Four Seasons Assisted Living Center

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10AM for a required one-year visit. The LPA met with Administrator Amber Leigh and explained the reason for the visit. Entrance interview conducted. At 10:18AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: Located on the first floor is the lobby, dining room, activity room, office, and kitchen that is attached to the Skilled Nursing Facility side of the building. Located on the second floor is an office and medication room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas. Required postings were found in the hallway on the first floor by the office. Emergency food and water were observed in a secured closet on the first floor. There is one (1) outdoor patio located on the first floor by the lobby which is utilized as a smoking area. The LPA observed a grill and outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. Report Continued on LIC 809-C RESIDENT ROOMS: The LPA observed six (6) randomly selected rooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 116.1 degrees F and 117.4 degrees F. KITCHEN: The kitchen is located on the 1st floor in the Skilled Nursing Facility. The kitchen was observed to be in compliance with Title 22 regulations. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality. Administrator stated the residents’ meals are carted in from the kitchen to the dining room/resident rooms. MEDICATION: Medication review began at 11:02AM. The LPA reviewed medications for three (3) residents. Medications are maintained locked and inaccessible to residents in the medication room located on the second floor. Resident #1 (R1) had two (2) medications that were not documented on the centrally stored medication and destruction record. Resident #2 (R2) was prescribed Trazadone instructed to be administered at bedtime and the cycle started on 05/29/2026. It was observed that the 05/31/2026 dosage remained and a review of the facility’s Medication Administration Record (MAR) did not document whether the medication was administered or refused. Interview with R2 indicated that sometimes the Med-Tech is late, and they were unable to recall whether they took the medication or refused. However, review of R2’s other bedtime medications indicated that it was administered. RECORDS: Records were reviewed at 11:35AM. The LPA reviewed six (6) resident files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. All records were in order. The LPA reviewed five (5) personnel records for, but not limited to: job application, health assessments, TB results, criminal record clearances, and first aid/CPR certification. All records were in order. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER: LPA reviewed the facility's infection control plan and emergency disaster plan. LPA noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with the last drill documented on 05/22/2026. The fire alarm system is tested annually with the last inspection on 03/11/2026 by Erin Associated Industries. Fire extinguishers were observed throughout the facility and last serviced on 05/01/2026. Pursuant to Title 22 Ca Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report were reviewed and provided.the state’s words, verbatim · CDSS document, Jun 2, 2026

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Incident visit at 11:31AM. The LPA met with Med-Tech Claudia Perez and explained the reason for the visit. The Administrator was unavailable during today’s visit and participated via telephone call. Entrance interview conducted. On 03/27/2026, the Department was notified of Resident #1 (R1) who was unattended at a related facility. The LPA contacted Administrator Amber Leigh via telephone call who stated that R1 left the facility on 03/23/2026, was independent, and able to provide their own transportation. The Administrator provided documents which indicated R1 was non-ambulatory, able to leave the facility unassisted, and unable to manage or have access to medications. During today’s visit, the LPA contacted the Administrator at 11:47AM. Beginning at 12:02PM the LPA and Med-Tech conducted a physical plant tour and reviewed R1’s medications. No immediate concerns were observed. The Administrator confirmed with the Med-Tech on shift on 03/23/2026 that R1 left the facility without notice and medications were not checked out to them. R1 then returned to the facility on 03/28/2026 and was immediately placed on a psychiatric hold due to aggressive behavior. Med-Tech Claudia Perez stated that they contacted R1 on 03/24/2026 and were unable to receive a clear answer on R1’s return to the facility and notified R1's physician. Report Continued on LIC 809-C The Administrator stated that going forward the facility will ensure that all appropriate parties are notified including law enforcement, responsible parties, and physicians if a resident is unable to be contacted, located, and does not return to the facility. The LPA also discussed reporting requirements with the Administrator as the Department has not received any Unusual Incident Reports since 04/16/2025. The Administrator stated they have faxed their reports and the LPA advised providing them through email. The Administrator agreed. Due to the Administrator’s unavailability, they have designated Med-Tech Claudia Perez to sign today’s report. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 9:08AM for a required one year visit. The LPA met with Administrator Amber Leigh and explained the reason for the visit. Entrance interview conducted. At 9:34AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a two-story building. The following was observed: COMMON AREAS: Located on the first floor is the lobby, dining room, activity room, office, and kitchen that is attached to the Skilled Nursing Facility side of the building. Located on the second floor is the activity room and medication room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas. Required postings were found in the hallway on the first floor by the office. There are fire extinguishers throughout the facility, which were serviced 05/02/2025. Emergency food and water is stored in a locked closet located on the first floor. There is one outdoor patio located on the first floor by the lobby which is utilized as a smoking area. The LPA observed a grill and outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. Report Continued on LIC 809-C RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 96.3 degrees F and 107.1 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. KITCHEN: The kitchen is located on the 1st floor in the Skilled Nursing Facility. The kitchen was observed to be in compliance with Title 22 regulations. Food deliveries occur every Tuesday and Friday. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality. Administrator stated the residents’ meals are carted in from the kitchen to the dining room/resident rooms. RECORDS: Records were reviewed at 10:25AM. The LPA reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. LPA observed one (1) out of ten (10) resident records did not have a TB test on file. Administrator stated the resident is currently in the Skilled Nursing Facility and will have a TB test completed while they are there. The LPA reviewed six (6) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, and first aid/CPR certification. LPA observed one (1) staff having a 1st Aid/CPR training which expired in 10/2023. INFECTION CONTROL/EMERGENCY DISASTER: LPA reviewed the facility's infection control plan and Emergency Disaster plan. LPA noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with drills conducted monthly, with the last drill documented on 05/06/2025. The fire alarm system is tested annually with the last inspection on 03/28/2025 by the Los Angeles Fire Department. Report Continued on LIC 809-C MEDICATION: Medications review began at 1:57PM. The LPA reviewed medications for five (5) residents. Medications are maintained locked and inaccessible to residents in the medication room located on the second floor. Five (5) out of five (5) resident medications reviewed were documented and stored in compliance with regulation at this time. Five residents and four staff were interviewed. No complaints noted. Documents obtained: LIC 500 Personnel Roster. Pursuant to CA Title 22 Regulations, the following deficiencies were cited (Refer to LIC 809-D). Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.the state’s words, verbatim · CDSS document, Jun 9, 2025

