ordered twice a week for facility to ensure that the facility has a sufficient amount of food supply for all residents in care. Interviews conducted with 8 out of 9 residents revealed that they are satisfied with the food service provided at the facility. 8 out of 9 residents stated that the food is healthy and satisfying, they are served different food options and if they do not want what is on the menu they can request a different meal option. 3 residents who were interviewed stated that they follow a special diet due to a health condition and they stated that they are satisfied with the meals that are served at the facility and stated that all meals served are healthy, well balanced and meet their dietary needs and the facility provides healthy alternatives as well as sugar free options and items such as sugar free substitutes. 1 resident stated that they are not served meals that meet their dietary need and they are forced to eat what is served. LPA toured the facility kitchen and cafeteria and observed facility menu and residents having their lunch. LPA observed the lunch being served to be well balanced with a selection of fruits and vegetables. LPA observed that the daily menu is posted and reflects what will be served for that day and also observed that there was an adequate supply of food which consisted of 2-day perishables and 7-day non-perishables. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and residents 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 Assistant Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240315165606

Allegation investigated: Facility staff pushed resident Facility staff speaks inappropriately to residents Facility staff yells at residents

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-3 (S1-3) and Residents 2-9 (R2-9). R1 was not at the facilty during the visit. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-9's facility files, and S1-3 files. LPA collected copies of documents pertinent to the complaint investigation. LPA conducted a tour of the facility inside and out which consisted of inspection and observations of the lobby, dining room, medication room, pation and (5) five resident rooms. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Facility staff pushed resident, it is alleged that a facility staff (S3) pushed a facility resident (R1) approximately 3 weeks ago and the incident was witnessed by another facility resident (R2). The alleged incident occurred in the courtyard/ patio area. R1 did not sustain any injuries. Interviews with facility staff revealed that facility staff have not pushed any resident. Staff stated that all residents are always treated with dignity and respect. Staff stated that R1 is very aggressive and does not follow house rules. They stated that R1 is the one that invades staff's personal space and screams and yells at staff and residents. LPA interviewed a total of 8 residents, and 7 residents stated that staff do not push residents. They stated that hey like the facility, they feel safe, staff treat them with respect and they do not have any concerns. 1 out of the 8 residents stated that they did witness S3 push R1 that R1 did not do anything in return and only walked away. 7 residents stated that they did not witness any staff push or chase any resident. R1 was not at the facility at the time of visit. LPA toured the facility and observed residents in the front patio, courtyard and throughout the facility and residents appeared comfortable. LPA did not observe any bruising on any resident and did not observe anything of concern. Based on statements gathered from interviews conducted with staff, residents and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegations, Facility staff speaks inappropriately to residents and Facility staff yells at residents, it is alleged that on 03/11/24, a facility staff (S3) yelled at R1 and used profanity towards the same resident. This alleged incident was witnessed by a facility resident (R2) who stated that they heard S3 yell and chase R1. It was additionally reported that S3 yells at other residents and at facility staff. R1 has been served an eviction notice by facility. Interviews conducted with facility staff revealed that all facility residents are treated with dignity and respect at all times, staff do not speak to any resident inappropriately or yell at any resident and/ or staff. Staff also stated that staff have not chased any resident. S3 denied ever speaking inappropriately to R1, yelling at R1 or any other resident and also denied chasing R1. S3 denied ever yelling at any staff. Administrator stated that R1 is very aggressive and continuously does not follow house rules and refuses to pay their rent. She stated that R1 has been served with a 60 day eviction notice on 02/15/24. Staff also stated there is a zero-tolerance policy on abuse and will make a report if they observe any staff verbally abusing a resident. Interviews conducted with 7 out of 8 residents revealed that they are satisfied with the services, staff treat them with dignity and respect, staff do not yell at residents and staff do not speak inappropriately to residents. 7 residents stated that they have never seen a staff chase a resident, 1 resident stated that they did hear S3 speak inappropriately to R1, yell at R1 and stated that they did not see the incident but only heard it. 1 resident stated that they did not see S3 chase R1 but has seen S3 push R1. R1 was not at the facility at the time of the visit. During the visit, LPA observed staff interacting with residents and did not observe anything of concern. The interactions between staff and residents were observed to be respectful. LPA reviewed R1's file and did observe an eviction letter dated 02/15/24. LPA Gonzalez reviewed all eviction documents, warning notices, and notes regarding R1's behavior and found the eviction notice to be legal. A copy of the eviction notice was provided to R1's placement agency. LPA additionally reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA record review and 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 Anna Rempel. did not observe anything of concern. The interactions between staff and residents were observed to be respectful. LPA reviewed R1's file and did observe an eviction letter dated 02/15/24. LPA Gonzalez reviewed all eviction documents, warning notices, and notes regarding R1's behavior and found the eviction notice to be legal. A copy of the eviction notice was provided to R1's placement agency. LPA additionally reviewed staff files and observed that they receive annual training on abuse. Based on statements gathered from interviews conducted with staff, facility residents and LPA record review and 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 Anna Rempel.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240318151857

