Crown Cove

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Andrea Mendivil and Taylor Simerly arrived on September 08, 2026 for an unannounced visit to follow up on a substantiated complaint investigation delivered on May 30, 2025. LPAs Andrea Mendivil and Taylor Simerly met with Executive Director Janette Hill and reviewed the report. On May 30, 2025, the Department concluded a complaint investigation regarding the following allegation: Resident sustained a severe burn as a result of neglect. The allegation was substantiated, and the licensee was cited under California Code of Regulations (CCR) § 87464(f)(1) – Basic Services. At the time of the complaint visit on May 30, 2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” The findings and analysis of the documents obtained, revealed on November 28, 2024, the resident sustained a popped blister on their chin and chest as a result of spilling hot coffee on themselves. The wound on the chest progressed and became infected. Today September 08, 2026 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on May 30, 2025, the amount of the civil penalty issued today will be $9,500. An exit interview was conducted. A copy of the report was issued. Appeal Rights provided to Janette Hill and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 8, 2026

Allegation investigated: Resident left in soiled urine and feces. Pests crawling on resident. Staff not keeping facility free from pests.

On January 30, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of continuing the investigation into the above allegations. LPA was greeted by the receptionist and was escorted into the private conference room. Wellness Director Michelle Angcaco and Executive Director Janette Hill later arrived on premise and remained at the facility to assist with the investigation. The investigation is as follows: On September 10, 2021, the Department received the complaint initiated by LPA Sean Haddad on September 16, 2021. During the course of the investigation, LPA Haddad toured the faciltiy and inspected eight resident units. Six staff, six residents, and one witness interviews were conducted, and the following documentation were obtained for review: Resident/Personnel Rosters, Identification and Emergency Information concerning Resident #1 (R1), Death Report for R1, Needs and Services Plan, Caregiver Schedule Report, pest control invoice statements and service summary reports. Unsubstantiated Regarding the allegation, Resident left in soiled urine and feces, it is alleged that a female resident and three other residents were left soiled in their feces. Four of six resident interviews indicated satisfaction with the quality of care and confirmed that they are changed as needed and showered regularly. The remaining residents are independent with their Activities of Daily Living (ADLs) or were asleep at the time of the interview. Three of six staff interviewed denied the allegation while the remaining staff were not employed at the time R1 resided at the facility. In an interview with one Witness (WI), there were no incident/charting notes to corroborate the allegation concerning R1. Regarding the allegation of Pests crawling on resident, it is alleged that there were "hundreds of ants" crawling on and inside R1's mouth. Two of six staff interviewed who monitored R1 at the time of R1's passing on September 5, 2021, denied observing ants crawling on R1. W1 also indicated that there were no notes or incidents of ants on R1. Regarding the allegation, Staff are not keeping facility free from pests, it is alleged that ants were observed around the facility between September 2, 2021 to September 5, 2021. LPA Haddad conducted a tour of the facility and inspected eight resident units in the Assisted Living and Memory Care Units. No ants were observed during the inspection on September 16, 2021. Four of six residents denied observing ants while two of six staff confirmed the presence of ants. The two staff reported the ant issues were in the memory care and was addressed immediately. Based on the review of the 2021 pest control summary reports, facility received alternating monthly or biweekly services. Summary report dated August 25, 2021 at 8:01am, documented treating ants in the interior hallways but no activity was found. Summary report dated September 8, 2021 at 7:55am, the memory care unit was checked for possible activity and treated the exterior perimer of facility. On September 22, 2021 at 7:47am, there was no activity found per summary report. Although there were evidence of ants noted in the pest control service summary reports, the facility took appropriate action by maintaining ongoing, recurring pest control services. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, 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 following allegations: Resident left in soiled urine and feces, Pests crawling on resident, and Staff not keeping facility free from pests are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Janette Hill, and a copy of this report including the LIC811 were provided at exit.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 22-AS-20210910090047

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and LPA Kimberly Lyman made an unannounced visit to conduct a required annual. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. The facility is a three level building with an approved fire clearance of nine ambulatory; eighty-eight non-ambulatory residents of which fifteen are approved for hospice. The facility currently has a census of 72 residents in care. LPAs toured the facility and inspected the physical plant, including but not limited to testing hot water temperature in the bathrooms. The hot water temperature measured 108.6 and 117.6 degrees Fahrenheit. The facility uses Cal Building Systems for smoke directors and fire sprinkler service and the last inspection was conducted on 03/18/2025. The facility conducted an emergency drill on 10/14/2025. LPAs inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPAs observed 3 cases of water in the underground parking structure for emergencies. LPAs reviewed 9 resident files, Residents 3, 6 and 7 did not have updated LIC 602 Physicians Report. LPAs reviewed 6 staff files and no staff had CPR or first aid training. LPAs observed staff did not have the annual training that includes 4 hours of training on the following topics: postural support, restricted health conditions and hospice care LPAs observed unsecured laundry room in Memory Care that contained an unsecured cabinet with toxins. LPAs did not observe PUB 475 in the entryway of the facility. LPAs observed Resident 3 who is listed as bedridden in a room that is not cleared for bedridden resident. Per Non Compliance Conference held on 09/05/2025 , Licensee agreed to maintain a staffing ration of 1 caregiver to 7 residents, per review there are 18 residents in Memory Care and only 2 caregivers on shift today. The following is being cited per Title 22. An exit interview was conducted and a copy of this report, LIC 858 and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

