Glen Park at Monrovia

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit. LPA met with Executive Director Pam Ogot and LPA explained the purpose of the visit. Executive Director helped assist the LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (40) residents in the facility who are 60 years and older, of which no residents are bedridden and two (2) are receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place. Surety bond is in place. Fire drill was last conducted on 02/20/2026. Disaster drill was last conducted on 02/20/2026. Physical Plant/Environment Safety: LPA along with Executive Director toured the facility. The facility is a 2-story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices, Physical Plant/Environment Safety [Cont.]: Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. LPA toured random rooms and observed each bedroom to contain the required furniture and linens. Extra linens and towels are in the storage room Each residents' room has their own restroom. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in six (6) random resident rooms (Rooms #1, #7, #9, #207, #211, #215) in the first & second floors and the water temperature readings were from 109.5 degrees F to 113.5 degrees F which were within the required 105 - 120 degrees Fahrenheit. LPA observed call signals in six (6) random resident rooms and were working properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. Two (2) Carbon Monoxide detectors were tested and are operable. LPA observed five (5) fire extinguishers throughout the facility and are fully charged and last inspected on 01/29/2026. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices are in place. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Staffing: A total of (34) staff members provide care and supervision to the residents, including the Executive Director. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records-Training: LPA reviewed six (6) staff files which include Job Application, health screening, TB clearance, medication management training, Employee Rights, food handling certificates, and 1st Aid/CPR/AED training. Executive Director's Administrator’s Certificate expires on 09/15/2026. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the lobby by the main entrance. The facility provides internet service to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Per Executive Director, there are no residents with a modified diet. LPA observed unlabeled food containers in the freezer and refrigerator. Incident Medical and Dental: Medications are centrally stored and properly labeled in their original containers or bubble packs. First aid kits are maintained in the medication room and in the front office. LPA reviewed five (5) residents medications in the medication room with no issues observed. Medical and dental transportation is provided. Resident Records/Incident Reports: LPA reviewed five (5) resident files that include Identification and Emergency Information Form, Admission Agreements, Physician's Reports, Pre-Placement Appraisal, TB clearance, Ambulatory Status, Functional Capability Assessment, Physician's Orders, Personal Rights, Appraisal Needs and Services Plan. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Facility provides training on staff's responsibilities during an emergency or disaster. Residents with Special Health Needs: Per Executive Director, (38) residents are receiving home health services, two (2) residents are under hospice care and no residents are bedridden. Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed half bed rails for mobility assistance in some resident beds. Physician orders for bed rails are in file. There are no residents with prohibited health conditions. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was provided to the Executive Director, Pamela Ogot.the state’s words, verbatim · CDSS document, Mar 19, 2026

Allegation investigated: Staff did not follow a physician's instruction resulting in a resident falling and sustaining a fracture. Staff refused to accept a resident back into the facility.

Staff did not follow a physician's instruction resulting in a resident falling and sustaining a fracture. Staff refused to accept a resident back into the facility. Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in response to the above-mentioned allegations. LPA met with Residential Care Specialist, Leonard Wynne and explained the reason for the visit. On 11/13/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA conducted a tour of facility and common areas with the Assistant Administrator. LPA also requested copies from Resident#1 (R1’s) file such as the Face Sheet, Physician’s Report, Admissions Agreement, and other pertinent documents. [Continue in LIC9099-C] Unsubstantiated Assistant Administrator will send remaining pertinent documents by COB. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. On 12/11/2025, a subsequent investigation visit was conducted. The investigation consisted of the following: LPA obtained the following documents: staff and resident rosters, R1’s Physician’s Orders and Hospital Discharge Notes. LPA interviewed the Executive Director, Assisted Administrator, Staff #1 (S1) to Staff #4 (S4), Resident #2 (R2) to Resident #6 (R6). LPA obtained Staff In-Service documents. During today's visit, LPA obtained the following documents: staff and resident rosters. LPA interviewed the Executive Director over the phone. The investigation revealed the following: in regard to the allegation, “Staff did not follow a physician's instruction resulting in a resident falling and sustaining a fracture.” It is alleged that on March 23, 2025, R1 fell and was sent to the Hospital and was diagnosed with a fractured wrist. This allegation was investigated by the Investigation Bureau (IB) and was assigned to Investigator Salant. LPA reviewed IB interviews which revealed the following: While R1 had a history of falls, there were no doctors’ orders requiring R1 to have bed rails on R1’s bed, be on a 1:1 supervisor, or any type of special orders for fall prevention. The staff acted timely and within the guidelines of their training in response to R1’s last fall, which ultimately led R1 to being hospitalized. In addition, staff followed the directions that were current, to the best of their knowledge, and at the time R1 fell, investigator Salant did not feel there was anything that could have been done differently that would have produced a different outcome. There is not enough evidence to substantiate. Allegation: “Staff refused to accept a resident back into the facility.” It is alleged that when R1 was ready to be discharged from the hospital, the facility would not take R1 back and R1 was forced to go to a rehabilitation center and not allowed to return to the facility. LPA interviewed two (2) out of five (5) residents that denied the allegation stating that when the resident was hospitalized and to be discharged from the hospital, the staff checked the resident to make sure the resident was able to return back to the facility. LPA interviewed three (3) out of five (5) residents that could not confirm nor deny the allegation stating they could not remember if they were ever refused to return from the facility. [Continue in LIC9099-C] LPA interviewed the Executive Director, Assistant Administrator, and one (1) out of four (4) staff that denied the allegation stating that when residents are hospitalized, the staff visits the resident at the hospital prior to assessing and determining if the resident needs higher level of care, rehabilitation, or return back to the facility. Three (3) out of four (4) staff could not corroborate nor deny the allegation since they all stated they are not involved in the acceptance of residents after being discharged from the hospital. The Executive Director and Assistant Administrator stated that on 03/23/2025, R1 was admitted to the hospital on 03/23/2025 and was discharged from the hospital on 03/24/2025 and transferred to the rehab center because R1 had to have rehab for the fractured wrist and provided physical therapy at a SNF prior to return to the facility. LPA obtained and reviewed Hospital Discharge Notes dated 03/24/2025 which indicated based on R1 is stable for discharge to skilled nursing facility (SNF) for further OT/PT. Per interview with the Executive Director, facility’s intention was to accept R1 back to the facility after the rehab is completed. Executive Director also stated that the facility did not refuse to accept R1 back to the facility since the Executive Director visited R1 at the SNF to assess R1 on 04/03/2025 to determine the status if R1 is clear to return back to the facility or require more rehabilitation. However, the facility was not able to assess R1 since R1 passed away on 04/03/2025 prior to being re-assed by the Executive Director. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Residential Care Specialist, Leonard Wynne.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 28-AS-20251110150841

Allegation investigated: Staff caused an injury to a resident in care.

Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in response to the above-mentioned allegations. LPA met with Martha Rosas, Assistant Administrator and explained the reason for the visit. Executive Director, Pamela Ogot arrived shortly after and the LPA explained the purpose of the visit. On 11/13/2025, the initial investigation visit was conducted. The investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA conducted a tour of facility and common areas with the Assistant Administrator. LPA also requested copies from Resident#1 (R1’s) file such as the Face Sheet, Physician’s Report, Admissions Agreement, and other pertinent documents. Assistant Administrator will send remaining pertinent documents by COB. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. Unsubstantiated During today's visit, LPA obtained the following documents: staff and resident rosters, R1’s Physician’s Orders and Hospital Discharge Notes. LPA interviewed the Executive Director, Assisted Administrator, Staff #1 (S1) to Staff #4 (S4), Resident #2 (R2) to Resident #6 (R6). LPA obtained Staff In-Service documents. The investigation revealed the following: in regard to the allegation, "Staff caused an injury to a resident in care." It is alleged that on 01/08/2025, R1 fell and sustained a purplish bruise on R1’s face. It is also alleged that on 03/23/2025, R1 suffered another fall and was hospitalized. LPA interviewed five (5) out of five (5) residents that denied the allegation stating that they were not injured caused by staff and did not witness any residents injured caused by staff. Four (4) out of five (5) residents also stated that they feel safe. One (1) out of five (5) residents stated feeling safe but the staff are not friendly. Four (4) out of five (5) residents stated that the staff treat them good and are well cared for. LPA interviewed Executive Director, Assistant Administrator, and four (4) out of four (4) staff that denied the allegation and stated that staff have not caused any injury to residents and have not witnessed any staff injure any residents. Executive Director, Assistant Administrator, and four (4) out of four (4) staff also stated that staff follow protocol of care for a resident by on-duty staff reporting the fall immediately to the facility LVN to assess the resident’s range of motion and contact 911 and non-emergency paramedic for the resident to be transferred to the ER. Executive Director and Assistant Administrator stated that when R1 fell on 01/08/2025 and 03/23/2025, the staff responded immediately by the staff assessing R1 and since it was an unwitnessed fall, staff contacted the paramedics and R1 was sent to the ER for further evaluation. LPA reviewed Staff In-Service training on resident fall protocols dated 08/01/2025, Personal Rights dated 05/27/2025, Meeting the Resident’s Personal Needs dated 04/29/2025, and Elder Abuse Training dated 01/06/2025. There is not enough evidence to substantiate. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Executive Director, Pamela Ogot.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 28-AS-20251110150841

Allegation investigated: Licensee does not ensure staff are appropriately trained to assist residents who have fallen.

Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10-day complaint visit in regards to the allegation listed above. LPAs explained the purpose of the visit to Martha Rosas, Assistant Administrator for the facility, and the LPA was granted entrance. Executive Director, Pamela Ogot arrived shortly after and the LPA explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters, Unusual Incident/Injury Reports, Facility’s Fall prevention policies, and staff training documents regarding falls. LPA toured the facility's common areas. LPA interviewed the Executive Director, Assistant Administrator, Staff #1 (S1) - Staff #4 (S4) and Resident #1 (R1) - Resident #5 (R5). The investigation revealed the following: in regards to the allegation “Licensee does not ensure staff are appropriately trained to assist residents who have fallen.” It is alleged that when residents have fallen out of their wheelchair or out of bed, they just need help getting back up instead, the staff called 9-1-1. Substantiated Five (5) out of five (5) residents interviewed feel safe at the facility. The Executive Director, Assistant Administrator, four (4) out of four (4) staff interviewed denied the allegations stating that the facility’s policy regarding falls is contacting 9-1-1 if the resident has a unwitnessed fall or has Dementia. However, based on record review, facility’s Fall Policy states that if the resident is severely hurt or severe pain, call 9-1-1. Based on record review, Special Incident Report dated 7/27/2025, 7/20/2025, and 7/13/2025, the facility called 9-1-1 due to a fall. These SIRs were missing the facility care staff conduct an assessment checking for visible injuries or severity of pain prior to contacting 9-1-1. The residents had no injuries noted. Based on record review, staff’s most recent documented in-service on fall prevention was conducted on 03/26/2025. However, based on staff interview, the Assistant Administrator and one (1) of the staff interviewed admitted that there was a recent staff in-service held on 07/26/2025, regarding an updated Fall Policy that indicates the facility hiring a Licensed Vocational Nurse that would help determine if the resident’s fall is a medical emergency in which the facility was unable to provide documentation of that in-service. Therefore, there was sufficient supportive evidence to concur with the reported allegation. Based on LPA's interviews conducted with the residents and staff, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099D. An exit interview was held with the Executive Director, Pamela Ogot, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 28-AS-20250725115853

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(6) · Plan of correction due date: Aug 15, 2025

a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties. This evidence has not been met as required by: Based on record review and staff interview, the facility is not following the Plan of Operations regarding the fall policy and procedures, the staff called 9-1-1 without doing an assessment to check for severity of pain and injuries.the state’s words, verbatim · CDSS document, Aug 1, 2025

Plan of correction: Executive Director will submited updated Fall policy and procedures and conduct a staff training and send staff training agenda and sign-up sheet to the LPA by the POC due date.

Allegation investigated: Staff did not keep the facility free from infestation.