Allegation investigated: Resident moved to higher level of care without consent

Licensing Program Analyst (LPA) Erica Mosley conducted an initial 10-day complaint visit to investigate the above allegation. Upon arrival at approximately 9:40 am, LPA Mosley was greeted by Activities Coordinator/ Social Worker, Ulka Sanghavi who called the Administrator to inform them of the visit. The Administrator Clarizze Punit was not able to attend and designated Ulka Sanghavi to sign the report and the reason for the visit was explained. On 09/30/2024, the Department received a complaint regarding the following allegation, Resident moved to higher level of care without consent. LPA toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Report Continued on LIC9099C... Unsubstantiated Report Continued from LIC9099... On the allegation, Resident was moved to higher level of care without consent it is the concern of the reporting party (RP) that Staff #1 (S1) sent Resident #1 (R1) to a higher level of care, skilled nursing facility (SNF) due to R1 having multiple falls which was untrue and R1 should not be at the SNF. The SNF R1 is currently residing at is located in the same building as the facility and a collateral visit was also conducted at this location during the investigation. To investigate this complaint, LPA requested pertinent documents to the investigation. The LPA also conducted interviews with the Administrator, two (2) Assisted Living staff, SNF Director of Nursing (DOR), one (1) SNF LVN Unit Manager, and resident R1 between 10:10am to 12:57pm. Interviews with assisted living staff revealed that R1 returned to the facility from the hospital on 09/06/2024 and on 09/10/2024 R1 had an unwitnessed fall in the bedroom. R1’s roommate, Resident #2 (R2) found R1 on the floor of the bedroom and immediately contacted second floor staff. Staff #2 (S2) responded and found R1 on the floor of the bedroom. S2 assisted R1 up, however S2 noticed a delay in speech and confusion. S2 called 911, R1 consented and was transported to the hospital. Interviews with SNF staff revealed that R1 had doctor orders to be released to SNF when they were discharged from the hospital. Record review and documents obtained revealed that R1 had a fall, loss consciousness, compression fracture, and UTI requiring antibiotics. R1 signed discharge summary indicating that R1 will be released to SNF to continue antibiotics along with occupational therapy and physical therapy. Interviews with staff and record review support that R1 was moved to a higher level of care with consent and physician orders for the health of the resident. The LPA attempted to interview R2 but they were unavailable for interview. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Resident was moved to higher level of care without consent is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 29-AS-20240930164354

Allegation investigated: Facility staff are withholding mail from resident(s)