Allegation investigated: Staff are not providing proper medication assistance to resident in care.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA spoke with Janette Hill, Executive Director Executive Director, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, copies or perteinent documents and interviews conducted. It is alleged staff are not providing proper medication assistance to resident (R1) in care. Interview with 2 of 2 staff stated there had been issues with medication and that as of November 30, 2022, they were made aware that there was medication that was not being administered. Records revealed in review of Continued on LIC9099-C Substantiated MAR (medication administration records from September 1, 2022, to November 30, 2022, reflect that R1 had 9 medications on record and all 9 medications have missed doses on several dates throughout the 3 month period reviewed. Missed doses are observed on multiple dates and/or multiple times for one day as missed or not administered. During the course of the investigation, there was sufficient evidence to substantiate the allegation. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Executive Director and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility. reflect the residents in memory care that received showers and the time. Shift logs for August 2022 to November 2022 reflect R1 to be receiving showers, refusing showers, and staff insisting for R1 to shower without success. Interview with staff stated that when a resident refuses to shower they check back with residents 3 times. Interview with 4 of 4 residents stated that they get help with showers, and they have never had an issue with getting a shower. It is alleged that staff are not providing proper food service to resident in care. Record review reflects that shift logs for August of 2022 to November of 2022 R1 has refused to eat meals on several times throughout the day as well reflects when and how much R1 ate for meals throughout the day. Interview with staff stated that when a resident refuses meals they check back with them 3 times for them to eat. Interview with 4 of 4 residents stated that they get their meals, staff bring them meals and/or staff help them with their meals. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 22-AS-20221123081721

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 21, 2025

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: based on documents and interviews, the staff did not ensure R1 received their medication as prescribed on multiple days and times. R1 missed multiple doses for 9 medications from September 1, 2022 to November 30, 2022. This poses an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Executive director stated they will provide in-house medication training with all staff on cited regulation and addressing importance of giving the residents their medication as prescribed. The proof of training will be submitted to the LPA via email POC date.

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver amended complaint findings for Complaint Control # 22-AS-20250121161311. LPA was greeted and granted entry into the facility and explained LPA Mendivil delivered an amended report to Culinary Service Director Kasan Soewono on 07/03/2025 and discussed the amended findings. An exit interview was conducted and a copy of this report and amended findings were provided to facility.the state’s words, verbatim · CDSS document, Jul 3, 2025

Allegation investigated: Resident sustained a severe burn as a result of neglect

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on January 23, 2025, and the initial 10-day visit was conducted that same day by LPA Mendivil. LPA Mendivil obtained copies of documents including physician’s reports, needs and services, medication records and admission agreements. Regarding the allegation resident sustained a severe burn as a result of neglect, the investigation revealed the following: It was alleged that Resident 1 (R1) had sustained a severe burn as a result of neglect. Based on physician’s report dated December 23, 2023, R1 has a history of skin breakdown and was listed as able to feed themselves. Per review of Senior Living Standard Level of Care and Services Plan dated September 11, 2024, it was reported that R1 needed assistance with eating. Review of emails between the facility and R1’s hospice nurse suggested that R1 be given finger foods to make eating easier for them. Substantiated Interviews with 8 out of 8 staff stated that R1 was not able to hold utensils on their own. It was also reported that due to the R1’s inability to hold utensils the resident would spill food on themselves during mealtimes. On November 28, 2024, R1 was visited by their family member, who reported they did not observe any burns on R1. The following day, on November 29, 2024, Witness interviews reported that R1 had burns on their chest. Photographic images obtained confirmed injuries on R1’s chest along with Facility progress notes dated November 29, 2024, in which staff notated that resident had a popped blister on their chest and small blisters on their chin. At the time of incident, R1 reported they had spilled coffee on themselves. Per interviews it was reported that R1 was given a cup of coffee at some point on November 28, 2024; However, no staff could confirm who provided R1 with the cup of coffee. Staff interviews did confirm stains on R1’s clothing around the suspected time of incident. R1’s blistered was treated by their Hoag at Home Hospice Nurse on November 29, 2024, who reported the blister had green drainage indicating an infection. Hoag at Home Hospice Nurse denied that any of R1’s underlying conditions could have caused the blisters. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation that resident sustained a severe burn as a result of neglect is determined to be Substantiated, meaning the complaint allegation is valid and that a violation has occurred. See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f) An exit interview was conducted with Kasan Soewono, Culinary Service Director. A copy of this report, along with LIC9099-D, Appeal Rights, Civil Penalty Assessment-LIC 421 IM and the LIC 811, identifying confidential names were provided and explained.” Per interviews with 2 out of 6 staff stated they give residents medication as prescribed, 4 of the staff members interviewed did not have direct knowledge of medication administration. Regarding the allegation staff did not ensure the resident’s room was cleaned. Interviews with 5 out of 5 residents stated the resident’s rooms are cleaned. Based on interviews with 6 out of 6 staff stated the facility and resident’s rooms are clean. During LPA Mendivil’s initial visit on January 23, 2025, LPA toured the interior of the facility and observed clear and uncluttered walkways and the facility to be free of dust and odors. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegations that staff did not administer medication to resident as prescribed and staff did not ensure the resident’s room was cleaned are determined to be UNSUBSTANTIATED, 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. An exit interview was conducted, and a copy of this report was providedthe state’s words, verbatim · CDSS document, May 30, 2025 · control 22-AS-20250121161311