Licensing Program Analysts (LPAs) Daniel Konishi and Gabriela Castro conducted a initial 10-day complaint visit in regards to the allegation listed above. LPAs explained the purpose of the visit to Martha Rosas, Assistant Administrator for the facility, and was granted entrance. Executive Director, Pamela Ogot arrived shortly after and was explained the purpose of the visit. The investigation consisted of the following: LPAs obtained resident and staff roster, Purchases of Service Dewey Pest Control Quality Assurance Reports for March 21, 2025, April 22, 2025, May 19, 2025, June 18, 2025, and June 30, 2025. LPAs interviewed Residents #1 (R1) to Resident #5 (R5), Assistant Administrator, Staff#1 (S1) to Staff #4 (S4), and also the Pest Control company representative. In regards to the allegation that "Staff did not keep the facility free from infestation", it is alleged that there are bed bugs and cockroaches in the facility. Four (4) out of five (5) residents interviewed stated that there were cockroaches found in the bedroom, hallways, and dining hall in the past. Unsubstantiated However, when the residents reported this to staff, the housekeeping and maintenance staff immediately treated the bedroom, hallways, and dining hall. Five (5) out of five (5) staff interviewed denied the allegation. Assistant Administrator interviewed stated that the facility contacted their pest control company to inspect the rooms for bedbugs and cockroaches, after which no bedbugs or cockroaches were found. Assistant Administrator also stated that the pest control company visits the facility. Based on record review, Dewey Pest Control, Quality Assurance Reports dated March 21, 2025, April 22nd, 2025, May 19, 2025, June 18, 2025, and June 30, 2025, that LPAs observed no pest issues verified on the reports. One (1) out of five (5) staff interviewed stated that whenever a bed bug is found in the bedroom, the facility would immediately replace the bed mattress, linens, sheets, blankets, pillows and other bed furnishings. Pest control company representative stated that there have no bedbugs observed in the facility and only cockroaches around a facility drain. During the facility tour, LPAs observed two small ants in one of the kitchen cabinets but did not observe any cockroaches or bedbugs in the kitchen, dining hall, activity room, four residents’ bedrooms at the first floor, and the four residents’ bedrooms at the second floor. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported 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 UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Executive Director, Pamela Ogot.the state’s words, verbatim · CDSS document, Jun 30, 2025 · control 28-AS-20250623135323

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA met with Asst. Administrator Martha Rosas and explained the purpose of the visit. Afterwards, Executive Director Pam Ogot arrived and assisted LPA with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. Currently, there are (45) residents in the facility who are 60 years and older, of which (1) is bedridden and (4) are receiving hospice care. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has an Infection Control Plan. Staff are adhering to infection control requirements. Emergency and disaster plan was completed and up to date. Infection control practices and Personal Protective Equipment (PPEs) were maintained. Operational Requirements: The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance is in place. Surety bond in the amount of $10,000.00 is current. Fire drill was last conducted on 03/20/2025. Physical Plant/Environment Safety: At 10:15am, LPA along with Asst. Administrator toured the facility. The facility is a 2 story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices, Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. Each residents' room has their own restroom. In some of the observed bathrooms, there were no grab bars and non-skid mats. The exit points of the building, including the residents' living units, had no signal systems. Cleaning supplies and toxic substances are inaccessible to residents. At 10:30am, LPA tested hot water temperature in six (6) random resident rooms (Rooms #5, #6, #9, #209, #212, #216) in the first & second floors and the water temperature readings were below the required 105 - 120 degrees Fahrenheit. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operational and compliant. The fire extinguishers were observed throughout the facility and are fully charged. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices in place. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. *****CONTINUED ON LIC809-C***** Staffing: A total of (32) staff members provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate expired on 09/15/2024, and renewal is still pending. Personnel Records-Training: LPA reviewed (6) staff files. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Resident Rights-Information: Resident personal rights, complaint hot line information and visitors policy posters are posted in the lobby by the main entrance. The facility provides internet service to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. LPA observed unlabeled food containers in the freezer and refrigerator. Incident Medical and Dental:. Medications are centrally stored and properly labeled in their original containers or bubble packs. First aid kits are maintained in the medication room and in the front office. LPA reviewed multiple residents medications in the medication room with no issues observed. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I Money Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Facility provides training on staff's responsibilities during an emergency or disaster. Residents with Special Health Needs: (5) residents are receiving home health services. (4) residents are under hospice care and (1) is bedridden. Facility admits residents with dementia and staff files reviewed today all have required training documented. LPA observed half bed rails for mobility assistance in some resident beds. Physician orders for postural support are on file. There are no residents with prohibited health conditions. Residents who are using oxygen have "No smoking In Use" signs posted on the residents doors. Pursuant to California Code of Regulations, Title 22, deficiencies were cited on the attached 809-D and Technical Violation, Technical Assistance were issued. Exit interview conducted and a copy of the report was provided to Pamela Ogot, Executive Director and Martha Rosas, Assistant Administrator.the state’s words, verbatim · CDSS document, Apr 22, 2025

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure adequate supervision was provided, resulting in a resident being injured.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Pamela Ogot, Executive Director and Martha Rosas, Assistant Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters, Resident #1 (R1) files such as: Identification and Emergency Information (Face sheet), Admission Agreement, Physician's Report, Preplacement Appraisal, Personal Rights, Resident Appraisal, Hospital Release Records, Unusual Incident/Injury Reports (10/28/2024) related to the incident and Police report (24-0197771). LPA toured the facility's common areas including R1-R3's rooms and interviewed Staff #1 (S1) - Staff #6 (S6) and Resident #1 (R1) - Resident #7 (R7). The investigation revealed the following: In regards to the allegation: “Staff did not ensure adequate supervision was provided, resulting in a resident being injured.” It is alleged that on 10/27/2024 at around 2 AM, 2 staff were both on a break at the same time when R1 sustained injuries because he had wandered into another residents room and was struck with a cane by the resident during the altercation.***REPORT CONTINUED ON LIC9099-C***. Unsubstantiated 6 out of 6 staff members interviewed denied the allegation. Staff interviewed stated that they care and monitor the residents closely. S3-S4 stated that at approximately 2am on the evening of 10/27/2024, they had just finished doing their rounds, which they do every 2 hours or less. S3 decided to take a break while S4 remained on the floor. Suddenly, S3-S4 heard someone screaming for help and they immediately rushed to the room to respond. Upon entering the room, they found R1 standing up with a bleeding wound. S3 called 911 right away and paramedics came, administered aid and transported R1 to the nearest hospital. Shortly after, the police came to investigate and no arrests were made. R1 does not have a one-on-one caregiver and had wandered into R2-R3's room which startled them. In a state of confusion and self defense, R2 started hitting R1 with a cane and R3 was frozen with fear and unable to move. 4 out of the 7 residents interviewed indicated they were not aware of this incident. Residents interviewed indicated that they feel there is sufficient staff to provide adequate supervision and monitoring to meet their needs. Residents interviewed indicated they feel safe and comfortable at this facility. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report was provided to the Executive Director, Pamela Ogot.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 28-AS-20241118093118

