Cottage Inn

Allegation investigated: Staff did not follow resident's advance health care directive

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit for the above allegation. LPA met with Facility Staff/Designee Judith Gonzalez. Administrator was contacted via telephone and joined the visit telephonically. Entrance interview conducted. During an initial complaint visit conducted on 01/06/2026, LPA interviewed staff from 11:13AM to 01:00PM, reviewed and obtained copies of relevant documents, and toured the physical plant at 02:03PM. Throughout the course of the investigation, interviewed Administrator telephonically, LPA attempted to interview three (3) additional relevant parties via telephone, and LPA reviewed all documents obtained. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated The complaint alleges that Resident #1 (R1) had a Do Not Resuscitate (DNR) directive and the facility staff did not follow this directive when R1 was found unresponsive. LPA reviewed all documents for R1, which did include a DNR form signed by R1’s representative and R1’s physician dated 02/24/2024. Interview with staff and management revealed that facility staff were unaware that R1 had a DNR and the first time they saw this form was on the night R1 was found unresponsive. On 12/10/2025, staff entered R1's room at 12:00AM to assist R1 with repositioning and care needs and found R1 unresponsive. Staff dialed 9-1-1. Fire department personnel responded to the facility and began to treat R1. The licensee attempted to reach R1’s family members to inform them of the situation, however, neither family member answered their phone. Fire personnel also attempted to reach R1’s family and were successful after about 20 minutes of treatment. It was then R1’s family member informed the fire personnel about R1’s DNR. According to staff, while on the phone with R1’s family member, fire personnel were able to locate R1’s DNR, possibly in R1’s room. Staff interviews revealed that each resident has an emergency folder, which contains all pertinent documents, including, but not limited to: medication list, medical assessment, consent for treatment, insurance information, as well as physician contact information and the DNR form if the resident has one on file. LPA observed the emergency folder for R1, which did not contain a copy of the DNR form. Staff interviews revealed that two (2) other residents in the facility have DNR forms and LPA confirmed the presence of the DNR forms in both these residents’ emergency folders. R1’s Admission Agreement indicated “I acknowledge the receipt of the facility’s policies on DNR orders,” which R1’s family member initialed upon admission to the facility. The facility’s policy indicates any DNR form is required to be given to facility management upon move in. All staff interviewed at the facility stated they had never personally received a DNR form from R1’s family, nor were the staff aware that R1 had a DNR form. However, R1’s family member indicated this form was submitted by another family member to the facility management along with R1’s other admission documents. LPA attempted to reach the fire personnel to confirm the details surrounding the night of the incident, however, LPA was unable to obtain any clarifying information. Although it appears R1 did have a DNR form, which was present in the facility, it is unclear whether the document was directly given to the facility staff per the facility policy. Based on the conflicting information obtained during the investigation, the Department does not have sufficient evidence to 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 above allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. Today's report was reviewed and a copy provided.the state’s words, verbatim · CDSS document, Apr 21, 2026 · control 29-AS-20251229112708

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. LPA met with Facility Staff/Designee Judith Gonzalez. Administrator was contacted via telephone and was unavailable during today's visit. Entrance interview conducted. Beginning at 02:03PM, LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and last serviced on 4/11/2025. During today's visit, the hardwired combination smoke and carbon monoxide detectors were tested at 03:13PM and were functional at the time of the visit. No fire clearance concerns were observed during today's visit. KITCHEN: LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives and all sharps are stored in a locked cabinet under the kitchen sink. All cleaning supplies are stored in a locked hallway closet. COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened. Report Continued on LIC 809-C GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, additional chemical storage and emergency food and water. BATHROOMS: There are three (3) bathrooms for shared resident use. Restrooms were observed to be equipped with slip-resistant surfaces. Grab bars were observed in the bathrooms. The water temperature was measured and was found to be in compliance with regulation. BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated for private resident use, one (1) staff room, and one (1) office. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. RECORD REVIEW: Began at 01:04PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident medical assessments, needs and service appraisal, and personal rights. All five (5) staff files and four (4) resident files observed were in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 12/03/2025. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Began at 01:40PM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA interviewed two (2) staff. No concerns were noted. No deficiencies cited. Exit interview conducted with Facility Designee and telephonically with Administrator. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 6, 2026