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 2, 2025

Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by Licensee did not ensure R1... was assisted with food services resulting in R1 reporting they spilled coffee or hot liquids on themselves. As a result, R1 sustained blisters on their chest. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, May 30, 2025

Plan of correction: Executive Director to conduct in services about residents needs in dining and potential use of adaptive utensils/cups. Immediate Civil Penalty issued * Manual 421IM form used due to technical difficulties

Allegation investigated: Staff is authorizing medical decisions without proper consent Resident sustained an injury from a fall while in care Staff did not seek timely medical attention for a resident Staff did not provide adequate supervision to a resident

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to continue the investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as care plans. Regarding the allegations that staff is authorizing medical decisions without proper consent, resident sustained an injury from a fall while in care, staff did not seek timely medical attention for a resident and staff did not provide adequate supervision to a resident, the investigation revealed the following: Per facility care plan dated 01/29/2021, Resident 1 (R1) requires assistance with showers and clothing but is independent with toileting, eating, grooming and medications. Resident does not require assurance checks and is able to leave the facility unassisted. Facility staff indicate notifying resident responsible parties when vaccinations are available however no signatures were required if resident was able to make their own decisions. CONTINUED ON LIC 9099C DATED 01/27/2024 Unsubstantiated Facility documentation indicated resident signed on own for flu vaccine and indicated receiving the Pfizer covid vaccine. There is no documentation of a durable power of attorney (DPOA) at the facility for R1 and document checklist does not show that a DPOA was received by the facility. Interview with Administrator at time of complaint denied knowledge of any falls. Facility does not have documentation of any falls and care plan states no history of falls. Facility does not have any documentation of hospitalization for a fall for the resident. Facility staffing levels are as follows: Three caregivers in Assisted Living and Memory Care and 2 med techs for 1st and 2nd shift and 1 caregiver and med tech for NOC shift. Three out of three staff and five out of five residents state current staffing levels are good and resident needs are being met. Interview with former Administrator indicated struggling with staffing during the pandemic and using agency to fill holes. Facility Administrator denies facility advertises having an RN on-site and state the facility employs an LVN only. Current facility website does not advertise any nursing staff. Due to the age of the complaint, facility is unable to provide all documents and/ or records requested by the department. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations did occur. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 27, 2025 · control 22-AS-20211220140822

Allegation investigated: Staff do not distribute residents' medications as prescribed Staff do not ensure that a resident takes medication as prescribed Licensee does not ensure that a skilled professional performs residents' medical care Staff did not ensure that a resident's dietary needs were met Staff do not maintain residents' records current Staff do not assist a resident with showering