Allegation investigated: Staff administers medications to resident without prior consent. Staff do not administer medications to residents as needed. Staff handles residents in a rough manner. Staff do not respond to resident's call light in a timely manner. Staff does not treat resident with dignity or respect.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. Upon arrival LPA met with Martha Rosas, Assistant Administrator and explained the purpose of the visit. At 11:35 am, Pamela Ogot, Adminstrator arrived and assisted LPA with the investigation. During today’s visit, LPA toured the facility’s common areas and inspected random rooms to check call lights in Room # 4 and Room #8. LPA obtained resident & staff roster, Unusual Incident/Injury Reports (SIRs) involving Resident #1 (R1)-Resident #2 (R2) and Resident #7 (R7) (March 2024-July 2024), Staff in-service training logs on Residents' Rights (March 2024) and Medication (June 2023-Nov 2023), Residents Incontinent Tracking (June-July 2024). LPA also reviewed and obtained Resident #1 (R1)-Resident #2 (R2) and Resident #7 (R7) records and files such as Face Sheets, Admission Agreements, Physician's Reports, Needs and Services Plans and Medication Administration Records (MARs) for June 2024-July 2024. LPA interviewed Resident #1 (R1) – Resident #6 (R6), Staff #1 (S1)-Staff #3 (S3) in person, Staff #4 (S4) - Staff #7 (S7) telephonically. Resident #7 (R7) has moved out of the facility, therefore not interviewed. ******CONTINUED ON LIC9099-C***** Unsubstantiated In regards to allegation: Staff do not respond to resident's call light in a timely manner. It is alleged that staff members do not respond to residents call light because they are chit chatting with other resident. Staff interviewed indicated that call lights are in operational condition. Staff stated that residents press the call light if they need help. The receptionist gets the call and then page for attention and help from caregivers on the floor. S6-S7 denied the allegation and stated that the allegation never happened. Staff stated that they always respond to the call light and if they are busy attending to other residents, they would inform the front desk or ask another staff member's help to attend to the call. Staff also indicated that they respond to call lights in less than (5) minutes. LPA toured Resident rooms #4 and #8 and tested the call lights in which staff responded to in less than (1) minute. Residents interviewed indicated that they have not had any issues with the call lights. Residents indicated that when they need assistance, they activate the call button and that staff arrive promptly. Staff and Resident interviews were unable to corroborate this allegation. In regards to allegation: Staff does not treat resident with dignity or respect. It is alleged that staff are not applying cream when changing a resident who is incontinent and has skin issue. Staff interviewed stated that they have not observed any resident being treated disrespectfully. Staff interviewed stated that residents are monitored and checked consistently, either every 2 hours or as needed. S2 stated that R7 had the staff's full attention and she was being monitored a lot. Staff indicated that they apply the cream to R7 and other incontinent residents as required. Staff also indicated that Home Health comes to the facility to monitor, check and manage R7's condition. Medication Administration Record (MAR) for R7 was reviewed and showed that cream was applied consistently, 3x a day as prescribed. Interviews conducted with residents indicated that staff members treat them with dignity and respect. Residents stated that they feel safe and comfortable in the facility. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported 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 UNSUBSTANTIATED. Exit interview, a copy of this report was provided to Pamela Ogot, Administrator. The investigation revealed the following: In regards to allegation: Staff administers medications to resident without prior consent. It is alleged that a staff gives a resident sleeping medication without the family member’s consent. (7) out of (7) staff interviewed denied the allegation. Staff stated that they only administer medications based on Physician's orders and document it on Medication Administration Record (MAR). Staff indicated that they never administer medication without the residents' consent. Staff also stated stated that medications including PRNs are prescribed and approved by the residents’ doctor and discussed with the family and the resident before being finalized. (6) out of (6) residents interviewed denied the allegation and reported that it never happened on them and never heard that happened in the facility too. Residents interviewed stated that they know what medications they are taking and have not heard or seen staff give them or others any medications that are not prescribed by their doctors. Therefore there was insufficient evidence to corroborate with this allegation. In regards to allegation: Staff do not administer medications to residents as needed. It is alleged that a staff will not administer the resident’s medication as requested. (7) out of (7) staff interviewed denied the allegation. Staff stated that if a resident ask them to apply cream, then they do it. Staff indicated that there are some creams that only Med Techs can apply because it is a prescribed medication. Staff stated that they follow what the doctors orders on medication for all residents. Residents interviewed do not corroborate the allegation. Residents stated that staff are nice and assist them when they ask. (4) out of (6) residents interviewed are incontinent and stated that the staff apply the cream on them whenever they get cleaned/changed. Some residents stated that they never experience a staff deny applying cream on them if they ask. Therefore there was insufficient evidence to corroborate with this allegation. In regards to allegation: Staff handles residents in a rough manner. It is alleged that a staff handles a resident in a rough manner when showering. Staff interviewed stated that they have not heard or witnessed any staff handled resident in a rough manner. Staff stated that they receive training on Residents rights on a regular basis and facility has zero tolerance policy on abuse. S1-S2 stated that they never received any report concerning any staff handling residents in a rough manner. S5 denied ever treating any resident aggressively nor handling any resident in a rough manner. R2 stated that he thought he was pushed by S5 in the shower chair but was not sure if S5 was playing with him or was serious. (5) out of (6) residents interviewed denied the allegation and indicated that they are satisfied with the services and do not have any concerns. Residents interviewed stated that staff are helpful and assist them whenever they asked. Some residents stated that they were never treated aggressively by any staff. Therefore there was insufficient evidence to corroborate with this allegation.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 28-AS-20240702104018

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20240702104018). The purpose of this visit is to issue deficiency that was observed by LPA that is not part of the complaint allegations. During this visit LPA observed that the medication administration record (MAR) for Resident #7 (R7) for July 2024 was documented improperly. Based on the incident report (SIR) reported on 7/02/2024, R7 became unresponsive while a family member was visiting and was sent to the hospital. R7 was since transferred to a different facility due to the need for a higher level of care. However, LPA observed that on July 2024 MAR, it showed that the medications were administered and signed by the staff from July 2-8, 2024 when R7 was away from the facility. Staff admitted to the mistake and corrected the MAR immediately. Deficiency is noted on LIC 809D. Exit interview conducted and a copy of this report was provided to Pamela Ogot, Administrator.the state’s words, verbatim · CDSS document, Jul 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 16, 2024

