Durando Home II

Type of visit: Required - 1 Year

On 4/18/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. The Administrator, James Durando arrived shortly after to assist with today’s visit. LPA asked for the census and Staff/Resident Roster. LPA conducted a physical plant tour at approximately 1:30 PM and the following was noted: The facility is a single unit building with five (5) bedrooms and two (2) bathrooms currently occupying four (4) residents. There is one (1) designated staff room. The facility has an approved fire clearance for one (1) ambulatory and three (3) non-ambulatory residents. The facility is vendor through North Los Angeles Regional Center (NLARC) and is being operated at a Level III Residential Care for the Elderly. Common areas: The living rooms and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 76°F. LPA observed a fire extinguisher to be located near the kitchen and dated 08/26/2025. LPA observed required postings such as See/Say Something, Long-Term Care Ombudsman, and Personal Rights located throughout the common areas. A working telephone was observed. Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Kitchen appliances were observed to be working and in proper condition. The knives/sharps were observed to be kept within a locked kitchen cabinet. (Continue to LIC 809-C) Laundry Room: The laundry appliances were observed to be located in the hallway’s passageway leading towards the bedrooms. The laundry appliances were observed to be in proper condition. LPA observed the cleaning solutions/toxins to be properly stored within the laundry room, locked and inaccessible to residents. Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. The Hallways/passageways were observed to be lighted appropriately. LPA observed extra linen/covers to be kept in a storage cabinet located along the hallway’s passageway. Staff Room: LPA observed staff room to have a locked storage cabinet. The Staff/Resident files were observed to be kept in locked filing cabinet located near the living room/staff reception area. Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations at 107.6 °F. Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water located at the facility. Garage: The garage can be accessed from inside of the facility. LPA observed the garage to be kept locked and used for storage purposes. Medications: The medications were observed stored in a locked kitchen cabinet. First-aid kit observed to be equipped with but not limited to bandages, scissors, and digital thermometer. Smoke detectors and carbon monoxide: LPA observed the smoke detectors and carbon monoxide to be working properly and were tested. The Last Fire Drill was conducted on 2/18/2026. Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be not complete and updated. Staff records: LPA conducted a complete file review of three (3) staff records. Staff records appeared to be not complete and updated. Citations issued please refer to LIC 809-D. There were no other immediate health and safety hazards observed during the day of inspection. Exit interview was conducted, appeal rights given and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 18, 2026

The state marks this report as 14 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing program Analyst (LPA) Tihesha Smith conducted a case management visit in conjunction with complaint visit: # 31-AS-20260121094640. LPA Smith observed the following: Front and backyard over grown, piles of wheelchairs stored on sides of home, old unserviceable truck in driveway with wheels flat, smoke detectors not securely attached to ceiling or with aid of bracket, window screens bent and/or coming out of window frame, electric outlet covers cracked or not available, cooling unit gaps filled with urinary liner, garage door knob missing, garage cluttered, old cans, rat/mouse trap box, and mouse/rat droppings present around water/heater, and issue concerning administrator qualifications. Due to time constraints case management will be completed at a later time. Exit interview conducted/copy of report given.the state’s words, verbatim · CDSS document, Jan 26, 2026

Allegation investigated: Staff not keeping resident’s room free from odor. Staff not changing residents diaper needs resulting in a rash. Staff not treating resident with respect. Staff left residents unsupervised for a period of time. Staff did not assist resident in a timely manner.