On this day, Licensing Program Analysts ( LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to continue complaint investigation. LPAs Mendivil and Lyman were greeted and granted entry into the facility and explained the reason for the visit. The Department received a complaint on 11/17/2023 and LPA Mendivil conducted the initial visit on 11/27/2023. LPA Mendivil interviewed staff and residents and obtained copies of pertinent documents such as physicians reports, assessments and dinning menus. Regarding the allegations staff do not distribute residents' medications as prescribed, staff do not ensure that a resident takes medication as prescribed, licensee does not ensure that a skilled professional performs residents' medical care, staff did not ensure that a residents dietary needs were met, staff do not maintain residents' records current, staff do not assist a resident with showering, the investigation revealed the following: Unsubstantiated Regarding the allegation staff do not distribute residents' medications as prescribed. Interviews with 3 out of 4 residents stated they receive their medications. Interviews with staff indicated if a resident refuses they will notate it. Interviews with 2 residents stated when they have left the community their medication was still distributed to them to take. Regarding the allegation staff do not ensure that a resident takes medication as prescribed. Based on interviews with 3 out 4 residents stated they take their medication a prescribed. The 4th resident would not answer LPAs questions about medications given. Interviews with 2 out of 2 staff indicate they provide medications as prescribed. Regarding the allegation licensee does not ensure that a skilled professional performs residents' medical care. Based on interviews with 2 out of 2 staff indicated they do not perform medical care that is out of their job duties. Regarding the allegation Staff did not ensure that a resident's dietary needs were met, based on interviews with 2 out of 4 residents they stated their dietary needs were met. The remaining 2 residents did not answer LPAs questions about dietary needs. Regarding the allegation Staff do not maintain residents' records current. 2 out of 2 staff stated they keep both electronic and written records. Per LPA Mendivil's review of documents for 4 out of 4 residents all had updated documents. Regarding the allegation Staff do not assist a resident with showering, per review 3 out of 4 residents interviewed stated they received the assistance they need with their showers. The 4th resident does not need assistance with showers. 2 out of 2 staff stated residents are given shower assistance as needed. Therefore based on records reviewed and interviews the allegations staff do not distribute residents' medications as prescribed, staff do not ensure that a resident takes medication as prescribed, licensee does not ensure that a skilled professional performs residents' medical care, staff did ot ensure that a residents dietary needs were met, staff do not maintain residents' records current, staff do not assist a resident with showering are determined to be UNSUBSTANTIATED, meaningthe state’s words, verbatim · CDSS document, Jan 27, 2025 · control 22-AS-20231117101241

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit in conjuction with a complaint investigation for complaint control # 22-AS-20231117101241. LPAs were greeted and granted entry into the facility by Gerrardo Garibay and explained the reason for the visit. Executive Director Janette Hill arrived shortly after. During the course of investigation LPA Mendivil requested a copy of either electronic/written Medication Administration Record for October 2023 to November 2023. Per conversation with Executive Director Janette Hill stated they were unable to locate the Medication Administration Records from 2023. Based on observations a deficiency is being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Feb 2, 2025

(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by facility did not obtain Medication Administration Records from 2023.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: Executive Director agreed to file all records in one central location and will conduct in services. Executive Director will provide proof by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by the Concierge at 8:25 AM and met with Resident Care Director (RCD). During today’s visit, LPA met with Janette Hill, Executive Director (ED). The facility is a three level building with an approved fire clearance of nine ambulatory; eighty-eight non-ambulatory residents of which fifteen are approved for hospice. The facility currently has a census of sixty-seven residents in care. As of July 1, 2024 the community is transitioning to Integral Senior Living and Discovery Senior Living. During today’s visit, LPA toured the facility with RCD and inspected the physical plant testing hot water temperatures in five of five resident bathrooms, and testing delayed egress on Memory Care exits. Two of three stairwells had evacuation chairs. LPA observed the observation deck and toured both the North and South Towers while visiting resident apartments. The hot water temperatures in resident bathrooms measured between 109.4 and 116.7 degrees Fahrenheit. Smoke detectors were tested by vendor Fire Alarm Systems on April 5, 2023. The Fire Marshall and Maintenance Director are currently working on testing the fire alarms for the past month and is still ongoing. Fire extinguishers were charged and serviced on August 7, 2024. The facility’s last fire drill was conducted by Direct Supply TELS on November 13, 2024 for all three staffing shifts. LPA inspected the facility kitchen and food supply with Culinary Director and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand with the required emergency water and supplies to accommodate all residents and staff. Food modifications are posted for all line staff to see and temperature logs and cleaning logs were observed. (Continued on LIC 809-C) (Continued from LIC 809) LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA toured the Memory Care and observed residents in Activities reading The Daily Chronicle and observed weights in Assisted Living for a fitness class. There is also a resident council meeting scheduled for this afternoon. LPA reviewed five of five staff training and fingerprint records and reviewed six of six resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on July 13, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Janette Hill, Executive Director and a copy of the report, LIC 9102-TV and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Nov 20, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting additional interviews for Complaint Control No. 22-AS-20201103132810. LPA met with Administrator (AD) Janette Hill and discussed the purpose of the inspection. During the inspection, LPA toured the facility with staff, interviewed seven residents and five staff, and requested and reviewed copies of the resident roster and staff roster. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 30, 2024

Allegation investigated: Facility did not provide treatment to resident with stage 3 pressure and ankle injury Facility did not report pressure/ankle injury to resident's responsible party Resident denied visitation from responsible party Facility staff missed dosages of medication