Allegation investigated: Resident sustained a fracture while in care. Resident sustained an unexplained bruise.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 10:22 AM. LPA met with facility staff who contacted the Administrator Dania Fayyad via telephone call. The Administrator was unavailable to come to the facility at the time of the visit. LPA explained the reason for the visit to Judith Gonzalez (S1) and entrance interview was conducted. On 01/17/2025 the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint alleging that resident #1 (R1) sustained a fracture while in the care of the facility. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laura Garcia. On 01/22/2025 between 10:30 AM and 01:30 PM LPA Cortez toured the physical plant, interviewed the Administrator, one (1) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. On 03/27/2025 between 10:35 AM and 01:45 PM LPA Byrne conducted a physical plant tour, interviewed Staff #1 (S1) and Staff #2 (S2), three (3) residents, conducted a medication review for four (4) residents, and collected copies of pertinent documentation. Unsubstantiated On 02/03/2025 at approximately 04:50 PM IB Investigator Garcia interviewed Witness #1 (W1). On 02/13/2025 at approximately 10:30 AM, Investigator Garcia interviewed the facility Administrator. On 02/14/2025 medical records pertaining to R1’s hospitalization were obtained. On 02/25/2025 at approximately 08:30 AM R1’s medical records were reviewed. On 03/06/2025 at approximately 11:30 AM IB reviewed additional records. On 03/11/2025 at approximately 04:30 PM IB completed the review of R1’s medical records. On 03/11/2025 at approximately 12:05 PM Investigator Garica interviewed S1. On 03/11/2025 at approximately 01:00 PM Investigator Garcia interviewed one (1) staff member. On 03/11/2025 at approximately 01:30 PM Investigator Garcia interviewed Resident #1 (R1). On 03/20/2025, 03/26/2025, and 04/08/2025 the Investigator attempted to contact Staff #3 (S3) with no response, voicemails were left. On 05/03/2025 the Investigator made contact and interviewed S3. On 06/03/2025 the Investigator conducted a follow-up interview with one (1) witness. On 06/04/2025 the Investigator interviewed R1’s physician. During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, two (2) residents, and two (2) witnesses, and collected copies of pertinent documentation between 10:22 AM and 12:56 PM. The allegation of “Resident sustained a fracture while in care.” Alleges that due to Neglect/ Lack of Care R1 sustained a fracture while under the care of the facility. During the course of the investigation, interviews were conducted with resident’s responsible party (W1), resident primary physician (W2), Facility Administrator, caregivers, and residents. Additionally, the medical records from the Hospital where R1 was treated were obtained and reviewed. According to Staff #3 (S3) who initially assisted R1 on the date of the incident, on 09/24/2024 at approximately 0800 hours, R1 was found by their commode on the floor. Staff immediately evaluated R1 for any injuries, pain or swelling. Staff did not observe any injuries, swelling or redness. R1 reported no pain and no discomfort. S3 stated that R1 mentioned that R1 only bumped their head but reported they were “okay”. R1 refused to seek medical attention or go to the hospital. Since R1 was not expressing any type of pain, staff continued to monitor the resident for the following 24-48 hours. Per the staff, R1 was closely monitored for any change in condition. Additionally, they were continuously observed ambulating utilizing a walker and continued having no pain. On 09/26/2024, it was noted that W1, came to visit R1 and subsequently took R1 out of the facility. Later that day, facility staff stated they received a call/texts messages from W1 advising that R1 was not feeling well and that they were taking R1 to the hospital because they had an accident when they were trying to put R1 inside the car and R1 was complaining of pain. CONTINUED ON LIC 9099C. IB reviewed R1’s medical records which concluded the following conditions: Lumber levoscoliosis with asymmetric multilevel advanced disc degeneration and facet spondylosis with multilevel central canal stenosis. Mild chronic stable compression fracture deformity. Nondisplaced fracture of the right inferior pubic ramus, mild deformity left inferior pubic ramus which most likely represents old, healed injury and degenerative changes of the hips and sacroiliac joints. Upon conducting research on these conditions IB determined that the conditions pose a higher risk of subsequent fractures in the elderly. Based on the above information and documentation provided, there is insufficient evidence to support when and how the fracture was sustained. Therefore, IB found the allegation of “Resident sustained a fracture while in care” due to neglect/ Lack of Care of Cottage Inn to be deemed “unsubstantiated” at this time. The allegation of “Resident sustained an unexplained bruise.” Alleges that R1 sustained an unexplained bruise on their forehead in early January 2025 while in the care of the facility. LPA interviewed W1 who described the bruise on R1’s forehead as 1-1 1/2 inch deep black and blue round/circular bruise. W1 was unable to provide LPA with photographic evidence of the bruise. LPA conducted a review of R1’s medications for December 2024 and January 2025. LPA observed four (4) medications on R1's Medication Administration Record (MAR) that had indicated side effects of “unusual bleeding and bruising”. LPA interviewed Staff #1 (S1), former staff #3 (S3), and staff #4 (S4). All staff interviewed denied observing a bruise on R1’s body during their stay at the facility in January 2025. LPA interviewed two (2) residents of the facility. Both residents interviewed stated that staff treat them well and that staff handle them gently while assisting in their care. Both residents had no concerns with the quality of care they received at the facility. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of “Resident sustained an unexplained bruise.” Therefore the allegation deemed to be “unsubstantiated” at this time. The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 29-AS-20250117165236