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit to this facility to continue the investigation on the above allegations and deliver determinations. LPA arrived to the facility and knocked on the door. Nobody answered. LPA contacted the administrator, James Durando by telephone but could not leave a voicemail. LPA contacted Nancy Magallanes the House Manager by telephone and explained the reason for the visit. The house manager stated staff should arrive shortly to grant access. To investigate the allegations, LPA Rios conducted an initial unannounced complaint visit on 04/07/2025. During the visit, LPA conducted a physical plant tour to ensure the health and safety of residents in care. No concerns were observed at that time. During the initial visit from 9:23 a.m. to 9:30 a.m., one (1) staff member was interviewed. Between 9:40 a.m. and 11:35 a.m., LPA requested and obtained copies of the following documents: staff roster, client roster, residents’ Individual Program Plans (IPPs), Physician’s Reports (LIC 602), Appraisals/Needs and Services Plans (LIC 625), and Staff #1(S1) record. Unsubstantiated From 2:00 p.m. to 4:00 p.m., LPA interviewed five (5) staff, Resident #1 (R1) and Resident #2 (R2). LPA attempted to interview, Resident #3 (R3) and Resident #4(R4) but they did not clearly respond to LPA's questions. Allegation: Staff not keeping resident’s room free from odor. It was alleged S1 is not keeping residents room free from odor. To investigate the allegation, on 04/07/2025 at 9:12 a.m., LPA conducted a physical plant tour. During the initial visit LPA interviewed the administrator, the house manager, six (6) staff and (2) out of four (4) residents. During the physical plant tour, LPA did not smell any unpleasant odor in residents' bedrooms. LPA did not observe any items on the floor. Interview with five (5) staff corroborated they did not have concerns regarding S1 or with the facility's cleanliness. Staff corroborate it is part of their job duties to clean residents bedrooms. During interviews with residents they did not express concerns regarding the facility's odor. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff not changing residents diaper needs resulting in a rash. Regarding the allegation is was reported residents have sustained diaper rashes due to S1 not changing their diaper for an extended amount of time. A co-complainant reported it was R1 that had developed a rash. LPA's interview with the house manger denied the allegation. LPA's interview with six (6) staff deny the allegation stating R1 is able to go to the toilet with assistance and is provided timely assistance with diaper changing. Staff corroborate they do not leave residents soiled for an extended time and have not started a shift when a resident in a soiled diaper. According to staff, R1 is able to communicate when they have to use the bathroom or have had an accident. During interviews with residents they did not express concerns regarding assistance and R2 denied witnessing staff purposely delay responding to residents. LPA's review of R1 Physician's Report revealed R1 is not bowl or bladder impaired. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Page 2 of 3) Allegation: Staff not treating resident with respect. Regarding the allegation, it was reported that S1 is not nice to R1 and does not treat R1 with respect. LPA could not obtain specific details regarding the allegation. To investigate the allegation, LPA interviewed six (6) staff and one (1) resident. Interview with five (5) staff revealed that they have never witnessed S1 mistreat any residents. Interview with S1 denied the allegation. According to staff R1 may have disruptive behavior such as yelling but staff are able to redirect R1. LPA’s interview with R2 denied the allegation and they stated they have not witnessed R1 or any other residents being mistreated by staff. R1 did not respond to LPA's question regarding staff treatment clearly. LPA observed the interaction between R1 and S1 on 11/14/2025 and noted no signs of hostility. Based on LPA’s interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff left residents unsupervised for a period of time. Regarding the allegation, it was reported that S1 will leave their shift early and leave residents unsupervised. To investigate the allegation, LPA interviewed six (6) staff and one (1) resident. Interview with five (5) staff revealed that they have never witnessed S1 leave residents unsupervised. Interview with S1 denied the allegation. LPA’s interview with R2 denied the allegation. R1 did not respond to LPA's question regarding to supervision clearly. Based on LPA’s interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff did not assist resident in a timely manner. Regarding the allegation, it was reported that S1 told R1 to wait, resulting in R1 waiting approximately 20 minutes before receiving assistance. Interview with six (6) staff which includes S1 denied residents are asked to wait an excessive amount of time. According to staff they have asked residents to wait when they are already assisting a resident but it is not a long time. Interview with residents corroborated they have been asked to "hold on" but staff will provide assistance. Residents did not provide a time frame for response time. Based on LPA’s interviews there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Staff was designated to sign todays report. No immediate health and safety issues observed during today's visit. Exit interview conducted and a copy of this report was provided to staff. (Page 3 of 3)the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 31-AS-20250328162226

Allegation investigated: Staff are not meeting residents’ health needs.