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Janette Hill, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegations that the facility did not provide treatment to resident with stage 3 pressure and ankle injury, the facility did not report pressure/ankle injury to resident's responsible party, a resident denied visitation from responsible party, and facility staff missed dosages of medication revealed the following: During the course of the investigation, LPA interviewed former administrators, staff, and a witness, and obtained and reviewed copies of the resident roster, staff roster, Photographs of Resident #1 (R1), R1’s Home Health Medical Records dated December 29, 2020, R1’s Home Health Medical Records dated January 21, 2021, R1’s Physician’s Report dated December 27, 2019, R1’s Assessment dated December 31, 2019, R1’s Preplacement Appraisal dated January 1, 2020, R1’s Service Plan dated March 25, 2021, R1’s Assessment dated February 28, 2020, R1’s Assessment dated October 16, 2020, Provider Information Notice (PIN) 20-07-ASC, PIN 20-08-ASC Substantiated R1’s Hoag Hospital Medical Records dated March 15, 2020, R1’s Primary Care Medical Records dated January 20, 2020, and Medication Administration Records for 2020. Regarding the allegation that the facility did not provide treatment to resident with stage 3 pressure and ankle injury: it was alleged that R1 developed a stage 3 pressure injury on their left ankle at the facility and did not receive proper treatment. LPA interviewed a witness who stated that prior to entering the facility on January 1, 2020, R1 did not have a pressure injury, but on August 16, 2020, while at an urgent care for ankle swelling, an ankle bandage over R1’s left ankle was removed and R1’s stage 3 pressure injury was first discovered and R1 was referred to wound care. LPA reviewed Photographs of R1 showing the ankle bandage on August 14, 2020, the status of R1’s ankle wound on August 16, 2020, and the current status of R1’s legs and ankles. LPA reviewed R1’s Home Health Medical Records dated December 29, 2020, which corroborate that R1 had an unstageable pressure injury on their left ankle as of August 22, 2020, which had not healed by November 18, 2020, and that home health was initiated on July 27, 2020, but that the pressure injury was not originally in the care plan as of that date. LPA reviewed R1’s Home Health Medical Records dated January 21, 2021, which corroborate that R1 had an unstageable pressure injury on their left ankle as of November 25, 2020, which became a stage 3 pressure injury on January 6, 2021. When interviewed, a former administrator stated that R1 had a skin tear, facility staff were providing treatment, home health was initiated on July 26, 2020, and home health provided wound care to R1 but did not indicate the stage of the wound, and the facility reported the issue to R1’s responsible party at an unknown date. LPA reviewed R1’s Physician’s Report dated December 27, 2019, which states that R1 has a history of left ankle cellulitis. LPA reviewed R1’s Assessment dated December 31, 2019, which indicates R1 has no skin breakdown but has healing wounds and is able to completely self-manage the condition. LPA reviewed R1’s Preplacement Appraisal dated January 1, 2020, which does not mention any issues with skin or wounds. LPA interviewed a former administrator who stated that that R1 had healing wounds documented as of February 22, 2020, and the goal was improved healing of the wound. LPA reviewed R1’s Service Plan dated March 25, 2021, which states that as of February 22, 2020, R1 has healing wounds but is able to completely self-manage the condition. LPA reviewed R1’s Assessment dated February 28, 2020, which indicates R1 has no skin breakdown and no healing wounds or bedsores. LPA reviewed R1’s Assessment dated October 16, 2020, which indicates R1 requires regular staff evaluation and assistance in managing skin care needs and has a healing wound and requires staff monitoring and assistance. Based on the information obtained, R1 had a known history of skin issues but due to lack of care, oversight, and treatment, R1’s skin issues worsened and R1 developed an unstageable pressure injury while in care which eventually became a stage 3 pressure injury. Regarding the allegation that the facility did not report pressure/ankle injury to resident's responsible party: it was alleged that the facility did not notify R1’s responsible party of R1’s stage 3 pressure injury. LPA interviewed a witness who stated that R1’s responsible party had no notice of R1’s pressure injury until it was discovered at an urgent care on August 16, 2020. When interviewed, a former administrator stated that the facility reported R1’s skin issue to R1’s responsible party at an unknown date. LPA reviewed R1’s Home Health Medical Records dated December 29, 2020, which corroborate that R1’s stage 3 pressure injury was not reported by the facility as R1’s home health plan of care and list of diagnoses did not include any pressure injuries as of July 27, 2020. Instead, R1’s unstageable pressure injury was added to R1’s home health plan of care and list of diagnoses on August 22, 2020, only after the pressure injury was discovered at an urgent care on August 16, 2020. Based on the information obtained, R1 developed an unstageable pressure injury at the facility and R1’s reporting party was not timely notified. Regarding the allegation of resident denied visitation from responsible party: it was alleged that during the facility’s COVID-19 lockdown, R1’s responsible party was not allowed to visit R1 in person for three months. LPA interviewed a witness who stated that the facility imposed a mandatory quarantine for any resident that left the facility for any reason, regardless of symptoms or exposure, R1 went to the hospital on March 15, 2020 and returned the same day and R1’s responsible was not allowed to visit R1 on that day, on March 18, 2020, or on March 24, 2020 due to the quarantine, and R1’s responsible party was advised that if R1 went outside the facility to see them R1 would have to be quarantined for another 14 days. When interviewed, a former administrator stated that the facility was not allowing visitation, but was allowing window visits. LPA