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced Case Management - Deficiencies visit at the facility at 10:22 AM. LPA met with facility staff who contacted the Administrator Dania Fayyad via telephone call. The Administrator was unavailable to come to the facility at the time of the visit. LPA explained the reason for the visit to Judith Gonzalez (S1) and entrance interview was conducted. During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, two (2) residents, and two (2) witnesses, and collected copies of pertinent documentation between 10:22 AM and 12:56 PM. Continued on LIC 809C. On 01/17/2025 the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint against the facility. The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laura Garcia. During the course of the investigation IB concluded the following. On 09/24/2024 at approximately 0800 hours, resident #1 (R1) was found by their commode on the floor. Staff immediately evaluated R1 for any injuries, pain or swelling. Staff did not observe any injuries, swelling or redness. According to staff, R1 was reportedly observed ambulating throughout the facility without pain. However, staff #1 (S1) indicated that when they initially found R1 by their commode, R1 told S1 that they bumped their head but expressed no pain. Upon review, it appeared that staff only monitored R1 for pain levels but failed to seek immediate medical attention on 09/24/2024. On 09/26/2024, R1’s responsible party (W1) came to visit R1 and noticed that R1 had pain and took them to get medically evaluated. R1 was noted to have a fracture to the pelvis. Based on the R1’s medical history it is unknown how/ where the fracture was sustained however, staff should have sent R1 to get medically evaluated. Based on the above information and documentation provided, there is sufficient evidence that the facility failed to seek immediate medical attention for R1. The following deficiency was cited (refer to LIC 809D). The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 11, 2025

87465 Incidental Medical and Dental Care (a) ...The plan shall... provide for assistance in obtaining such care... (1) The licensee shall arrange...for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above as facility staff observed R1 on the floor after falling off of their commode. R1 expressed that they hit their head but staff did not seek medical attention for R1 which posed a potential health risk to clients in care.the state’s words, verbatim · CDSS document, Oct 28, 2025

Plan of correction: Administrator agreed to submit a statement of understanding confirming that they will seek timely medical attention appropriate to the needs and conditions of the clients in care. Administrator agreed to submit the document to CCLD for review no later than POC due date.

Allegation investigated: Staff did not provide adequate supervision resulting in resident leaving the facility. Staff did not answer resident's call button in a timely manner. Staff did not ensure resident's showering needs were being met.