On 11/12/2025 at approximately, 9:40 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by staff and stated the reason for their visit. Administrator, James Durando along with facility’s manager, Nancy Magallanes arrived shortly after to assist with today’s meeting. At 09:45 AM, LPA requested census, resident and staff roster. At approximately 10:00 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. At 11:00 AM, LPA requested pertinent documentation pertaining to the investigation such as but not limited to: Admission Agreement, Needs and Services and Physician’s Report. In between 11:30 AM – 1:30 PM, LPA attempted interviews with four (4) residents (R1-R4), eight (8) staff members (S1-S8) and conducted record review. (continue to LIC 9099-C) Substantiated Regarding the allegation: Staff are not meeting residents’ health needs. It was alleged that residents are not receiving their health and dental needs as needed. To investigate the allegation, LPA attempted to interview four (4) residents and eight (8) staff members. LPA’s interview with R1 revealed that they have been requesting their dental appointment due to their teeth hurting. R1 stated that S1 and S2 have told them that they are in the process of working out the insurance to be able to book an appointment. LPA attempted to interview R2, R3 and R4 but due to their inability to communicate due to various medical reasons, LPA terminated the interviews. LPA’s interview with four (4) of the eight (8) staff members confirmed that R1 has been requesting to go to the dentist. LPA’s interview with both S1 and S2 revealed that R1 has not gone to the dentist due to R1’s dental insurance needing to be changed over to Medical. LPA questioned if there are documentation showcasing the process of switching R1’s dental insurance over to Medical where both S1 and S2 could not provide. LPA’s record review revealed that three (3) of the four (4) residents were missing their updated medical assessment since February of 2025. LPA’s interview with S2 revealed that the physician who oversees all four (4) residents would not complete their updated medical assessment until later this year (November 2025). When questioned if there was any documentation of all four (4) residents’ dental visits within the last two (2) years, both S1 and S2 could not provide documentation. Based on interviews and record review, staff have not ensured that residents are receiving their medical appointments as needed, therefore the allegation is SUBSTANTIATED at this time. Citation issued, please refer to 9099-D. No other immediate health and safety hazards observed during the time of the visit. Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Administrator. Regarding the allegation: Staff are not treating residents with dignity and respect. It was alleged that staff members are not speaking to residents in an appropriate manner and ignoring them. To investigate the allegation, LPA attempted interviews with four (4) residents and eight (8) staff members. LPA’s interview with R1 revealed that staff raise their voices towards them but do not yell. LPA attempted to interview R2, R3 and R4 but due to their inability to communicate due to various medical reasons, LPA terminated the interviews. LPA’s interviews with six (6) of the eight (8) staff members stated that they have not nor witnessed any staff members being disrespectful towards any of the residents. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other immediate health and safety hazards observed during the time of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 31-AS-20251106095711

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 3, 2025

87465 Incidental Medical and Dental Care.(a) ...routine medical and dental care and provide for assistance in obtaining such care... (1)The licensee shall arrange, or assist in arranging, for medical and dental care... This requirement is not met as evidenced by: Based on interviews and Record review the licensee did not ensure that four of the four residents received their health appointments as needed which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 12, 2025

Plan of correction: The licensee will review the regulation and email LPA Segovia a statment of understanding including documentation confirming the process of updating R1's dental insurance by POC due date.

Allegation investigated: Staff allowed uncleared adults to be present in the facility. Staff smokes marijuana at the facility while on shift. Staff did not treat resident with dignity and respect. Staff did not ensure resident's room were kept clean. Staff did not provide proper food service to residents in care.