interviewed another former administrator who reported that the policy around March 15, 2020 was that residents had to isolate for 14 days after leaving the facility. LPA reviewed California Department of Social Services Provider Information Notice (PIN) 20-07-ASC, effective March 13, 2020, which states that, as prevention measures, facilities should restrict visitors, where there are COVID-19 confirmed cases in the surrounding community, and limit resident activities outside of their rooms. However, this PIN does not allow for the isolation of a resident unless the resident has a known exposure or is displaying symptoms of COVID-19. PIN 20-08-ASC, effective March 18, 2020, superseded, PIN 20-07-ASC, but does not change this guidance. LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which do not indicate R1 was exposed to or symptomatic for COVID-19. Based on the information obtained, the facility was not following the applicable PIN by requiring isolation of residents and not allowing outdoor visits. Regarding the allegation that facility staff missed dosages of medication: it was alleged that there were multiple instances where R1’s medication times were missed. LPA interviewed a witness who stated that they observed R1 not receiving their medication on time and that the medications would be given hours late which would cause R1 to be groggy. LPA reviewed R1’s Primary Care Medical Records dated January 20, 2020, which indicate that R1’s doctor recommended R1’s Parkinson’s Disease medication be administered at 8AM, 1PM, and 6PM and that the medication will wear off after 5 hours and make R1 a higher fall risk. LPA interviewed a former administrator who was unable to provide information about this allegation. LPA reviewed R1’s Medication Administration Records for 2020 which show multiple instances of R1’s Parkinson’s Disease medication, Carbidopa-Levodopa, and other medications not being signed off by facility staff as having been given to R1 and that R1 did not receive their Trazodone and other medications for extended periods of time because the medications were not available. LPA obtained information corroborating that facility staff missed multiple doses of R1’s important medications that could have led to increased fall risk and other serious issues. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that staff did not call 911: it was alleged that during an emergency, facility staff did not call 911 but instead called R1’s responsible party to request permission to call the paramedics. LPA interviewed a witness who stated that on the morning of March 15, 2020, facility staff had checked on R1 at 6:30AM and 8:00AM but could not wake R1 and should have called 911 then, but instead waited until 10:20AM to call R1’s responsible party to ask for permission to call 911 which was given. However, LPA did not obtain information corroborating that facility staff observed R1 having a medical emergency at 6:30AM or 8:00AM. LPA reviewed the facility’s Internal Incident Reports for R1 and did not find an incident report for this date. LPA interviewed a former administrator who was unable to provide information about this allegation. LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which indicate R1 made to the hospital by 11:32AM, was alert with no distress, was not diagnosed with any medical conditions, and was released the same day with no new diagnoses. LPA did not obtain information corroborating the length of delay or that R1 sustained any serious injury as a result of this incident or any delay in the facility seeking care for R1. Regarding the allegation that facility staff overmedicated resident: it was alleged that R1 suffered a fall at the facility, went to the hospital, and the emergency room physician and R1’s physician verbally stated they thought R1 must have been overmedicated. LPA interviewed a witness who was told by the emergency room physician on March 15, 2020, that R1 was overmedicated. LPA interviewed a former administrator who was unable to provide information regarding this allegation. However, LPA reviewed R1’s Hoag Hospital Medical Records dated March 15, 2020, which do not corroborate this allegation. LPA did not obtain information corroborating this allegation. Regarding the allegation that facility staff falsified care plan documentation: it was alleged that the facility falsified R1’s care plan documentation. LPA interviewed a witness who stated that that R1’s care plan was updated at the end of May 2020 and that while the original care plan was created by the facility’s nurse, the updates to the care plan were made by the facility’s memory care activities director. LPA interviewed a former administrator who was unable to provide information regarding this allegation. LPA reviewed a Service Change Approval Form dated May 28, 2020, which shows that the facility’s nurse approved the changes to the care plan and an interview with another former administrator revealed that the changes were made by the memory care director, not the activities director. LPA did not obtain information corroborating that R1’s care plans were falsified or created by unqualified staff. Regarding the allegation of unlawful increase in care cost: it was alleged that on May 8, 2020, R1’s responsible party received an invoice showing an increase in level of care from tier 2 to tier 3, inquired why the level of care had increased, but was not provided any explanation as to why the level of care had increased or what new care R1 needed. LPA interviewed a witness who stated that at the end of May 2020, the facility raised R1’s level of care from tier 2 to tier 3 without a proper care plan or discussion, but that after the increase was disputed, the facility corrected the issue and began charging the new rate after a new care plan was created by a nurse. LPA reviewed a Service Change Approval Form dated May 28, 2020, which shows that the facility’s nurse approved the changes to the care plan and that these changes were discussed with R1’s responsible party. The information obtained is conflicting and LPA did not obtain information corroborating that R1’s responsible party had to pay an amount which they disputed. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 22-AS-20201103132810

