Humble Haven RCFE II

Type of visit: Required - 1 Year

On 07/02/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit. LPA Melissa Spaeth was greeted by the live in caregivers. The caregivers called the Licensee, Nicole De Las Alas and informed her LPA was present at the facility. The facility is licensed to serve six (6) non-ambulatory residents of which one (1) may be bedridden. There is a hospice waiver for three residents. LPA and the caregivers toured the facility at 9:40 am until 10:20 am. Kitchen - LPA observed a two-day supply of perishable foods and a seven-day supply of non-perishable food items. LPA observed a kitchen drawer was unlocked and contained a resident's medication. At 10:10 am, LPA instructed the caregiver to remove the medication. LPA observed the caregiver locked the medications in the medication cabinet. LPA observed the cleaning supplies were locked underneath the kitchen sink. The knives were locked in a drawer. Resident Bedrooms – The bedrooms contained a bed, linens, night stand, night lamp, chest of drawers and closet. Staff Room – At 9:55 am, LPA observed the staff’s bedroom was not locked and a staff member's medication was sitting out and not locked in a secure location. Continued on 809_C Bathrooms – The two bathrooms contained hand soap, paper towels, trash can, a slip resistant mat, and grab bars. Water Temperature - LPA Spaeth tested the water temperature at 10:50 am and the water temperature was 123 degrees F. The caregiver adjusted the water temperature. LPA again tested the water temperature at 11:13 am and the temperature was 118 degrees F. Hallway Closet – The closet contained clean linen and PPE supplies. Garage – The garage was locked and contained the washer, dryer, laundry detergent and an additional deep freeze filled with frozen meats and vegetables. Smoke/Carbon Monoxide Detector- The detectors were tested at 11:10 am and were functional. LPA reviewed the residents’ files at 11:30 until 11:50 am. LPA observed the Admissions Agreement and Appraisal & Needs Service Plan were missing from R1's file. LPA reviewed the staff files at 11:50 am until 12:15 pm. The staff files were missing the health screening documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to the caregiver.the state’s words, verbatim · CDSS document, Jul 2, 2025

Allegation investigated: Facility staff did not ensure that dangerous items were inaccessible to the residents. Facility staff did not ensure that medications were properly stored.

On 3/28/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the three caregivers. LPA Spaeth spoke to the Administrator, Nicole De Las Alas at 10:45 am and explained the purpose of the visit was to tour the facility, interview the Administrator and present findings. LPA Spaeth interviewed the Administrator at 11:00 am until 11:10 am. Continued 9099-C Substantiated Regarding the allegation: Facility staff did not ensure that dangerous items were inaccessible to the residents. It’s alleged a knife was observed on the kitchen counter but staff were not preparing food. The Administrator confirmed a visitor had visited the facility on 3/13/2025 and observed a knife was sitting on the kitchen cabinet and the staff were not present in the kitchen when this was observed. The visitor immediately called the Administrator and expressed their concerns. The Administrator stated there had been issues with the staff and the Administrator would provide training to the staff. The Administrator confirmed with LPA Spaeth they had spoken to the visitor regarding the issue. Regarding the allegation: Facility staff did not ensure that medications were properly stored. It’s alleged the medication cabinet was also unlocked and unattended. The Administrator confirmed the visitor also stated the medication cabinet located in the kitchen was also unlocked and staff were not present. The Administrator confirmed with LPA Spaeth they had spoken to the visitor regarding the issue. LPA Spaeth received two photos that were taken at the facility during the incident of 3/13/2025. Upon reviewing the photo of the knife on the kitchen cabinet, LPA observed the exact location the knife was sitting on the kitchen cabinet. LPA took a photo of that location as proof the 3/13/2025 photo was the actual location of the incident. LPA reviewed the 3/13/2025 photo of the medication cabinet. LPA observed the exact location of the medication cabinet and took a photo of that location. Based upon LPA’s observations and interview of the Administrator, the allegations are substantiated. Exit interview conducted, appeal right discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 28, 2025 · control 31-AS-20250326141036

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Apr 1, 2025

87309 Storage Space & Access (a) Except as specified in subsection (b), the licensee shall ensure…knives, matches…are in locked storage & are not left unattended if outside the locked storage. This is evidenced by: The staff failed to securely lock the knives and medications in a secure location. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: The Licensee will conduct a staff in-service training regarding the physical enviornment regulations, The Licensee will send a report stating the regulations that were reviewed and the staff's signature when the training is completed. The documents will be sent to LPA Spaeth via email.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melissa Spaeth conducted a complaint investigation for Complaint #31-AS-20250326141036. During the visit, LPA reviewed the residents' files at 12:00 pm until 12:30 pm and observed the resident files were not complete. LPA Spaeth observed Resident (R1), Resident (R2), Resident 5 (R5) were missing documentation. Based upon LPA's observations, the following deficiencies were cited. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Apr 4, 2025