Allegation investigated: Resident was physically abused while in care.

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1 and 2 (S1 and S2) and Residents 1-8 (R1-8) from 9:50 AM to 11:45 AM .LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file, and collected copies of documents pertinent to the complaint investigation. Interview was conducted with R 1's Case Manager from the VA telephonically at 11:50 AM. and interview was conducted with Conservator for Resident R 1 telephonically at 12:00 PM. In regards to the allegation Resident was physically abused while in care based on interviews conducted and information gathered it was revealed by R 1's Case Manager that R 1 had been mentally and physically off. R 1 was only at hospital for a fall and stated that R 1 never mentioned an attack. Stated she had not Unsubstantiated witnessed any bruises and doubts that the allegation occurred. Interview with Conservator for R 1 who stated that R 1 had been delusional lately and he only went to the hospital for a fall. Stated she has no evidence to support the allegation occurred. Interview with staff who stated that R 1 is very aggressive and loud and tries to hit others with his cane. Staff have never observed or heard of any resident being harmed physically. Interview with Resident's R 2- R 8 who all stated that they have never seen or heard of R 1 or any resident being attacked and physically harmed. Stated R 1 will get loud and scream and gets in trouble being bad with people. All stated that staff do a great job and are very efficient. 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. A copy of the report was provided to Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20240307171251

Allegation investigated: Staff do not ensure special diet plans are followed for residents in care

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Anna Rempel and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-4 (S1-4) and Residents 1-8 (R1-8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-8's facility files, collected copies of documents pertinent to the complaint investigation. LPA conducted a tour of the facility inside and out including included lobby, dining room, kitchen and food storage. LPA additionally collected copies of facility menus. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Staff do not ensure special diet plans are followed for residents in care, it is alleged that the facility does not serve food for residents who are diabetic and residents who have a special diet must eat whatever the facility serves to the other residents. Interviews conducted with facility staff revealed that the food that is served to residents does meets all residents dietary needs and stated that all servings include grains, protein, fruits and vegetables. Administrator stated that the menu is reviewed and approved by a registered dietician every month. The dietician reviews the menus to ensure that the meals that the facility is serving to residents that follow a special diet are meeting their daily dietary needs as well as the needs of all residents in care. Administrator stated that food is ordered twice a week for facility to ensure that the facility has a sufficient amount of food supply for all residents in care. Interviews conducted with 8 out of 8 residents revealed that they are satisfied with the food service provided at the facility. 8 out of 8 residents stated that the food is healthy and satisfying, they are served different food options and if they do not want what is on the menu they can request a different meal option. 4 residents who were interviewed stated that they follow a special diet due to a health condition and they stated that they are satisfied with the meals that are served at the facility and stated that all meals served are healthy, well balanced and meet their dietary needs and the facility provides healthy alternatives as well as sugar free options and items such as sugar free substitutes. LPA toured the facility kitchen and cafeteria and observed facility menu and residents having their lunch. LPA observed the lunch being served to be well balanced with a selection of fruits and vegetables. LPA observed that the daily menu is posted and reflects what will be served for that day and also observed that there was an adequate supply of food which consisted of 2-day perishables and 7-day non-perishables. Based on LPA observations, LPA review of facility menus, and statements gathered from interviews conducted with staff and residents 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. A copy of the report was provided to Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Feb 16, 2024 · control 28-AS-20240213100003