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jul 16, 2024

87465 Incidental Medical and Dental Care. (a) … (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 documents and interviews, the licensee did not ensure R1, who had known skin issues, received proper assistance and medical care resulting in R1 developing an unstageable wound, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: The licensee stated they have created a protocol for preventing pressure injuries in residents with skin issues and mobility issues and that staff have been trained on this protocol. Licensee stated they will submit the protocol and training records to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 29, 2024

Observation of the Resident. ... When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of … the resident's responsible person, if any. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1’s worsening skin condition was noted and brought to the attention of their responsible party, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: The licensee stated they have created a protocol for documenting skin issues and other changes of condition with residents and notifying their families and doctors and that staff are trained on these protocols. Licensee stated they will submit the protocol and training records to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jul 16, 2024

87468.1 Personal Rights of Residents in All Facilities. (a) … (6) To leave or depart the facility at any time... This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not licensee did not ensure that R1 was free to leave or depart from the facility without being forced to quarantine in their room upon return, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: The licensee previously submitted a plan of correction on 06/12/20 that included a letter to residents and family with an updated policy that does not mandate forced quarantine and has already conducted in-service training to all staff as well. Licensee stated they will submit their current infection control protocols regarding isolation to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 16, 2024

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on documents and interviews, the licensee did not ensure R1 received multiple medications as prescribed, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: The licensee stated they created a protocol for auditing medications, ordering medications timely, and ensuring residents receive their medications as prescribed and that staff are trained on this protocol. Licensee stated they will submit this protocol and training records to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20201103132810. LPA met with Administrator (AD) Janette Hill and discussed the purpose of the inspection. During the course of the investigation, LPA interviewed a witness who stated that Resident #1 (R1) complained to the facility that due to a broken window their room, they were not able to open or close the window when needed to regulate the temperature in their room and that the facility’s response was to screw the window permanently shut. LPA reviewed a photograph of the window showing a screw in place to prevent the window from opening. LPA interviewed AD who stated there were likely two windows at the time. LPA inspected R1’s former room and noted there are two windows and both windows currently function properly. LPA reviewed the facility’s emergency disaster exit plan which does not indicate that windows would be used in an emergency and also observed that R1’s room was close to the stairs and a small balcony that can be entered using a full-size door. It is unclear whether only one window or both were alleged to have been screwed shut and the information obtained does not corroborate that screwing one window shut would have negatively affected a fire evacuation. However, permanently closing the window interfered with R1’s comfort and enjoyment of their room. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 29, 2024

87468.1 Personal Rights of Residents in All Facilities (a) … (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 had safe, healthful, and comfortable accommodations by permanently closing their window, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Licensee stated they understand that windows cannot be permanently closed. Licensee stated they have created a protocol for resident requests for maintenance and will submit recent maintenance records to LPA by POC due date.