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 10:33 AM. LPA met with facility staff who contacted the Administrator Dania Fayyad via telephone call. The Administrator was unavailable to come to the facility at the time of the visit. LPA explained the reason for the visit to Judith Gonzalez (S1) and entrance interview was conducted. During the initial complaint visit on 01/22/2025 between 10:30 AM and 1:30 PM, LPA Cortez toured the physical plant, interviewed the Administrator, one (1) staff, conducted a file review, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today’s visit LPA Byrne conducted a physical plant tour, interviewed two (2) staff, three (3) residents, conducted a medication review for four (4) residents, and collected copies of pertinent documentation between 10:35 AM and 01:45 PM. Continued on LIC-9099C Substantiated The allegation of “Staff did not provide adequate supervision resulting in resident leaving the facility.” alleges that the facility did not have functioning auditory alarms or adequate staff supervision to prevent resident #1 (R1) from leaving the facility unassisted. During the initial complaint investigation on 01/22/2025 LPA Cortez observed the front door and the sliding glass door of the front living room to be equipped with auditory alarms. LPA observed these alarms to be non-functional when the doors were opened. Facility staff informed LPA that the alarms worked but were turned off. During today’s visit LPA Byrne observed the kitchen side door, the sliding glass door of the front living room, and the hallway sliding glass door to be equipped with auditory alarms that were in the off position. All three (3) Auditory alarms failed to alert when the doors were opened. LPA asked staff why the alarms were turned off, staff were unsure but believe that it may have been because of the gardeners working. Additionally, in the month of December R1 eloped from the facility grounds without the notification of an auditory alarm. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of “Staff did not provide adequate supervision resulting in resident leaving the facility.” Therefore, the allegation is deemed Substantiated at this time. The allegation of “Staff did not answer resident's call button in a timely manner.” alleges that the facility staff did not answer R1’s call button in a timely manner. During interviews with residents, two (2) residents stated that staff have been slow/unresponsive in the past to their calls for assistance. Resident #2 (R2) stated that facility staff have silenced their call button before after attempts to notify staff that they need assistance. LPA pressed the call button for R2 during the interview at 10:56 AM. At the time of the button press LPA attempted to listen for a chime but was unable to hear any notification that a call button was pressed. LPA waited 15 minutes until 11:11 AM and no staff responded to the call button press. LPA asked S1 for the reason the call button was not answered. S1 stated that they must have not heard the notification and denied that resident call buttons are ever silenced. At approximately 12:50 PM LPA asked staff #2 (S2) to press the resident’s call button. When this button was pressed LPA observed the alarm to go off. S2 confirmed that R1, while they resided at the facility, had a call button to notify staff that they required assistance. Staff denied ever missing a call button notification and S1 reiterated that their average response time to resident’s requests for assistance does not exceed seven (7) minutes. Based on the information obtained during the physical plant tour and interviews there is sufficient evidence to support the allegation of “Staff did not answer resident's call button in a timely manner.” Therefore, the allegation is deemed Substantiated at this time. Continued on LIC 9099C. The allegation of “Staff did not ensure resident's showering needs were being met.” alleges that the facility staff were not showering R1 on an appropriate basis. Interviews with two (2) residents revealed that they feel like facility staff are not showering/bathing them enough. One (1) resident stated that they have asked staff for a shower previously and were told that staff would do it later in the day. The resident stated that staff “Blew them off” and never returned to shower them. One (1) resident interviewed stated that they had gone a month without a shower. LPA interviewed staff members who stated that resident’s showers are on a schedule and are given 2-3 times per week. Both staff interviewed denied skipping resident’s showers unless the resident refused. S2 stated that some residents have refused showers this month and it is logged in the shower binder. LPA observed the shower log for the month of March. LPA observed one resident to have a shower that was not given according to the schedule. One resident confirmed that they had not been getting showers on the dates that were logged in the binder. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff did not ensure resident's showering needs were being met.” Therefore, the allegation is deemed Substantiated at this time. The following deficiencies were cited (refer to LIC 9099D). The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report and appeal rights were provided. The allegation of “Staff did not follow medical directions for resident's medical needs.” alleges that the facility staff did not follow medical directions prior to a uranalysis appointment for R1 and that facility staff did not assist in the proper storage of a urinalysis sample. LPA interviewed S1 who recalled the incident with R1’s urine sample. S1 stated that R1 had utilized the restroom prior to their scheduled urinalysis appointment. LPA interviewed Witness #1 (W1) who corroborated this statement. As R1 was unable to urinate at the time of their appointment they were given a sample collection cup to submit at a later date. S1 stated that they had R1 urinate in the sample cup the next day but the staff member assisting R1 got distracted by a call from another resident and left the sample on the counter of the bathroom. S1 stated that R1 took the cup and poured the sample into the toilet. W1 stated that they arrived to the facility to take R1 to drop off the sample and staff were trying to have R1 produce another sample. W1 stated that they told staff to take care of submitting the sample and did not believe R1 would pour out the sample. LPA confirmed with S1 and W1 that a sample was submitted to the lab the same day. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not follow medical directions for resident's medical needs.” Therefore, the allegation is deemed Unsubstantiated at this time The allegation of “Staff did not provide resident adequate food meals.” alleges that the facility staff did not provide R1 with nutritious meals. Interviews with three (3) residents revealed that the facility serves enough food to the residents in care. Interviews with staff revealed that the facility offers a variety of foods to residents and accommodations are made if residents do not want what is being served. LPA observed the facility to have adequate amounts and variety of foods to be served to residents. LPA observed the portions of food being served to residents at 01:47 PM and observed the portions to be adequate. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Staff did not provide resident adequate food meals.” Therefore, the allegation is deemed Unsubstantiated at this time. The Administrator was unavailable to come to the facility at the time of this inspection but has designated S1 to sign on their behalf. Report was read to the Administrator via telephone call. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 29-AS-20250117165236