On 6/12/2025 at approximately 10:50 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, James Durando and stated the reason for their visit was to deliver the findings of the complaint. To investigate the allegation(s), on 6/04/2025 LPA conducted a physical plant tour, requested pertinent documentation, and attempted interviews with four (4) residents (R1-R4) and eight (8) staff members (S1-S8). (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff allowed uncleared adults to be present in the facility. It was alleged that S1 had allowed adults into the facility whom had not obtained Criminal Record Clearance. To investigate the allegation, LPA interviewed eight (8) staff and four (4) residents. Interview will all eight (8) staff members revealed that they have never brought or witnessed any other staff bring any uncleared adults into the facility. LPA’s interview with R2 confirmed that they have not witnessed any staff members bring any adult visitors into the facility. LPA attempted to interview R1, R3 and R4 but due to their inability to communicate due to various medical reasons, LPA terminated the interviews. LPA’s record review of the facility’s staff roster in comparison to both: Guardian Background Check System and Licensing Information System (LIS) databases, all eight (8) staff members were shown to have approved background clearance for the facility. During LPA’s physical tour of the facility, LPA did not witness any other adults other than the approved staff and residents within the facility. Based on LPA’s interviews, record review and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff smokes marijuana at the facility while on shift. It was alleged that S1 has been smoking marijuana at the facility. To investigate the allegation, LPA interviewed eight (8) staff and one (1) resident. Interview with all eight (8) staff members revealed that they have not smoked marijuana in the facility nor have witnessed any other staff members do so. Interview with R2 confirmed that they have not witnessed any staff members smoking marijuana in the facility. During LPA’s physical tour, LPA did not smell any odor of marijuana or witness any staff members under the influence of marijuana or any illicit drugs. Based on LPA’s interviews and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not treat resident with dignity and respect. It was alleged that S1 has yelled and neglected R1. To investigate the allegation, LPA interviewed eight (8) staff and one (1) resident. Interview with all eight (8) staff revealed that they have never witnessed S1 yell or mistreat any residents. Interview with S3 revealed that S1 understands R1 the best and R1 enjoys being around them. LPA’s interview with R2 confirmed that they have not witnessed R1 or any others being mistreated by staff. In addition, LPA’s observation of R1’s interaction with S1 did not show any signs of distress or discomfort surrounding S1’s presence at the facility. (Continue to LIC 9099-C) Based on LPA’s interviews and observation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident’s room were kept clean. It was alleged that resident’s bedrooms are being left with soiled diapers and trash on the floor. To investigate the allegation, LPA interviewed eight (8) staff and one (1) resident. Interview with all eight (8) staff confirmed that resident’s rooms are cleaned daily. Interview with R2 confirmed that staff clean the bedrooms daily. During LPA’s physical tour, LPA observed all resident’s room to be neat, clean and organized. LPA observed resident’s bedroom floors to be free of any clutter and/or trash. Based on LPA’s interviews and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not provide proper food service to residents in care. It was alleged that S1 does not prepare dinner for the residents at the allocated time and/or not at all. To investigate the allegation, LPA interviewed eight (8) staff and one (1) resident. Interview with all eight (8) staff revealed that all residents eat three (3) meals a day including snacks. Interviews with all eight (8) staff confirmed that dinner is served after 4:00 PM. Interview with S6 revealed that if residents, “…want their dinner earlier then they will prepare it for them”. Interview with S4 revealed that they have witnessed, “…leftovers from the previous night’s dinner” inside of the refrigerator confirming that dinner was prepared. LPA’s review of the facility menu showcased a variety of meal options for the entire week. Interview with S3 confirmed that residents, “…can always request something different from the menu”. During LPA’s physical tour, LPA observed a variety of perishable and nonperishable food readily available for residents. In addition, during the day of the visit, LPA observed S1 prepping dinner for the residents. Furthermore, based on LPA’s interviews, record review and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. In addition, LPA’s review of the facility’s history revealed similar allegations pertaining to S1. Such allegations have included but not limited to: use of illicit drugs, allowed entrance of uncleared adults, treatment of residents, care and supervision of residents and failing to provide meals to residents all ranging from the year 2022 to present. The allegations were investigated and deemed unsubstantiated. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 12, 2025 · control 31-AS-20250530113528

Allegation investigated: Uncleared adult is present in the facility Staff smokes marijuana in front of residents in care Staff leave residents alone in the facility