At approximately 9:55am Licensing Program Manager (LPM) KaSandra Lopez, and Licensing Program Analyst (LPA) Erica Mosley conducted an initial 10-day complaint visit to investigate the above allegation. Upon arrival, LPM Lopez and LPA Mosley were greeted by Activities Coordinator/ Social Worker, Ulka Sanghavi who called the Administrator to inform them of the visit. The Administrator Clarizze Punit arrived later during the visit at 10:08am. The LPM and LPA met with Administrator and explained the reason for the visit. On 09/20/2024, the Department received a complaint regarding the following allegation, Facility staff are withholding mail from resident(s). LPM and LPA toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Report Continued on LIC9099C... Unsubstantiated Report Continued from LIC9099.. On the allegation Facility staff are withholding mail from resident(s), it is the concern of the reporting party (RP) that Staff 1 (S1) is withholding mail from Resident #1 (R1). To investigate this complaint, LPM and LPA requested pertinent documents to the investigation. The LPM and LPA also conducted interviews with the Administrator, three staff members, and seven residents, including R1 between 10:12am to 11:30am. Interviews with residents revealed that no other resident other than R1 had an issue with receiving mail. Residents stated they receive mail from staff in a timely manner and had no concerns regarding mail. Residents state that the only person they are aware of having any issues with mail is R1. Interviews with staff revealed that mail is passed out regularly and no resident, other than R1 has concerns receiving mail. During the interview with S1, S1 stated that mail is not withheld from any resident including R1. Staff interviews support that mail is monitored and passed out by staff regularly without any concerns of mail being withheld. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Facility staff are withholding mail from resident(s) is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 29-AS-20240920151349

Type of visit: Case Management - Deficiencies

At approximately 9:55am Licensing Program Manager (LPM) KaSandra Lopez, and Licensing Program Analyst (LPA) Erica Mosley conducted a Case Management - Deficiencies visit due to a deficiency observed during complaint investigation of complaint control number 29-AS-20240920151349. The LPM and LPA advised the Administrator Clarizze Punit the reason for the inspection. During the physical plant tour that started at 9:57am the LPA and LPM observed two (2) carts with cleaning supplies including Ajax with bleach, WD40, among other cleaning supplies on both carts that were unattended. It was also observed that the at 10:06 am the laundry room was unlocked with laundry detergent and bleach that were accessible to residents in care. Administrator was informed of the immediate health and safety hazard and was asked to ensure the door is locked at all times and that the carts were relocated to a locked location inaccessible to residents in care. This citation is a repeat violation of the same deficiency cited on June 25, 2024. Therefore, civil penalties will be assessed. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Sep 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 11, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by: Based on observation the licensee did not comply with the section cited above in two carts with cleaning supplies were left unattended and the laundry room was unlocked with laundry detergent and bleach which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 27, 2024

Plan of correction: Administrator secured the carts and locked the laundry room immediately during the visit. Administrator agrees to provide training to all staff regarding the regulation and submit proof by plan of correction date 10/11/2024.

Allegation investigated: Financial abuse. Staff have not ensured resident's dwelling lock/key operate properly.

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with Administrator Clarizze Punit and explained the reason for today's visit. On 06/08/2023, the Department received a complaint alleging “financial abuse” and that “Staff have not ensured resident’s (R1) dwelling lock/key operate properly”. It was alleged that R1 was confronted by administration staff and a rent bill for $15,820.98 was presented to R1 for the period from 9/8/2021-6/8/2023. On 06/13/2023, LPA Angel A. conducted staff and resident interviews beginning at 1:00 p.m., conducted a facility tour starting at 01:20 p.m. and obtained pertinent document. LPA Angel A. conducted a subsequent visit on 08/08/2023. During this subsequent visit from approximately 12:45pm – 3:25pm, LPA reviewed additional records, met with staff and residents including R1. The interviews conducted did not reveal any financial abuse or room maintenance. (Continue to Lic9099c) Unsubstantiated On 7/23/2024 at approximately 2:45p.m., LPA Chochian conducted a collateral visit to interview R1. R1 did not state being a victim of financial abuse or having any other issues while residing at the Four Season Assisted Living facility. R1 expressed wanting to go back to Four Seasons Assisted Living. R1 declined to answer any further questions and was very agitated. LPA spoke with two Social Workers and the current attending Licensed Vocation Nurse (LVN) from the Woodland Center regarding R1. Social Workers and attending LVN report that R1 is very aggressive and agitated most of the time therefore it is very hard to communicate with R1. LPA asked if R1 ever reported any financial abuse or any other issues to them about this facility and both Social Workers and attending LVN confirmed that R1 did not make any complaints to them about this facility. LPA Chochian made a subsequent complaint visit to this facility today and met with facility Administrator and Ulka Sanghavi, Social Service staff. LPA discussed the financial abuse allegation and concerns. Between approximately 12:30pm-1:45pm, LPA toured facility conducted interview with (8) random residents. Regarding “financial abuse” allegation – Interview conducted with R1, facility staff, and other potential witnesses did not reveal/confirm that R1 was a victim of financial abuse at this facility. Interviews revealed that R1 did not pay the facility rent since 10/2021 and statements were provided to R1 at the facility and mailed to mailing address on file. R1 refused to provide any information to LPA. Potential witness interviewed reported that facility provided R1 a statement with a balance statement for 15,820.98 on 4/1/2023 and prior to this date R1 was never told or provided a invoice/statement balance from facility. According to Administrator and facility Social Service staff, R1 was aware of the balance since no payment was made from 10/2021. Rent statements were provided by Administrator showing non-payment of rent since 10/2021 during today’s visit. No other residents reported any type of financial abuse. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Financial abuse” is deemed UNSUBSTANTIATED at this time. Regarding allegation “Staff have not ensured resident's dwelling lock/key operate properly” – Interview conducted with R1, facility staff and other potential witnesses did not confirm/validate this allegation. R1 was asked about this allegation and R1 refused to answer any further questions and expressed wanting to return to this facility. (Continue to 9099c). Eight (8) random residents interviewed during today’s visit validated that their room door lock/key function properly. Staff interviewed reported that if there are any maintenance issues special with a resident’s lock/key for the room it is replaced immediately. Staff reported that R1 never reported that there was an issue with the room lock/key. Staff stated that they were made aware by a visiting nurse on 3/15/2024 that R1 needs a new key which was provided to R1 that same day. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Staff have not ensured resident’s dwelling lock/key operate properly” is deemed UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 29, 2024 · control 29-AS-20230608083803