87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff... This requirement is not met as evidenced by: Based on interviews and review of documentation, R7's Medication Administration Record (MAR) for July 2024 is inaccurate. Staff initialed the medication log from July 2-8 2024 when R7 was hospitalized and has already left the facility which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR). Administrator to re-train staff on medication management and documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by the POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPAs were met by Asst. Administrator Martha Rosas and explained the purpose of the visit. At 10:40am, Administrator, Pam Ogot arrived and assisted LPAs with the inspection. Facility is licensed for 45 non-ambulatory, maximum of (8) hospice residents and (4) bedridden residents ages 60 and over. There are currently (46) residents, 60 years and older residing in the facility, no bedridden and (1) under hospice care. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance lobby. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. Facility accepts and retains residents with dementia. Approved Dementia Care Plan is in their plan of operation. There is no separate memory care unit inside the facility. Facility is approved for (8) hospice residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 12/05/2024. Surety bond in the amount of $10,000.00 is current. Fire drill was last conducted on 03/27/2024. Physical Plant/Environment Safety: The facility is a 2 story building located in a residential community. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Lobby, Administrative offices, Medication room, Laundry room, (1) Elevator, Large Dining area, Kitchen, Pantry, Activity room/patio, Storage room, Patio by the main entrance, and resident rooms. Second floor: Resident bedrooms, Beauty shop, Activity room and a community shower. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility is equipped with cameras in the common areas. Each residents' room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars and non skid mats. The resident rooms have signal systems and were operable. Cleaning supplies and toxic substances are inaccessible to residents. At 10:50am, LPAs toured and tested hot water temperature in eight (8) random resident rooms (Rooms #3, #4, #7, #8, 207, #209, #210, #215) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. Fire extinguishers were observed throughout the facility and were fully charged, last serviced on 04/05/2024. The carbon monoxide detectors are operable and in compliance. Smoke detectors were observed and tested throughout the facility and were operable. Pull Fire alarm system observed and connected to the City of Monrovia Fire Department. Delayed egress devices in place. *****CONTINUED ON LIC809-C***** Staffing: A total of (32) staff members provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate is valid and will expire on 09/15/2024. Personnel Records-Training: LPAs reviewed (4) staff files. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the lobby by the main entrance. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPAs observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: A total of five (5) centrally stored resident medications were reviewed containing 30-day supply of medications. A complete first aid kit is maintained in the medication room and med carts. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I Money Records. The Incident report binder was reviewed. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Ten (10) residents are receiving home health services. One (1) resident is under hospice care. LPAs observed half bed rails for mobility assistance in some resident beds. Physician orders for postural support are on file. There are no residents with prohibited health conditions. Residents who are using oxygen have "No smoking In Use" signs posted on the residents doors. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Pamela Ogot, Executive Director and Martha Rosas, Assistant Administrator.the state’s words, verbatim · CDSS document, Apr 16, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management visit to investigate a self reported incident received by CCLD on 3/27/2024 of suspected elder abuse by staff on Resident #1. LPA met with the Executive Director, Pamela Ogot and explained the purpose of the visit. The report stated that on 3/18/2024 at about 2:50am, Staff #1 (S1) witnessed another staff (S2) hit the lower body part of Resident #1 (R1) with his hand and screamed at the same time because R1 refused to be changed. During today's visit, LPA interviewed the Executive Director, and obtained copies of the staff/resident rosters,and R1's latest Physician's report. Per the Executive Director, the incident happened on 3/18/2024 at 2:50am. S1 did not report it to her until 3/22/2024 at 5:30pm over the phone. Executive Director conducted an immediate investigation and spoke with S2 the same day who denied the allegation. The following day, the Executive Director spoke with R1 and performed a body check on her, no noticeable injuries found. On 3/23/204, Executive Director reminded S1 to submit an incident report to her, but S1 never did. On 3/24/2024, S1 did not show up for work. S1 reported back to work on 3/26/2024 and submitted a letter of resignation the following day, 3/27/2024. According to the Executive Director, there was no credible evidence found on her investigation to substantiate it. LPA reviewed R1's Physician's report which showed that R1 is non ambulatory with cognitive impairment and requires assistance with activities of daily living. LPA spoke with R1 in person during the visit, and R1 could not remember the staff nor an incident of being hit on the lower part of the body. LPA observed that R1 was speaking and walking normally. LPA was unable to find anyone to corroborate that the alleged incident or physical and verbal abuse occurred at this time. Based on the information gathered, there is no signs of neglect or lack of supervision found. No deficiency was issued. An exit interview was held, and a copy of this report was provided to the Executive Director, Pamela Ogot.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Staff are inappropriately administering medications to residents.

Licensing Program Analsyts (LPA) Tena Herrrera conducted an unannounced initial complaint visit in regards to the allegation listed above. LPA met with Assistant Administrator Martha Rosas and explained the purpose for todays visit. The investigation consisted of the following: LPA obtained copies of both Staff and Resident Rosters, SIR submitted to licensing on 1/22/24 with discription of alleged incident, Copies of Resident #1's (R1's) Physician Report, Police Report Number (for alleged incident), Discharge Paperwork from hospital dated 1/18/24, follow up visits with R1's physicians post incidnet; R2's Physician's Report, R2's Special Medication Order and copies of the staff in-service training that was held on 1/23/24 covering Resident ADL's, including Medication Administration. LPA also interviewed 4 staff and 5 residnets. (Continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff mismanages residents' medications. It is alleged that staff mismanages residents medications as R1 accidentally consumed food that contained medication belonging to R2 and was thus sent to the hospital because of this incident. Per Staff interviews it was determined that during medication administration Staff #3 (S3) placed crushed medication in food for R2 and R1 grabbed the food and ate some of it. S3 immediately let front staff know of incident and 911 was called, ambulance arrived and transported R1 to hospital for cleansing and observation and returned to facility same day, all responsible parties were notified and an SIR was submitted to licensing. Facility provided R1 with all follow up appointments following the incident. After medical record review it was found that R2 has a physicians order stating that medication of R2 is able to be sprinkled in food and consumed. S1 stated that an in-service training was conducted after this incident and covered medication administration, S1 provided LPA with a copy of the In-Service training log with participant signatures and training materials. During interview with S3, staff confirmed in-service was conducted after incident covering the medication administration and that they attended the training. LPA reviewed 5 resident medications during visit with no issues observed. LPA interviewed 5 residents and 5 out of 5 residents stated that they are provided medication at the facility and have never experienced staff mismanaging their medication. During interview with R1, resident stated they didn't know that there was medication in the food, went to the hospital right after and had follow up visits with their doctors after the incident. Based on LPA's observations and interviews which were conducted, and resident record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights was provided to Assistant Administrator Martha Rosas. The investigation revealed the following: Allegation: Staff are inappropriately administering medications to residents. It is alleged that staff are inappropriately administering medications to residents by placing medication in residents food. What was witnessed was R2 being administered medication on food and R1 then taking the food and consuming it when staff was not looking. Per record review R2 has a doctors order in which staff administering medication are granted permission to crush medication and sprinkle on food for taste. Facility followed protocols by calling authorities, ambulance, reporting parties and notifying licensing, R1 was taken to the hospital for observation and treatment if needed and facility followed up with primary physician's once R1 returned to the facility. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that all medication is administered per doctors orders and is documented in the Medication Administration Record (MAR). Interview with S3, staff stated that the above incident did occur, however, medication was being administered to to correct resident but R1 took the food not knowing there was medication in it. LPA interviewed 5 residents and 5 out of 5 residents stated that they feel staff are giving them their medication properly and have not been administered medication from another resident. Interviews with residents stated that staff announce what the medication is and what it is for while administering medication. LPA reviewed 5 Resident medications during todays visit and there were no issues observed. Although medication was consumed by the incorrect resident (which this error is being addressed on a 9099-A), there was no evidence found to support the above allegation. Based on statements and interviews conducted with staff and residents, and review of resident records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Assistant Administrator Martha Rosas.the state’s words, verbatim · CDSS document, Feb 22, 2024 · control 28-AS-20240215122633