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(d) · Plan of correction due date: Apr 10, 2025

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as exit doors throughout the facility were observed to be equipped with auditory alarms that were turned off and did not alert when opened which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee will submit a statement of understanding confirming that they understand the importance of auditory alarms being turned on while staff is not actively monitoring the exit. Additionally, Licensee will submit proof of all exits being equipped with functioning auditory alarms by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 10, 2025

87468.2 Additional Personal Rights... (a) In addition to the rights... (4) To..services that meet their individual needs... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as a call button was pressed and no staff responded within a 15 minute timeframe which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee will submit proof that all call buttons are operable, and will submit a statement of understanding confirming that staff will respond to resident's call buttons and ensure that call buttons are always operational and not turned off/silenced. Licensee will submit these corrections no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Apr 10, 2025

§1569.312 Basic services... Every facility... shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as multiple residents stated that their shower needs are not being met by staff which poses a potential health or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 27, 2025

Plan of correction: Licensee will submit their plan on how they will meet resident's showering needs. This plan may include residents signing off that they have received a shower or a similar method of tracking. Licensee will submit their plan to CCLD no later than POC due date.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit. LPA met with Facility Staff/Designee Judith Gonzalez. Administrator was contacted via telephone and was unavailable during today's visit. Entrance interview conducted. Beginning at 9:40 a.m., LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and last serviced on 4/19/2024. Hardwired combination smoke detectors/carbon monoxide detectors, as well as sprinkler system are professionally inspected annually, with the last inspection conducted on 7/8/2024. No safety concerns were noted in the report provided. No fire clearance concerns were observed during today's visit. KITCHEN: LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives and all sharps are stored in a locked cabinet under the kitchen sink. All cleaning supplies are stored in a locked hallway closet. COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened. BATHROOMS: There are three (3) bathrooms for shared resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured and was found to be in compliance with regulation. Report Continued on LIC 809-C Report Continued from LIC 809 BEDROOMS: There are eight (8) total bedrooms in the facility; six (6) bedrooms are designated for private resident use, one (1) staff room, and one (1) office. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, additional chemical storage and emergency food and water. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. RECORD REVIEW: Began at 10:23 a.m. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All six (6) staff files and four (4) resident files observed were in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted in November 2024. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Began at 11:47 a.m. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident. During the visit, LPA obtained copies of the following documents: LIC 500 liability insurance No deficiencies cited. Exit interview conducted with Facility Designee. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2025

Allegation investigated: Staff left resident in soiled diaper for extended period of time Resident is dehydrated Staff are not responding to residents call button