Allegation investigated: Facility staff are withholding resident's P&I money.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Anna Rempel and explained the reason for the visit. The Investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-4 (S1-4) and Residents 1-8 (R1-8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-8's facility files, collected copies of documents pertinent to the complaint investigation. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Facility staff are withholding resident's P&I money, it is alleged that R1 has not been provided their P&I funds of $268 each month, since the resident has resided at the facility and R1 has been at the facility for several years. It is alleged that on 01/31/24, R1's records showed that they were paid their P&I funds except for December of 2023 and January of 2024 and on 02/01/24 R1 again stated that they had not received their P&I funds. R1 allegedly stated that they never said anything because they were afraid. Interview conducted Administrator Anna Rempel revealed that R1's responsible party is Telecare Corp and they pay their rent and issue P&I funds for R1 as well as other residents. She stated that R1 receives their money each month at the beginning of the month as well as any other resident who's responsible party are Telecare. She stated that many residents are independent and either they handle their own money or a family member does. Interviews conducted with with 4 out of 5 facility staff revealed that residents receive their P&I funds at the beginning of the month. 1 out of 5 staff stated that they are not aware of anything that is financial as they only provide caregiver services to the residents. Interviews conducted with 7 out of 8 residents revealed that they do not have any concerns regarding their money and once they pay their rent they are left with a certain amount that is given to them at the time when their rent is paid. They stated that they have have always been given their money and do no have any complaints about their money not given to them by the previous administrator Gary Kitt or current Administrator Anna Rempel. They also stated that they like the facility and do not feel afraid. 1 out of 8 residents stated that they have been given their money but it is only paper money and stated that they are scared of being around any people and do not feel safe around anyone. They also stated that they staff are nice at the facility. LPA reviewed residents P & I ledger(s) and did not observe that staff are withholding residents P & I money. LPA also reviewed R1's Physician's Report for Community Care Facilities which states that R1 is able to handle their own cash resources. Based on statements gathered from interviews conducted with staff, residents and LPA record review 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. A copy of the report was provided to Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 28-AS-20240202135715

Allegation investigated: Staff did not safeguard resident's money. Staff did not provide resident with privacy.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigating the above-mentiond allegations. LPA Maldonado met with staff, Gary Kitt, and Administrator, Ana Rempel, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, and Resident Personal Property and Valuables sheet (LIC621). LPA also conducted interviews with Residents# 2-9 (R2-R9), and Staff# 1-6 (S1-S6). LPA was unable to interview R1 due to R1 out in the community during the visit. The investigation revealed the following: Regarding allegation: Staff did not safeguard resident's money. It is alleged that a S3 stole $600 on 1/28/24 and $1,000 on 1/29/24 from R1's room, totaling $1,600. LPA was unable to interview R1 to obtain additional information. (Report continued on LIC9099-C...) Unsubstantiated Per interviews conducted with R2-R9, (8) of (9) residents could not corroborate the allegation. Per staff interviews, (6) of (6) staff denied the allegation. S1 and S2 stated that R1 reported the amount missing to them around the end of January 2024. However, this is not the first time R1 alleges to be missing said quantity of money, which happens to be the amount of rent due. S2 stated that R1 may have reported it to local law enforcement as they visited on 2/7/24 and attempted to speak with R1, but R1 was out in the community at the time. No police report was left by law enforcement and could not be provided. Per R1's Physician's Report, R1 is self-responsible for R1's finances. Regarding allegation: Staff did not provide resident with privacy. It is alleged that on 1/30/24, at about 6am, R1 found S3 in R1's room without R1's permission. Per interviews with staff, (6) of (6) denied the allegation. S3 stated to have walked into R1's room with R1's permission, as R1 was awake and they had a conversation. Shortly after S3 left R1's room, S3 stated to have heard R1 telling S1 that S3 was in R1's room without R1's permission and stole R1's money. S3 is unaware of the amount of money R1 accused of S3 taking. S3 denied taking anything from R1's room and is unsure why R1 accused S3 of this. Per resident interviews, (8) of (9) residents denied the allegation and stated they have no issues with staff giving them privacy in their rooms. 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 held and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 28-AS-20240131085828