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 23, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: During investigation it was found that the alleged incident did occur as R1 ate food that contained medication that was prescribed to R2 in error.the state’s words, verbatim · CDSS document, Feb 22, 2024

Plan of correction: Administrator/Licensee to conduct a training in medication management and medication administration. Copies of Training and Training Log with Participants to be provided to LPA. **incident took place on 1/18/24 and facility held staff training on 1/23/24 - all copies of taining were provided to LPA during visit**

Allegation investigated: Staff are not assisting residents with showering Staff did not keep facility free of bed bugs

Licensing Program Analsyts (LPAs) Erik Zaragoza and Daniel Konishi conducted a subsequent complaint visit in regards to the allegations listed above. LPAs explained the purpose of the visit to Martha Rosas, Assistant Administrator for the facility, and was granted entrance. The investigation consisted of the following: During the initial visit, LPA Ashley Calderon obtained resident and staff roster, Purchases of Service Reports for 1:1 for Resident #1 (R1), October 2023 Schedule for R1's 1:1 caregiver, Dewery Pest Control Quality Assurance Reports for August and September 2023, obstained shower records and shower schedule, and also interviewed Residents #1 - 6 (R1 - R6), Staff #1 - 6 (S1 - S6), and also Witnesses #1 -2 (W1 - W2). During today's visit, LPAs Erik Zaragoza and Daniel Konishi obtained current staff and resident rosters, resident shower schedule, and interviewed Residents #7 - 9 (R7 - R9). Unsubstantiated The investigation revealed the following: In regards to the allegation that "Staff are not assisting residents with showering", it is alleged that residents who require assistance with showering are not getting assistance from caregivers for weeks at a time. During interviews with the residents, seven (7) out of nine (9) did not corroborate the allegation. One resident interviewed stated that they do require assistance with showering and need to seek out a caregiver in the hallways to assist them, and sometimes never get assistance. Other residents interviewed indicated that they do require assistance with showering and do get proper assistance showering from the facility staff. During interviews with staff, none corroborated the allegations that residents are not being assisted with their showering needs. One staff interviewed stated that residents that require assistance with showering are assisted at least two (2) times per week, or even more if necessary. Another staff member explained that sometimes the shower log is not initialed due to time restraints and being busy, however no resident that requires assistance with showering goes over a week without getting help with showering. In regards to the allegation that "Staff do not keep facility free of bedbugs", it is alleged that a few residents have had problems with bedbugs and that the facility is not doing anything to address it. During interviews with the residents, zero (0) out of nine (9) corroborated the allegation that the facility has a problem with bedbugs. One resident interviewed stated that there was bedbugs in a room identified that had an issue with bedbugs, however they explained that facility staff removed the mattress from the room and replaced it, and that ever since the room has not had a problem with bedbugs. Other residents stated that they have never seen bedbugs within the facility. During interviews with staff, none of them corroborated the allegation that bedbugs have been an issue in the facility. One staff interviewed stated that bedbugs have been reported, and that in response they contacted their pest control company to inspect the rooms for bedbugs, after which no bedbugs were found. A representative from the pest control company was contacted as well, and they stated that there were no bedbugs in the room, and only cockroaches around a facility drain. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported 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 UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 15, 2024 · control 28-AS-20231003134542

Allegation investigated: Facility staff did not seek medical attention for resident. Facility staff did not notify resident's responsible person of wounds requiring medical attention. Facility staff did not ensure that resident's grooming needs were met.

*****This report superseads report dated 01/11/2024. The reason for superseading is to include missing additonal supportive information in the original 9099. No other changes have been made to the report. Investigation findings remain the same.***** Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent unannounced visit to provide additional information to the report regarding the allegations listed above. LPA was greeted by Administrator Pamela Ogot and Assistant Administrator Martha Rosas, the reason for the visit was explained. (Continued on 9099-C) Unsubstantiated The investigation included the following: During initial vist conducted on 1/3/24 LPA obtained copies of Resident and Staff Rosters and copies of documents within Resident #1’s (R1) file including: Admission Agreement, Identification and Emergency Information, Current Physician's Report, Appraisal and Appraisal/Needs and Services Plan, Copies of Most Current Nursing Home Podiatrist Visits, Hospice Information and Communication Log. LPA toured R1’s room and observed R1 to be clean, well groomed and social. During subsequent visit dated 1/11/24 LPA interviewed 5 Staff, 5 Residents, R1's Power of Attorney, and Hospice Staff. LPA also interviewed the Responsible Parties of the 5 Residents interviewed. The investigation revealed the following: Allegation: Facility staff did not seek medical attention for resident. It is alleged that, "the resident's toes are "raw and bloody", "infected" and "toe nails are coming off", and that R1 was in need of wound care and facility failed to seek wound care to resident. Per interviews with R1’s family, upon visiting resident on 1/1/24 it was discovered that resident had wounds to right foot/toes and family were providing their own wound care for 3 consecutive days to resident until facility provided care. Per R1’s medical records and hospice nurse notes/shower logs dated 12/21, 12/26 & 12/28, R1 had a complete shower with no signs of injuries and/or signs of pain noted by staff. Per interview with R1's hospice nurse, treatment to feet began on 1/3/24 and have been monitored during each visit, injuries to toes/foot observed on 1/3 were minor and there were no signs of infection. LPA observed R1 during initial visit on 1/3/23 and resident had a bandage on foot and hospice nurse was assisting resident, during todays visit LPA interviewed R1 and resident stated that their foot got the proper care, can now wear socks and that caregivers and nurse have been treating their foot on a daily basis. Resident was observed to be wearing clean socks and shoes during visit. Interviews with staff 5 out of 5 staff stated that while assisting with ADL’s staff did not observe the wounds to R1’s feet prior to 1/3/24 but have since then been making sure wounds are being treated and have undergone an In-service training dated 1/3/24 that covered care and monitoring of R1’s right foot and toes. Interviews with residents, 5 out of 5 residents stated that they get the proper medical treatment and staff are helpful when they have any need for medical assistance. (Continued on 9099-C) Allegation: Facility staff did not notify resident's responsible person of wounds requiring medical attention. It is alleged that Responsible Party (RP) was not notified of wounds to R1’s feet or medical attention needed to residents’ feet. Per RP they were never notified of foot treatment needed for R1. Per staff interviews 5 out of 5 staff stated that they were unaware of R1’s foot condition prior to 1/1/24, facility contacted hospice regarding R1’s feet and hospice provided foot care to resident on 1/3/24, after it was brought to staffs attention by RP during a visit. Per hospice staff the injuries to feet were minor and did not need immediate medical treatment, per hospice attending nurses during visits dated 12/21, 12/26 & 12/28 there were there were no signs of foot treatment needed at that time therefore no contact to responsible party was given, per shower logs also dated same as visits "full showers were given and resident denied any pain". Allegation: Facility staff did not ensure that resident's grooming needs were met. It is alleged that R1’s grooming needs are not being met as R1 had allegedly been wearing the same clothing for 3 consecutive days and clothing is visibly dirty. LPA observed resident during initial visit and R1 was well groomed with clean clothing, during subsequent visit LPA observed resident to be well dressed, groomed with clean nails and clean clothing. Interview with R1, resident stated they were provided with a bath in the morning and are given baths regularly. Interviews with Staff 5 out of 5 staff stated that R1 often refuses baths, however, with redirection R1 will comply. Interviews with S1 and S2, both stated that R1 does receive hospice service in which they bathe resident 3 times a week along with baths (as needed) that caregivers provide resident with. Communication log with hospice indicated that hospice staff bathe resident 2-3 times a week. Interviews with Residents 5 out of 5 residents stated that they are provided with showers/baths regularly and all appeared to be well groomed, with clean clothing and clean hands. Additionally, LPA interviewed Responsible Parties of the 5 residents interviewed and 4 out of 5 stated that residents appear clean and well groomed during visits, with a majority of visits being unannounced, and that they have never had any concerns regarding the above allegation. Based on statements and interviews conducted with staff, residents and their responsible parties, review of R1's file and hospice records/communication logs, there was not enough supportive evidence to concur with the reported 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 UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Assistant Administrator Martha Rosas.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 28-AS-20240102094739