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit to this facility to deliver findings at approximately 8:45 a.m., on 02/19/2025. LPA arrived at to the facility and could hear a vacuum. LPA rang the door bell but no one answered the door. LPA contacted the Administrator, James Durando by telephone, and he explained they were on their way to an appointment with a client but staff should be at the home to grant LPA entry. LPA explained to the administrator the reason for the visit. LPA was then greeted by staff and granted access. Administrator assistant, Nancy Magallanes Silva contacted the staff and designated staff to sign for today's report. At approximately 9:00 a.m., LPA conducted a health and safety physical plant tour of the facility inside and out. LPA did not observe any health or safety issues. At 9:20 a.m., LPA requested a copy of Personnel Report (LIC500) and obtained copies of staff time sheets. (Cont. to LIC9099-C) Unsubstantiated Allegation: Uncleared adult is present in the facility On 02/24/24, during the initial complaint visit, LPA Tihesha Smith toured the facility inside and out, requested, and reviewed copies of documents relevant to the investigation from approximately 10:35 a.m., to 2:30 p.m. These documents included, but were not limited to personnel report, and resident roster. LPA Smith was unable to interview S1 as they were not present at the facility during time of visit and four (4) of four (4) residents refused or were not able to engage in an interview. Interviews conducted with three (3) of three (3) staff members revealed they do not have any knowledge of an uncleared adult being present in the facility. During the interviews, the administrator confirmed that there are no known current exclusions for staff. To corroborate these statements, the Licensing database was reviewed by LPA Smith. This review confirmed that no facility staff have an active exclusion with the department. At the time of this visit LPA Rios reviewed staff time sheets compared with the information pulled from the Guardian Background Check System. The staff census matched the Licensing records. Based on record review and interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. Allegation: Staff smokes marijuana in front of residents in care It was alleged that Staff smokes marijuana daily on the facility premises and in front of the resident’s in care. Interview with three (3) out of three (3) staff revealed have not smoked marijuana in front of residents and have not witness any other smoking marijuana in front of residents. Administrator revealed staff can smoke cigarettes outside, and all staff are aware that marijuana use in or around residents and facility is prohibited. During facility visits, LPA Smith did not smell any marijuana odors in or around facility and did not observe any discarded pieces of tobacco rolling paper, commonly known as "roaches," on the premises. At the time of this visit LPA Rios inspected the facility inside and out and did not smell marijuana odor or observe any staff smoking marijuana or cigarettes. Based on interviews and observations there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time. ( Page 2 of 3) Allegation: Staff leave residents alone in the facility It was alleged that staff leave residents alone in the facility. To investigate this allegation, interviews were conducted with three (3) staff members. All three (3) staff members categorically denied ever leaving residents alone in the facility or arriving for their shifts to find residents unattended. Each staff member confirmed that there is always at least one (1) staff member present in the facility at all times. Additionally, two (2) of the three (3) staff members noted that S1's spouse occasionally picks up S1's vehicle, and no other vehicles may be parked at the house, which might give the impression that no one is home. However, these staff members emphasized that despite the absence of vehicles, staff are always present with the residents. Based on interviews, there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety hazard is noted during his visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 31-AS-20240216153939