Allegation investigated: Licensee does not ensure facility has a certified administrator

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The Investigation consisted of the following: LPA conducted an interview with Administrator Anna Rempel and obtained copies of Staff and Resident Rosters. LPA reviewed Administrator Rempel facility file and collected a current copy of Residential Care for the Elderly Administrator Certificate. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Licensee does not ensure facility has a certified administrator, it is alleged that Administrator Gary Kitt's administrator certificate is expired and the facility is currently operating without an active administrator to manage the facility. Interview conducted with Administrator Anna Rempel revealed that as of January 1, 2024 she is the administrator of the facility. She stated that she provided Community Care Licensing Division (CCLD) with the required documents needed to update the change of administrator as previous Administrator Gary Kitt retired as of 12/31/23. On 12/01/23, CCLD did receive a request for administrator change along with required documents and that packet is currently under review. LPA Gonzalez will review all submitted documents for change of administrator and will update the change once review of paperwork is finalized. LPA reviewed Administrator Rempel's current copy of Residential Care for the Elderly Administrator Certificate which has an expiration date of 06/11/24. Based on interviews conducted with facility staff, and LPA review of documents 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. A copy of the report was provided to Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 28-AS-20240124140408

Allegation investigated: Staff do not keep the facility free from bed bugs Staff asked the residents for money while in care

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Anna Rempel and explained the reason for the visit. The Investigation consisted of the following: LPA conducted interviews with Administrator Anna Rempel, Staff 1-4 (S1-4) and Residents 1-8 (R1-8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-8's facility files, collected copies of documents pertinent to the complaint investigation, and RNS Pest Elimation Service receipts. LPA also conducted a tour of facility which included observations of two floors and inspected a total of 5 resident bedrooms (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff do not keep the facility free from bed bugs, it is alleged that a resident's bed has bed bugs and as a result the resident has pimple-like bumps on their legs. The resident allegedly informed facility staff and they did not take action. Interview with Administrator Rempel and facility staff revealed that the facility ensures that the facility is free from pests. They stated that pest control treats the facility monthly to ensure that the facility is free from pests. Staff deny that there are bed bugs at the facility or that any facility resident was bitten by bed bugs at the facility. Staff indicated there are no issues with bed bugs at this time. Facility has a contract with RNS Pest Elimination Services which treats the facility twice a month. LPA reviewed pest control company invoices for January 2024 and observed that the facility is treated for different pests including bed bugs and no activity was reported. 7 out of 8 residents interviewed indicated they have not seen any bed bugs in their rooms. 1 out of 8 residents stated that they have not seen bed bugs on their bed but do have bug bites on their legs and they have to be from bed bugs. LPA did not observe any bed bugs in the resident rooms that were toured. Based on interviews conducted with facility staff, facility residents, LPA observations and record review there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff asked the residents for money while in care, it is alleged that a new staff, who's name begins with an "L" and is either a caregiver or a housekeeping staff asked a resident for money. The resident did not give the staff any money. It is also reported that this same staff allegedly also asked another resident for money. Interviews conducted with facility staff revealed that they do not ever ask or take any residents money. Administrator stated that she has not gotten a complaint from any resident reporting that a staff is asking them for money. Administrator stated that if a resident reports that they have any missing belongings including any money they will document and investigate all alleged theft and loss of personal property. Staff will be responsible for searching for missing items and if items cannot be found, an estimate of the value will be assessed. If the theft amount exceeds $100.00, a report will be filed with appropriate law enforcement agency. S1 stated that a resident recently told them that a new staff asked them for money but that the resident did not give the staff money. S1 stated that she had not heard anything like that from any resident before and has never seen or heard from anyone else that a staff has asked a resident for money. Interviews conducted with 7 out of 8 residents revealed that facility staff have never asked them for money and they have not had any issues with their money. 1 out of 8 residents stated that 1 staff that is new attempted to ask them for money but they did not give the staff any money. 1 out of 8 residents stated that another resident was also asked for money by the same staff but they could not remember the other residents name and thinks they just now the resident's room number. Based on statements gathered from interviews conducted with staff and residents 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 Anna Rempel.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 28-AS-20240126125649