87458 Medical Assessment (a) Prior to person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment... to be kept in the resident's record. This is evidenced by: The Licensee failed to obtain the Physician's Assessment (LIC 602) for Resident one, and resident 5. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: The Licensee will obtain the LIC 602 for resident one and 5. The Licensee will send a copy to LPA Spaeth via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(a) · Plan of correction due date: Apr 4, 2025

87507 Admissions Agreements (a) The licensee shall complete an individual written admission agreement… with each resident or the resident's representative, if any. This is evidenced by: The Licensee failed to obtain the Admissions Agreement for Resident two. This poses a personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: The Licensee will obtain the Admiissions Agreement for resident two. The Licensee will send a copy to LPA Spaeth via email.

Allegation investigated: Illegal eviction Staff do not ensure adequate care is provided to residents in care Staff do not ensure showering assistance is provided for residents in care Staff do not ensure toileting assistance is provided to residents in care Staff does not ensure residents are allowed to choose their own health care providers Staff do not ensure resident is accorded personal privacy while in care Staff did not ensure residents medications were properly managed Staff do not ensure medications cabinet is properly secured at all times Staff did not ensure medications were dispensed as prescribed to residents in care Staff do not ensure residents are spoken to in an appropriate manner

On February 5, 2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the caregiver. LPA explained the purpose of this visit was to deliver the findings. The investigation consisted of the following: On 12/27/2023 LPA conducted an initial visit and reviewed the residents’ files at 11:55 am until 12:40 pm. LPA received copies of the residents’ records, resident roster, and the staff work schedule. LPA interviewed four residents (R1-R4) at 2:20 pm until 3:45 pm. LPA Spaeth also interviewed staff members (S1-S2) and the Administrator at 3:45 pm until 4:15 pm. Continued on 9099-C Unsubstantiated Regarding the allegation: Illegal eviction. It’s alleged a resident was given a thirty-day eviction notice. R1-R4 all confirmed they were not given a thirty-day eviction notice. S1-S2 stated they did not observe a thirty-day eviction notice was given to a resident. The Administrator denied the allegation. Regarding the allegation: Staff do not ensure adequate care is provided to residents in care. It is alleged that staff do not provide twenty-four-hour care to the residents. R2-R4 stated staff members always assist them with their daily needs. S1-S2 stated they provide the care needed and stated residents have not complained about the service provided. The Administrator denied the allegation. Regarding the allegation: Staff do not ensure showering assistance is provided for residents in care. It is alleged a resident only received assistance with a shower once a week. R1-R4 confirmed staff assist with showering or a sponge bath at least two times a week. S1-S2 confirmed they assist residents with showering and sponge baths at least two times a week. The Administrator denied the allegation. Regarding the allegation: Staff do not ensure toileting assistance is provided to residents in care. It is alleged that staff do not assist residents to the bathroom. R1 stated staff assistance is limited. R2 stated they don’t need assistance with toileting. R3-R4 stated when they ask staff for assistance, the staff always assists them to the toilet. S1-S2 confirmed they assist some residents to the toilet and also change diapers. S1-S2 also confirmed they always check with residents at least four to five times a day regarding their toileting needs. The Administrator denied the allegation. During LPA’s visit, LPA observed two residents were assisted to the toilet. Regarding the allegation: Staff does not ensure residents are allowed to choose their own health care providers – It is alleged the Administrator tried to force a resident to use a specific home health provider. R2-R4 confirmed they choose their own health care provider. S1-S2 and the Administrator denied this occurred. Regarding the allegation: Staff do not ensure resident is accorded personal privacy while in care – It is alleged a resident entered another resident’s room without permission and staff have not handled the issue. R2-R4 stated other residents do not Continued on 9099-C enter their room. S1-S2 stated this has not occurred. The Administrator denied the allegation. Regarding the allegation: Staff did not ensure a residents’ medications were properly managed. It is alleged that the staff did not reorder a resident’s medication and the resident missed three doses during the month of December, 2023. R2-R4 stated the staff have never missed ordering their medication and they always receive their medication each day. S1-S2 denied this occurred. The Administrator stated they ensure residents’ medication is always available at the facility. LPA reviewed the residents’ medications, the Centrally Stored Medication Destruction Records and the Medication Administration Record (MARS) for each resident. R1-R4 have taken their medication each day. Regarding the allegation: Staff do not ensure medications cabinet is properly secured at all times. It is alleged staff members have left the medication cabinet unlocked. R1-R4 stated they have never observed the medication cabinet unlocked. S1-S2 and the Administrator denied the allegation. During LPA’s tour of the facility on 1/17/2024, LPA observed the medication cabinet was locked. Regarding the allegation: Staff did not ensure medications were dispensed as prescribed to residents in care. It is alleged a resident’s medication was given at incorrect times. R2-R4 all confirmed they receive their medication each day at the designated time. S1-S2 and the Administrator also denied this occurred. Upon reviewing the Centrally Stored Medication Destruction Records and the MARS for each resident, LPA did not observe any errors. Regarding the allegation, Staff do not ensure residents are spoken to in an appropriate manner. It is alleged staff have yelled at a resident. R2-R4 denied this has occurred and stated staff treat residents with respect. R2-R4 also stated they have never witnessed a staff member yelling at another resident. S1-S2 stated they would never yell at residents. The Administrator denied the allegation. Based upon interviews and review of residents’ records, the allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 31-AS-20240111081949