Type of visit: Required - 1 Year

On 12/12/2024 at approximately 09:40 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Caregiver Myriam Reina. LPA stated the reason for the visit. The Administrator James Durando along with House-Manager Nancy Magallanes arrived shortly after to assist with today's visit. LPA asked for census, staff, and resident files…. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted: There is only one entrance being utilized at the facility. The facility is a single unit building with five (5) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) room is designated for staff use only. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Required postings such as Emergency Disaster Plan, See/Say Something, Long-Term Ombudsman were located alongside reception desk within the living room. Common areas observed to be neat, clean, and organized. Common areas observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 70°F. Fire extinguisher located near the kitchen and dated 05/30/24. The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked alongside medication in a kitchen cabinet inaccessible to residents. Stove observed to be working and in proper condition. Small dining table located in the kitchen observed to be neat, clean, and properly furnished. (continued on LIC 809-C) The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in this facility. Smoke detectors and carbon monoxide observed to be working properly and were tested. The laundry room is located along the hallway leading towards the bedrooms. Laundry room observed to be locked and inaccessible to residents. Laundry detergents, cleaning agents, and other toxins are stored within laundry room and are locked inaccessible to residents. The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Residents have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. Sufficient availability of clean lien and extra PPE stored in hallway cabinet. Appropriate grab bars and skid mats observed. Medications: LPA observed medication stored in kitchen cabinet locked and inaccessible to residents. Medication usage recorded and stored properly. LPA along with Administrator Durando conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual. Resident records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. An exit interview was conducted, One (1) citation issued for Liability Insurance not being readily available and/or expired. Appeals rights and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2024

Allegation investigated: Facility staff not meeting incontinence care needs of residents. Facility staff not providing meals to residents.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with caregiver, Mariam Raina, and explained the reason for the visit. --- Facility staff not meeting incontinence care needs of residents. It was alleged that staff do not change the residents' diapers. To investigate the allegation, on 07/12/2024 LPA conducted physical plant tour at around 01:30 PM, interviewed one (01) staff and two (02) out of four (04) residents between 02:30 PM to 03:30 PM. During the physical plant tour, LPA observed all residents were clean and well groomed. LPA did not experience any malodor. During interviews with staff, Staff #1 (S1) stated that residents are changed frequently throughout the day and checked on every two hours. Staff added that residents are not left soiled for an extended time. (CONT on LIC 9099-C) Unsubstantiated During interviews with residents, two (02) of four (04) residents stated they are checked on frequently for incontinent care, changed often and are not left soiled for an extended time. LPA was unable to interview other residents. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff not providing meals to residents. It was alleged that staff do not feed the residents at mealtimes. To investigate the allegation, on 07/12/2024 LPA conducted physical plant tour at around 01:30 PM, interviewed one (01) staff and two (02) out of four (04) residents between 02:30 PM to 03:30 PM. During the physical plant tour, LPA observed residents being offered mid-day snacks. LPA also observed at least seven (07) days perishable and two (02) days non-perishable foods in the facility. During interviews with staff, Staff #1 (S1) stated that residents are served breakfast, lunch, dinner and offered snacks throughout the day. During interviews with residents, two (02) of four (04) residents stated they are served all meals and that snacks are available upon request. LPA was unable to interview other residents. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 31-AS-20240705161421

Allegation investigated: Staff do not assist resident with incontinence needs Staff do not provide adequate supervision to residents