Allegation investigated: Facility staff did not seek medical attention for resident. Facility staff did not notify resident's responsible person of wounds requiring medical attention. Facility staff did not ensure that resident's grooming needs were met.

Licensing Program Analyst (LPA) Tena Herrera made an unannounced subsequent visit to the facility, was greeted by Assistant Administrator Martha Rosas and explained the reason for the visit. The investigation included the following: During initial vist conducted on 1/3/24 LPA obtained copies of Resident and Staff Rosters and copies of documents within Resident #1’s (R1) file including: Admission Agreement, Identification and Emergency Information, Current Physician's Report, Appraisal and Appraisal/Needs and Services Plan, Copies of Most Current Nursing Home Podiatrist Visits, Hospice Information and Communication Log. LPA toured R1’s room and observed R1 to be clean, well groomed and social. Due to insufficient information available at the time, the above allegations needed further investigation. During subsequent visit LPA interviewed 5 Staff, 5 Residents, R1's Power of Attorney, and Hospice Staff. (Continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not seek medical attention for resident. It is alleged that R1 was in need of wound care and facility failed to seek wound care to resident. Per interviews with R1’s family, upon visiting resident on 1/1/24 it was discovered that resident had wounds to right foot/toes and family were providing their own wound care for 3 consecutive days to resident until facility provided care. Per R1’s medical records and hospice nurse notes, injuries to toes/foot were minor and there were no signs of infection, hospice treatment to feet began on 1/3/24 and have been monitored during each visit. LPA observed R1 during initial visit on 1/3/23 and resident had a bandage on foot and hospice nurse was assisting resident, during todays visit LPA interviewed R1 and resident stated that their foot got the proper care, can now wear socks and that caregivers and nurse have been treating their foot on a daily basis. Resident was observed to be wearing clean socks and shoes during visit. Interviews with staff 5 out of 5 staff stated that while assisting with ADL’s staff did not observe the wounds to R1’s feet prior to 1/3/24 but have since then been making sure wounds are being treated and have undergone an In-service training dated 1/3/24 that covered care and monitoring of R1’s right foot and toes. Interviews with residents, 5 out of 5 residents stated that they get the proper medical treatment and staff are helpful when they have any need for medical assistance. Allegation: Facility staff did not notify resident's responsible person of wounds requiring medical attention. It is alleged that Responsible Party (RP) was not notified of wounds to R1’s feet or medical attention needed to residents’ feet. Per RP they were never notified of foot treatment needed for R1. Per staff interviews 5 out of 5 staff stated that they were unaware of R1’s foot condition prior to 1/1/24, facility contacted hospice regarding R1’s feet and hospice provided foot care to resident on 1/3/24, after it was brought to staffs attention by RP during a visit. Per hospice staff the injuries to feet were minor and did not need immediate medical treatment. Last hospice visit prior to 1/1/24 was on 12/28/23 and per hospice staff there were no signs of foot treatment needed at that time therefore no contact to responsible party was given. (Continued on 9099-C) Allegation: Facility staff did not ensure that resident's grooming needs were met. It is alleged that R1’s grooming needs are not being met as R1 had allegedly been wearing the same clothing for 3 consecutive days and clothing is visibly dirty. LPA observed resident during initial visit and R1 was dressed, well groomed with clean clothing, during today’s subsequent visit LPA observed resident to be well dressed, groomed with clean nails and clean clothing. Interview with R1, resident stated they were provided with a bath in the morning and are given baths regular. Interviews with Staff 5 out of 5 staff stated that R1 often refuses baths, however, with redirection R1 will comply. Interviews with S1 and S2, both stated that R1 does receive hospice service in which they bathe resident 3 times a week along with baths (as needed) that caregivers provide resident with. Communication log with hospice indicated that hospice staff bathe resident 2-3 times a week. Interviews with Residents 5 out of 5 residents stated that they are provided with showers/baths regularly and all appeared to be well groomed, with clean clothing and clean hands. Based on statements and interviews conducted with staff and residents, review of R1's file and hospice records/communication logs, there was not enough supportive evidence to concur with the reported 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 UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Administrator Pamela Ogot.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 28-AS-20240102094739

Allegation investigated: Facility staff failed to assist resident with hygiene needs. Staff did not prevent client from losing excessive weight.