Licensing Program Analysts (LPAs) Erika Miller (Miller) and Jenny Olson (Olson) conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. During the investigation, LPA, Angel Ascencio, toured the facility and interviewed Administrator, staff, and residents on May 10, 2022 from 11:45am to 4:30pm. LPAs Miller and Olson also toured the facility on January 23, 2024 and interviewed residents and staff from 10:52 a.m. to 11:10 a.m. LPAs also obtained and reviewed relevant documents. LPAs met with Lead Staff, and explained the purpose of the visit. On the allegation: Staff left resident in soiled diaper for extended period of time. On 5/28/22, a witness visited the facility and observed Resident 1 (R1) had dried feces on them, a rash, a Urinary Tract Infection (UTI), and chronic C-diff. R1’s physician’s report dated 4/22/2022 indicated they had bowel and bladder impairment, and needed assistance with toileting. R1’s previous stroke rendered them incontinent at times, and R1 also required incontinence care. LPAs interviewed residents, who indicated sometimes staff take a while to respond to their call buttons. Continued on 9099-C (pg 2) Unsubstantiated One resident indicated sometimes they have to wait “a while” for staff to change them. Administrator stated R1 had a redness on their bottom but not an open sore. On 5/3/2022, a witness had a scheduled visit to the facility, and R1 was in the shower when they arrived and observed R1 had diaper cream on their buttocks after the shower. Administrator stated staff check on residents about every 45 minutes, but it could be 1-2 hours when staff are busy. Administrator stated they change residents at breakfast, lunch, and dinner, and “what’s needed in between, or as needed.” Staff interviewed stated they changed residents when needed, or when residents indicate they are soiled. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Resident is dehydrated. On 5/4/2022, a witness visited R1 and observed R1 to be dehydrated in their opinion. The witness rang R1’s bell to get water for R1, and staff did not respond to the bell. Per the witness, they believe the staff could not hear the resident’s bell. Staff interviewed indicated one of the residents drinks a lot of water, and therefore uses the restroom frequently. Staff also stated another resident had UTI symptoms and needed to drink a lot more, so they encourage the resident to drink or give them more liquid during meals. Staff stated they also have snacks between meals, which include smoothies, milk or other liquids. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are not responding to residents call button. According to the witness, R1 indicated staff do not respond to their bell when they ring it for assistance. On 5/4/2022, a witness visited R1 and observed R1 to be dehydrated in their opinion. The witness rang R1’s bell to get water for R1, and staff did not respond to the bell. Per the witness, they believe the staff could not hear the resident’s bell. R1 was non-ambulatory, and was unable to walk without assistance, including a walker and wheelchair. R1 required help transferring in and out of bed. During the visit on 5/10/2022, LPA observed a resident use their call bell for assistance at 3:26 PM. The resident rang the bell, and staff left to assist the resident at 3:27 PM. LPAs interviewed residents about their call bells and how long it takes staff to respond. One resident indicated they did not know how to call for help, but indicated it takes a while for staff to come assist. Other residents indicated when they ring their bell, sometimes it takes a while for staff to respond. On 5/10/22 Administrator stated they use hand bells as a call system, and staff respond to residents when they ring the bell. Continued on 9099 C- (Page 3) On 1/23/24 Staff stated that three out of five residents have an electronic call button. One resident’s spouse prefers that they have a hand bell. Staff stated that another resident does not know how to use an electronic bell and uses the hand bell. Staff stated R1 had a call alert button in their room that they used to summon staff. Staff interviewed indicated they respond to resident’s needs. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 29-AS-20220505160911

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:14AM. LPA met with facility staff/Designee Judith Gonzalez. Administrator was contacted via telephone and was unavailable during today's visit. Entrance interview conducted. Beginning at 09:57AM, the LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and last serviced on 03/20/2023. Hardwired combination smoke detectors/carbon monoxide detectors, as well as sprinkler system are professionally inspected annually, with the last inspection conducted on 03/10/2023. No safety concerns were noted in the report provided. No fire clearance concerns were observed during today's visit. KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives and all sharps are stored in a locked cabinet under the kitchen sink. All cleaning supplies are stored in a locked hallway closet. COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility has two (2) fireplaces - one (1) in the living room and one (1) in the family room. Both were observed to be adequately screened. BATHROOMS: There are three (3) bathrooms for shared resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured and was found to be in compliance with regulation. Report Continued on LIC 809-C BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated for private resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, additional chemical storage and emergency food and water. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. RECORD REVIEW: Began at 09:38AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 10/10/2023. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Began at 10:20AM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and one (1) resident. During the visit, LPA obtained copies of the following documents: LIC 500 liability insurance No deficiencies cited. Exit interview conducted with Facility Designee. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2024