Allegation investigated: Staff are not maintaining a complete record for resident. Staff do not dispense resident’s medication as prescribed.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Assistant Administrator Anna Rempel and explained the reason for the visit. The Investigation consisted of the following: LPA conducted interviews with Assistant Administrator Anna Rempel, Staff 1-3 (S1-3) and Residents 1-8 (R1-8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-8's facility files, R1-8's medications and Medication Administration Records (MARs), S1-3 files and collected copies of R1-8 MARs for December 2023 and January 2024 and other documents pertinent to the complaint investigation. LPA additionally conducted a tour of the facility including medication room. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff are not maintaining a complete record for resident, it is alleged that medication logs are not properly updated and staff are not tracking the date and time of medication distribution so there is no way of knowing if resident(s) are receiving their medications. Facility allegedly only maintains MARs for some medications and they are incomplete with missing information and the the staff need assistance with organizing their medication records. Interviews conducted with Assistant Assistant Anna Rempel and S1-3 revealed that when medications are given to residents, staff initial each resident MARs for each medication and for each dosage. Staff stated that if a resident refuses to take their medications or are not at the facility due to being out or in the hospital the MARs are completed to indicate why the resident did not take their medications and proper reporting is done to any applicable agencies such as CCLD and other programs. Staff stated that the medications are given to residents as prescribed by the doctor. They stated that if a medication has to be taken with food they ensure that the medications are given to them with their meals. Interviews conducted 8 out of 8 facility residents revealed that they do not have any concerns regarding medication management and indicated that they receive their medications at the appropriate times that they have to take them as prescribed by their doctor. LPA reviewed R1-8's MARs and observed that MARs were properly completed by facility staff after medication administration at the time of LPA visit. LPA reviewed 3 staff files that assist with medication and each file had the required medication administration training documented in their personnel files. LPA observed staff as they were administering medications to facility residents and did not observe anything of concern. LPA review of R1's records revealed that R1 was being given only the medication that was prescribed to them and MARs was properly completed at the time of the visit. LPA also reviewed R1-8's Centrally Stored Medication and Destruction Records and observed the forms to be properly completed. LPA toured medication room and did not observe anything of concern. Based on interviews conducted with facility staff, facility residents, LPA review of records and observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Staff do not dispense resident’s medication as prescribed, it is alleged that the facility staff are not giving facility residents their medications and due to that R1 was acting "bizarre" and was confused as to whether they received their medication(s) on 01/11/24. It is also alleged that the facility has had ongoing issues with medication discrepancies. Interview conducted with Assistant Administrator Anna Rempel revealed that facility staff properly administer resident medications at their appropriate prescribed times on a daily basis. Interviews conducted with S!-3 revealed that they administer and give residents their medications daily as prescribed by the doctor. Interviews with 8 out of 8 clients revealed that they get their medications on time everyday and that staff make sure that they take their medications. LPA review of R1-8s MARs revealed that medications have been given to clients. LPA also reviewed R1-8's Centrally Stored Medication and Destruction Records and observed the forms to be properly completed. LPA did not observe R1 to appear as confused during the interview. Based on interviews conducted with facility staff, facility residents, and LPA review of documents 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 Assistant Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Jan 19, 2024 · control 28-AS-20240116090448

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alma Gonzalez conducted a case management visit for the death of Resident 1 (R1) which occurred on 07/22/22. LPA made an initial visit on 07/26/22. LPA reviewed death certificate and the death certificate indicates that the immediate cause of death for R1 was Sudden Cardiac Arrest and Atherosclerotic Cardiovascular Disease. A Biopsy was not performed. An autopsy was not performed. Other Significant Conditions contributing to death were listed as None. Place of Death: 186 S Commonwealth Avenue, Los Angeles 90004. Based on the available information reviewed, LPA did not note any deficiencies in reference to R1's death. Exit interview conducted and copy of report was provided to Assistant Administrator Anna Rempel.the state’s words, verbatim · CDSS document, Jan 19, 2024