This is an amended report of original report dated 11/7/23, the purpose for amendment is to remove confidential information.This amended report does not change the findings.LPA Herrera redelivered report on 11/27/2023 and obtained signatures on the hard copy. Licensing Program Analyst (LPA) Tena Herrera conducted unannocuned subsequent compliant visit to deliver findings pertaining to the above-mentioned allegations. LPA met with Administrator Pamela Ogot who also assisted with the visit. (Continued on 9099-C) Unsubstantiated The investigation consisted of the following: An initial 10-Day visit was conducted by LPA Herrera on 11/7/23. During the visit LPA obtained copies of resident and staff roster, shower records/log, food menu, LPA observed meal being served for dinner and food menu. LPA obtained copies of Resident #1 (R1) files which included: admission agreement, needs and service plan, face sheet, ID and Emergency information, Resident Appraisal, Dietary Preference, Activity Program Information, doctors notes/summary, and medical records. LPA interviewed 5 Staff and 5 Residents during visit. (LPA later received a returned call from Staff # 5 (S5) and interview was conducted via telephone). It was determined that further investigation will be required and LPA will return at another time. LPA reviewed food menu, observed dinner being served on visit dated 11/7/23 and toured kitchen which was observed with an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Interviews with 5 out of 5 residents stated they are fed 3 meals daily with snacks in between. During subsequent visit LPA attempted to interview R1's daughter via phone call and was not successful on both attempts. LPA interviewed R1 and obtained copy of Hospice Evaluation approval from R1's doctor. The investigation revealed of the following: Allegation: Facility staff failed to assist resident with hygiene needs. It is alleged that staff have neglected to assist R1 with hygiene needs as it was stated that R1 was observed to have feces under fingernails and R1 was found in the shower alone, without assistance. Interviews with 6 out of 6 staff (whom work directly with R1) stated that R1 always rejects assistance with ADL's, R1 is a fall risk resident who ambulates with a walker. R1 does have incontinence management and often times refuses help with changing and cleaning and states "I can do it on my own", refusing to allow staff to properly assist, therefore, sometimes may have unsanitary fingernails. Staff all stated they have not seen R1 with feces under fingernails and always try to assist resident with all ADL's. S1 and S4 stated that they assist R1 with nail clippings in efforts to avoid any feces under nails as R1 tends to try and clean self without the needed assistance. Staff stated that R1 will attempt to bathe and clean self regularly and refuses help. S4 stated that on one occasion during rounds found resident attempting to bathe self and was able to redirect R1, explaining that staff is there to assist to ensure safety of R1 and was allowed to assist with R1 with shower. (Continued on 9099-C) Based off review of shower log R1 is assisted with baths 3-4 times weekly. Based off interviews with residents 5 out of 5 residents stated that staff assist with their hygiene needs on a frequent basis and have no complaints. Residents also stated that they have never been left unattended while being assisted with showers. Interview with R1, resident stated that they are offered assistance frequently but are not in need of any assistance and can do all things on their own. LPA observed resident to be in good spirits, well groomed with clean clothing and clean hands/fingernails. Allegation: Staff did not prevent client from losing excessive weight. It is alleged that R1 is "is dishelved and has lost weight". Based off weight record and interview with S6, R1 has lost a significant amount of weight from October 2023 to now. All other months Jan 2023 - Sept 2023 showed steady weight records with no dramatic changes. Doctors visits held in September and early October indicated no dramatic weight loss. S6 stated that R1's doctor and family were notified of the weight loss and the cause of the weight loss is still under review. S6 stated that they are working closely with R1's daughter to admit R1 to facility with higher level of care and are in progress of receiving hospice care for R1. Hospice Care was to assess R1 for services on 11/7/23, however, R1 was experiencing severe arm pain and was sent to the hospital for evaluation.The assessment has now been rescheduled for a later date. Interviews with staff 6 out of 6 staff stated that although they have noticed that resident has dropped a bit of weight, R1 does have a great appetite and eats their 3 meals and snacks daily. During interview with R1, resident stated that they have eaten breakfast and are about to eat lunch soon. R1 stated that they are provided 3 meals and snacks at facility and enjoy the food served. Interviews with 6 out of 6 residents indicated that they are provided with 3 meals daily and snacks in between. Based on statements and interviews conducted with staff and residents and review of R1 files, there was not enough supportive evidence to concur with the reported 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 UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Administrator Pam Ogot.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 28-AS-20231030113747

Allegation investigated: Resident sustained pressure injuries while in care. Resident did not have care plan for pressure injuries.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Martha Rosas (Assistant Administraor) and explained the purpose of the visit. Investigation consisted of the following: During the initial visit conducted on 07/28/21, LPA Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility LPA reviewed the file of Resident #1 (R1) and obtained copies of the following documents; Client Information Sheet, Admission Agreement , Agreements and Consent for Medical Treatment, Individual Program Plan (IPP), Unusual Incident/Injury Reports, Physician/Nurse Notes, Facility Progress Notes, Hospital Reports, Lab Results, Resident Roster and Staff Roster. Due to insufficient information available at the time, the allegations needed further investigation. (continued on 9099-C) Unsubstantiated Investigation revealed the following: In regards to the allegations “resident sustained pressure injuries while in care” and “resident did not have care plan for pressure injuries”. It is alleged that Resident #1 (R1) did not have a care plan for pressure injuries and therefore sustained pressure injuries while in care at the facility. This allegation was investigated by Investigator Brunelli with the Investigations Branch. R1 was diagnosed with Cerebral Palsy, history of epilepsy, and later non-ambulatory with contractures of arms and legs. R1 was admitted to facility and transferred to hospitals for wound care treatments from dates 2/18/21 – 7/20/21. Wounds would be treated and monitored at facility by home health. Based on interview with both hospitals Wound Care Ostomy Nurses and Home Health Care Nurses treating R1, all revealed the pressure injuries were not infected, looked healthy, small, and superficial and there were no concerns for abuse or neglect based on the pressure injuries. Based off of two hospital record reviews for R1, facility file review, interviews with both hospitals treating wound care nurses, interviews with family, interviews with treating home health care nurse, and previous medical history it was determined that it does not appear the care provider delayed in transferring R1 to a hospital for Skilled Nursing Facility (SNF) for wound treatment. Based off of record review and interviews with treating home health care nurse there was a wound care plan for R1 with a written order from the facility doctor with recommendations and a progress plan. Based on statements and interviews conducted with staff and family, review of R1 files and medical records, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Assistant Administrator Martha Rosas and Administrator Pamela Ogot.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 28-AS-20210726164431