Allegation investigated: -Facility does not have adequate staffing to meet the resident's needs.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews, review documentation and conclude findings for complaint allegation listed above. LPA Quiroz was greeted and granted entry by front desk concierge. LPA met with Business Office Manager (BOM) Gerardo Garibay and Executive Director (ED) Carrie Galloway and explained the nature of the visit. The 10 day visit was conducted on 8/31/2020 by LPA Patricia Velazquez. During the course of the investigation, LPAs conducted interviews with interviewees consisting of staff and Residents, conducted facility tour observations and conducted documentation review but not limited to resident roster, staff roster, physician report, identification form, needs and services plan and staff schedules. Regarding the allegation "Facility does not have adequate staffing to meet the resident's needs," the investigation revealed the following: Title 22 regulation states: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Interviews conducted with Nine of fifteen interviewees concluded that currently facility CONTINUED ON NEXT LIC 9099-C PAGE... Unsubstantiated CONTINUED... does have adequate staffing to meet the resident’s needs and not able to provide feedback for staffing ratios for year 2020 indicating having no knowledge of facility staffing during that time. Seven of fifteen interviewees indicated that staffing was challenging during COVID-19 pandemic due to staffing call offs, acuity due to COVID-19 pandemic and relying on Agency staffing. (ED) Galloway indicated “We are fully staff currently, however still actively hiring for back up/on call positions to fill in as needed. We stopped using Agency staff effective 2/28/2023.” Scheduling records from February 2020 to June 2020 revealed that facility had 2-4 caregivers scheduled on AM shift, 2-3 caregivers scheduled on PM shift, and 2-4 caregivers on the NOC shift varying on Assisted Living and Memory Care Unit. Facility census at the time of complaint was 65 residents. Documentation review of Staffing schedules for November 2023 and December 2023 reveal facility is currently staffing the following staff in Assisted Living area: 3 caregivers, 2 shared medication technicians, shared Memory Care Director, and shared Resident Care Coordinator with memory care unit on AM Shift, 2-3 caregivers, 1 shared medication technician with memory care unit on PM shift and 1-2 caregivers and 1 shared medication technician with memory care unit on NOC shift. Documentation review of Staffing schedules for November 2023 and December 2023 reveal facility is currently staffing the following staff in Memory Care Unit: 2-3 caregivers, 2 shared medication technicians, shared Memory Care Director, and shared Resident Care Coordinator with Assisted Living Unit on AM Shift, 2 caregivers, 1 shared medication technician with Assisted Living Unitt on PM shift and 1-2 caregivers and 1 shared medication technician with Assisted Living Unit on NOC Shift. (ED) Galloway indicated that she has requested increase staffing for 2024 budget as the census has increased and to continue to able to provide good quality care services to residents in care. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation "Facility does not have adequate staffing to meet the resident's needs" is deemed Unsubstantiated. An exit interview was conducted with (ED) Galloway and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 22-AS-20200826161002

Allegation investigated: -Staff is not providing adequate care and supervision to the residents

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purpose to conduct additional interviews, review documentation and conclude findings for complaint allegations listed above. LPA Quiroz was greeted and granted entry by front desk concierge. LPA met with Business Office Manager (BOM) Gerardo Garibay and Executive Director (ED) Carrie Galloway and explained the nature of the visit. The 10 day visit was conducted on 11/18/2021 by LPA Quiroz. During the course of the investigation, LPAs conducted interviews with interviewees consisting of staff and Residents. LPA Quiroz also conducted documentation review but not limited to resident roster, staff roster, physician report, identification form, needs and services plan and staff schedules. Regarding the allegation " Staff is not providing adequate care and supervision to the residents," the investigation revealed the following: Title 22 regulation states: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Interviews conducted with Fourteen of fifteen interviewees concluded that currently facility is providing adequate care and supervision to the residents in care, indicating not able CONTINUED ON NEXT LIC 9099-C PAGE... Unsubstantiated CONTINUED...to provide feedback for staffing ratios for 2020 year. Eight of fifteen interviewees indicated having no knowledge of facility during complaint time-frame. Seven of fifteen interviewees indicated that staffing was challenging during COVID-19 pandemic due to staffing call offs, acuity due to COVID-19 pandemic and relying on Agency staffing. (ED) Galloway indicated “We are fully staff currently, however still actively hiring for back up/on call positions to fill in. We stopped using Agency staff effective 2/28/2023.” Scheduling records from February 2020 to June 2020 revealed that facility had 2-4 caregivers scheduled on AM shift, 2-3 caregivers scheduled on PM shift, and 2-4 caregivers on the NOC shift varying on Assisted Living and Memory Care Unit. Facility census at the time of complaint was 33 residents. During today's facility inspection visit, LPA Quiroz observed pull chords throughout the facility including hallways, bathroom areas and common living areas and resident bathroom areas. LPA Quiroz observed resident carrying pendants on their possession readily available to call for assistance when needed. Documentation review of Staffing schedules for November 2023 and December 2023 reveal facility is currently staffing the following staff in Assisted Living area: 3 caregivers, 2 shared medication technicians, shared Memory Care Director, and shared Resident Care Coordinator with memory care unit on AM Shift, 2-3 caregivers, 1 shared medication technician with memory care unit on PM shift and 1-2 caregivers and 1 shared medication technician with memory care unit on NOC shift. Documentation review of Staffing schedules for November 2023 and December 2023 reveal facility is currently staffing the following staff in Memory Care Unit: 2-3 caregivers, 2 shared medication technicians, shared Memory Care Director, and shared Resident Care Coordinator with Assisted Living Unit on AM Shift, 2 caregivers, 1 shared medication technician with Assisted Living Unitt on PM shift and 1-2 caregivers and 1 shared medication technician with Assisted Living Unit on NOC Shift. (ED) Galloway indicated that "a staff gross for 2024 budget has been approved, and will be implemented as census gross to continue to able to provide good quality care services to residents in care." Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation “Staff is not providing adequate care and supervision to the residents” is deemed Unsubstantiated. An exit interview was conducted with (ED) Galloway and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 22-AS-20211109133758