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required Annual visit. The LPA met with Administrator Clarizze Punit and explained the reason for the visit. At 2:39 p.m. the LPA toured the physical plant areas inside and outside, with the administrator to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms were observed to be single and double occupancy. At 2:41 p.m. the LPA observed a whole in the residents restroom door in room #101. At 2:45 p.m. the LPA observed two (2) clorox wipes bottles, one (1) Lysol can, one (1) Arnica Roll, (1) simply saline nasal mist bottle in room #103. At 3:00 p.m. the LPA observed one (1) Resolve Pet expert stain and color remover, one (1) container of Kaboom oxiclean, one (1) Miralax bottle, one (1) container of Tide Pods, one (1) container of fabric softener, one (1) bottle of prescribed Nystatin 100,000 unit/GM powder, and one (1) kitchen knife in room #105. At 3:22 p.m. the LPA observed a whole in the wall in room #226. At 3:28 p.m. the LPA observed one (1) bottle of Tide free and gente detergent, and dust and stains on the floor in room #228. At 3:30 p.m. the LPA observed one (1) bottle of Raid Ant &Roach, one (1) bottle of Pepto-Bismol, one (1) bottle of Lysol, and the drawer of the residents dresser falling, in room #227. All bedrooms that were observed were unlocked. The flooring was checked for cleanliness and carpet in bedrooms appeared stained in most bedrooms. RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Restroom hot water were measured in resident restrooms between 112.6 and 116.4 degrees Fahrenheit between 02:44 p.m. and 3:20 p.m. Report will continue on LIC 809 - C. KITCHEN: At 2:50 p.m. the LPA observed the kitchen/dining area. Knives are stored inaccessible to the residents in care. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. The facility has a pre-set menu however offers the option for residents to choose from a variety of different options if menu choices are not to their taste. COMMON and OUTDOOR AREAS: At 3:34 p.m. the LPA observed stains throughout the carpet in the hallway on the second floor and a rip measuring at 5 feet. At 3: 36 p.m. the LPA observed a floor tile inside the elevator broken measuring at 14 inches by 10 inches. The LPA observed the outdoor area. A small patio area is adjacent to the building and is accessible to residents. A shaded area with furniture is accessible to visitors and residents to visit. he common areas included a front lobby area, downstairs entertainment area and upstairs activity room. All areas were accessible for resident use with appropriate furnishings. The LPA observed cameras in all common spaces. Smoke detectors are hardwired and interconnected, at approximately 3:40 p.m. the smoke detectors were tested and operable. The LPA observed fire extinguishers fully charged and last serviced on 05/05/2024. INTERVIEWS: The LPA conducted three (3) resident interviews. No immediate concerns were voiced during the visit. Due to a time constraint, the LPA will return at a later date to complete the annual. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties Exit interview conducted and copy of the report was ssued.the state’s words, verbatim · CDSS document, Jun 25, 2024

Allegation investigated: Staff are not following physician’s orders.