Allegation investigated: Staff stole resident's belonging. Staff did not safeguard resident's personal belongings. Staff do not treat resident with dignity and respect. Staff do not clean resident's room. Staff do not provide resident with toilet paper.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator, Gary Kitt, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident roster, staff roster, and the facility Theft and Loss Policy. LPA Maldonado also obtained the following records for Resident# 1 (R1): Facesheet, Physician's Report, and Resident Personal Property and Valuables (LIC621), and conducted interviews with Staff# 1-3 (S1-S3) and attempted interviews with Residents# 1-8 (R1-R8). The investigation revealed the following: Regarding allegation: Staff stole resident's belonging. It is alleged that upon 48 hours of moving into the facility, R1 was robbed of coat hangers, a coat rack, a leather jacket, and personal memorabilia by an unknown staff member. (3) of (3) Staff interviewed denied the allegation. (Report continued on LIC9099-C...) Unsubstantiated S3 stated to recall R1 calling the police on the second day of R1 residing here, as R1 stated that someone had stolen a clothing rack. S3 states that police came and staff and police checked R1s room, only to find the clothing rack there. Police left and no report was made due to the item being found. (7) of (8) Residents interviewed could not corroborate the allegation. Per the facility's Theft and Loss Policy, the facility is to document and investigate all alleged and actual theft and loss of personal property. After doing so, staff are responsible for searching for missing items- if items could not be found, an estimate of the value would be assessed, and if the theft amount exceeds $100.00, a report would be filed with appropriate law enforcement agency. This was done by the facility. Regarding allegation: Staff did not safeguard resident's personal belongings. It is alleged that (2) unknown residents stole money, medication, and coins from R1, and staff did not do anything about it when R1 reported it. (3) of (3) staff interviewed denied the allegation. Staff stated that reports made by R1 were investigated and R1's items were found by staff. S1 stated that the last thing R1 reported missing was candy. S1 stated that S1 gave R1 $20.00 for the alleged missing candy, although S1 observed that R1 still had that candy. During interviews with residents, R1 admitted to S1 giving R1 $20.00 for the candy. R2 stated to have been roommates with R1 for a few weeks (dates were unspecified). R2 stated that while rooming with R1, R1 accused R2 of stealing R1's medications, candy, and a plant. R2 denied stealing anything and stated that staff helped R1 find R1's alleged missing items. (6) of (8) residents interviewed could not corroborate the allegation. Regarding allegation: Staff do not treat resident with dignity and respect. It is alleged that staff speak to R1 as if they are insignificant. (3) of (3) staff interviewed denied the allegation and stated they treat residents with dignity and respect. However, residents sometimes do not treat staff with respect. (4) of (8) residents interviewed denied the allegation and stated that staff treat them well. (3) of (8) residents could not corroborate the allegation. Regarding allegation: Staff do not clean resident's room. It is alleged that staff do not clean, sweep, mop, empty the trash, or wash the bathroom for R1, and that on 12/20/23, R1's roommate urinated on the floor and as of the 12/21/23, staff had yet to clean it. Upon entry to the facility, LPA observed staff sweeping and mopping common areas and resident rooms, taking out the trash, and picking up laundry. LPA inspected R1's room and it was not malodorous. The bathroom appeared clean and sanitary, the trash can was empty and the floor was clean- no urine, hazards, or obstructions were observed. (3) of (3) staff interviewed denied the allegation and stated staff provide housekeeping one to two times per week, and as needed. (4) of (8) residents denied the allegation and stated to have no issues with housekeeping services being provided. (3) residents could not corroborate the allegation. (Report continued on LIC9099-C...) Regarding allegation: Staff do not provide resident with toilet paper. It is alleged that staff do not provide R1 with toilet paper and has had to purchase their own in the past. (3) of (3) staff interviewed denied the allegation. Staff stated that each room is provided with one to two rolls of toilet paper daily, depending on how many residents reside in the room. Staff stated that additional toilet paper is provided as needed. (4) of (8) residents interviewed denied the allegation and stated that staff provide them with toilet paper and anything else they need, upon request. (3) of (8) residents could not corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Gary Kitt.the state’s words, verbatim · CDSS document, Dec 28, 2023 · control 28-AS-20231221163709