On 5/18/2024 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with James Durando/Licensee. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Resident interviews (R#2-R#3). LPA obtained the following documents: Resident’s roster, Personnel roster, (R#1-R#3) Identification and Emergency Information, (R#1-R#3) Admissions agreements, (R#1-R#3) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#3) Needs and Services Plan, (R#1-R#3) Medication Administration Record (MAR) for the month of May 2024. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff do not assist resident with incontinence needs. The details of the complaint alleged that facility staff do not assist residents with their continence needs. During the records review, LPA observed (R#1)'s Physician's Report for the Residential Care Facilities for the Elderly (RCFE) or LIC 602A, which was dated and signed by a physician on 2/22/2024. LPA noticed that (R#1) is not confused or disoriented but is able to follow instructions and communicate their needs. Additionally, (R#1)'s LIC 602A states that they can care for their own toileting needs with some assistance from facility staff, and that (R#1) is able to transfer to and from a bed independently. During an interview with the licensee (L#1), he stated that the facility staff assist residents with their daily continence needs. (L#1) noted that there is one caregiver during the morning shift from 6 am to 2 pm, one from 2 pm to 10 pm, and one from 10 pm to 6 am. Additionally, (L#1) mentioned that no resident in care has been left in a soiled diaper for an extended period. During an interview with resident 1 (R#1), they stated/sign that facility staff assist them in going to the restroom and changing their adult diapers when needed. In addition, (R#1) stated/sign that they can go to the bathroom by themselves. (R#1) only uses night depends, but they can get up in the night to use the restroom and have not been left in a soiled diaper for a long time. During Interviews with Residents (R#2-R#3), LPA could not communicate with them due to cognitive impairment. During interviews with facility staff (S#1-S#3), (3) out of (3) care staff stated that they assist residents with their toileting needs. They also mentioned that there are always three caregivers available every day at the facility: one in the morning, one in the afternoon, and one at night. Additionally, (3) out of (3) staff stated that no resident has ever been left in a soiled diaper for an extended period. LPA attempted to interview the Quality Assurance Specialist for the North Los Angeles Regional Center, but they were unable to reach them by phone. Evaluation Report continues LIC 9099-C Allegation: Staff do not provide adequate supervision to residents. The details of the complaint alleged that facility staff do not provide adequate supervision to residents in care. LPA Iniguez conducted a records review and inspected the facility’s staff schedule. The schedule indicates that there is one care staff scheduled from 6:00 AM to 2:00 PM, the next care staff is scheduled from 2:00 PM to 10:00 PM, and the last staff is scheduled from 10:00 PM to 6:00 AM. During a physical tour of the facility, LPA Iniguez observed that the facility was clean, sanitary, and in good repair. In addition, LPA observed that knives and cleaning supplies were locked and secured, not accessible to (R#1). Also, LPA observed that (R#1)’s medications were centrally stored and locked. Furthermore, LPA observed plenty of perishable and non-perishable food at the facility. Moreover, LPA inspected (R#1)’s room, bed, and bedding, which were in good condition and appropriately furnished during the visit. During an interview with the licensee (L#1), he stated that facility staff provided adequate supervision to the resident in care, and no resident in care has ever been left alone for an extended period. During interviews with resident (R#1), they confirmed that facility staff are taking good care of them. (R#1) pointed out the care staff attending to them and stated that they have never been left alone for an extended period. During Interviews with Residents (R#2-R#3), LPA could not communicate with them due to cognitive impairment. During interviews with staff (S#1-S#3), (3) out of (3) stated that they are providing adequate supervision to the residents in care and have never left them alone for an extended period. LPA attempted to interview the Quality Assurance Specialist for the North Los Angeles Regional Center, but they were unable to reach them by phone. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found 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, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Nancy Magallanes/House Magallanes.the state’s words, verbatim · CDSS document, May 18, 2024 · control 31-AS-20230921120914

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Tihesha Smith made a subsequent visit to this facility at 12:35 pm to complete annual inspection from 02/24/2024. LPA disclosed to staff the purpose of the visit. The administrator was not present in the facility. At 1:15 pm LPA reviewed staff and resident records. Staff records contained current First aid and CPR and trainings and resident records contained admissions agreements. IPPs have been requested and Administrator will email LPA. Smoke detectors/carbon monoxide detector were tested and operable at time of visit 02/24/24. LPA Smith observed the following items that need to be address: Window screens missing from resident bedroom next to front door Window screens from other windows torn, ripped or missing Walls thought facility need to be either cleaned, repaired and/or painted Garage needs to be cleaned and items discarded Deficiencies cited on 809D Exit Interview/Copy of report issued.the state’s words, verbatim · CDSS document, Feb 29, 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: Required - 1 Year

Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 10:35 am and observed surroundings before exiting vehicle. The administrator was present at the facility and LPA Smith disclosed the purpose of the visit. LPA conducted a tour of the physical plant at approximately 11:03 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, dining room area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. The medication, sharps and first aid kit are stored in single cabinet near sink. The medications and sharps were observed to be inaccessible to residents. There is one (1) fire extinguisher attached to family room wall. Fire extinguisher observed to be charged. Laundry room is in hallway behind accordion doors. The appliances observed to be functional. Due to time constraints this required annual will be completed at a later time. Exit interview conducted/Copy of report given.the state’s words, verbatim · CDSS document, Feb 24, 2024