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced initial complaint investigation for the above allegation. Upon arrival, LPA with the Administrator, Clarizze Punit and the reason for the visit was explained. Entrance interview. During today’s visit, LPA toured the facility to ensure there are no health or safety concerns at 10:30 a.m., conducted interviews with the Administrator and one staff between 10:23 a.m. and 10:57 a.m., conducted a resident file review at 11:05 a.m., and obtained copies of pertinent documents relevant to the investigation. It was alleged that staff are not following physician’s order. It was reported that Resident #1 (R1) is to receive Hydrocodone – Acetaminophen (Norco) every eight (8) hours and as needed, but facility staff is only providing Norco to R1 every other day. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... Information obtained and records reviewed revealed that per R1’s physician’s report dated 09/14/2021, R1 is able to follow instructions and is able to communicate their needs. Additionally, the LPA reviewed physician orders dated 12/12/2023 and 03/14/2024, which indicated R1 was prescribed Norco 5-325mg, one (1) tablet every eight (8) hours as needed for severe pain. The LPA reviewed the Narcotic Medication Record starting on 12/13/2023 and noted that R1 was given Norco for pain consistently from 12/13/2023 to 03/23/2024 in the mornings upon waking up; and more recently noted R1 was also given Norco in the evenings on 03/15/2024, 03/17/2024, 03/19/2024, and 03/23/2024. Interviews conducted with staff revealed that R1 would request Norco upon waking up due to pain and added that they would offer R1 Norco in the evenings when R1 appeared to be in pain but was not communicating symptoms with staff. Staff also added that R1 would request more Norco shortly after receiving it; however, they are required to follow the physicians order which stated, “one orally every 8 hours as needed for severe pain… Do not exceed 3 tablets in 24 hours”. Furthermore, Norco was prescribed to R1 as a PRN to take once every eight (8) hours as needed for pain and not every eight (8) hours and as needed. Based on the information obtained and reviewed, there is insufficient evidence to support the allegation of “staff are not following physician’s order”. Therefore, this allegation is being deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. Copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 29-AS-20240328080922

Allegation investigated: Resident not accorded dignity in relationships with staff. Resident not free from intimidation and/or other actions of a punitive nature.

Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent visit to this facility today to deliver findings. At 11:25 a.m., the LPA met with and explained staff, Ulka Sawghavi reason for the visit. At 12:45 p.m., the Administrator, Clarizze Punit arrived at the facility. During the initial visit on 01/11/2022 between 10:15 a.m. and 12:00 p.m., LPA Salia Walker conducted an interview with one (1) staff and the Administrator at the time, Melissa Christopher. On 01/11/2022, LPA Walker also reviewed and obtained copies of pertinent documents. On 04/01/2022, LPA Walker conducted a subsequent visit between 9:30 a.m. and 3:30 p.m. and during the subsequent visit, LPA Walker conducted a physical plant tour, interviewed residents and facility staff. During today’s visit on 03/07/2024, starting at 11:39 a.m., LPA Peraldi along with the staff conducted a physical plant tour. During todays visit, between 11:40 a.m. and 12:16 p.m., LPA Peraldi conducted interviews with seven (7) out of twenty nine (29) residents and three (3) staff. On 03/07/2024, at 12:46 p.m., the LPA conducted an interview with the Administrator, Clarizze Punit. Continued on LIC 9099-C. Unsubstantiated Regarding the allegations: Resident not accorded dignity in relationships with staff. It was alleged that Staff #1 (S1) was being disrespectful to Resident #1 (R1). Resident not free from intimidation and/or other actions of a punitive nature. It was alleged that S1 intimidated R1 and threaten to evict R1. Per record review, on January 2, 2022, R1 and S1 had a verbal altercation where R1 believed that S1 called R1 a “bitch” and R1 became aggressive towards S1. According to internal notes from the facility, S1 told R1 that R1 has been “aggressive and unwelcoming to new residents by constantly shouting and embarrassing them at lunch time and that it would be best to have better manners in the community to avoid an eviction.” During the course of the investigation, it was revealed that S1 does not work at the facility anymore. Resident interviews revealed that residents don’t have a problem with any staff members at the facility. Interviews with multiple residents revealed that staff treat residents with respect and dignity. Furthermore, interviews with multiple residents did not reveal any concerns regarding resident feeling intimidated by staff. Resident interviews revealed that residents feel safe at the facility. Interviews with the Administrator and various staff revealed that there have not been any recent issues between staff and residents. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. 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 deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 29-AS-20220103090532