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Spaeth conducted an unannounced visit and was met by two staff members. LPA observed one staff member was a new staff member. LPA stated the purpose of the visit was to conduct a case management visit. LPA Spaeth spoke to the Administrator, Nicole De Las Alas via phone at 2:15 pm. LPA Spaeth conducted a tour with the caregiver at 2:00 pm until 2:30 pm. LPA Spaeth observed a staff member had not been associated to the facility. The Administrator stated they are working on associating the new staff member to the facility. Based upon LPA's observations, the following deficiencies were issued. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87761(b)(1) · Plan of correction due date: Jan 8, 2025

87761 Penalties (b) Notwithstanding Section 87761(a) above, an immediate penalty of $100 per cited violation per day….shall be assessed…requested a transfer of a criminal record clearance…This is evidenced by: The Licensee failed to ensure a staff member had been associated to the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: The Licensee will send notification to LPA Spaeth via email that the staff member was associated to the facility

Allegation investigated: Staff speaks to resident in an inappropriate manner.

On 12/05/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by two staff members. LPA spoke to the Administrator via phone and explained the purpose of this visit was to conduct interviews, review residents’ documents and present findings. LPA conducted a physical plant tour at 10:00 am until 10:15 am. LPA reviewed residents’ documents at 10:30 am until 11:00 am. LPA received copies of residents' records. Continued on 9099-C Unsubstantiated LPA interviewed four (R1, R2, R3, R4) out of five residents at 11:00 am until 11:30 am. A resident (R5) was unavailable for an interview. LPA Spaeth interviewed three out of four staff (S1, S2, S3) at 11:30 am until 11:45 am. Regarding the allegation: Staff speaks to a resident in an inappropriate manner. It’s being alleged a staff member is verbally abusive and yells at residents. R1 – R4 unanimously stated staff are never verbally abusive and never yells at them. R5 was unavailable for an interview. S1 – S3 also confirmed they have never verbally abused or yelled at the residents. S1 – S3 also confirmed they have never witnessed another staff member verbally abusing a resident or yelling at a resident. Based upon resident and staff interviews, the allegation is unsubstantiated. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 31-AS-20241126153912

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Spaeth conducted an unannounced visit to investigate complaint #31-AS-20241126153912. Upon arrival, LPA was greeted by two staff members (S1 and S2). LPA observed S1 has fingerprint clearance. However, staff member (S2) has not obtained the fingerprint clearance. LPA Spaeth spoke to the Administrator at 11:45 am regarding the issue. The Administrator stated they are awaiting the clearance notification from the state. LPA stated S2 must leave the facility. At 12:00 pm, a staff member (S3) arrived who has obtained fingerprint clearance. LPA Spaeth observed S2 left the facility at 12:05 pm. Based upon LPA's observation, the following deficiency is issued. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Dec 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87761(b) · Plan of correction due date: Dec 5, 2024

87761 Penalties(b)…a immediate penalty of $100 …per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted …has not obtained a California clearance or a criminal record exemption… This is evidenced by: The Licensee failed to ensure a staff member had obtained a California Clearance or a criminal record exemption. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: LPA Spaeth observed the staff member (S2) left the facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced case management visit and was greeted by the caregiver. An Informal Meeting was conducted at the Woodland Hills Office on 9/17/2024 with the Licensee, Nicole De Las Alas. LPM Troy Agard discussed the deficiencies cited at the facility during an annual visit conducted on 08/07/2024. LPA Spaeth reviewed the deficiencies with the Licensee and informed the Licensee the deficiencies must be cleared by Tuesday, 9/24/2024. Upon arrival, LPA explained the purpose of the visit was to review the residents' files and receive a copy of a staff member’s (S2) CPR/First Aid training certificate. LPA Spaeth received a copy during the visit LPA toured the facility at 10:20 am until 10:55 am. At 10:45 am, LPA observed a bedridden resident was not in the designated bedridden room. At 11:00 am, LPA observed the auditory device on the front door and the exit doors to Rooms 2 and 5 were not working. LPA Spaeth reviewed the resident's files at 11:15 am until 12:00 pm. LPA observed five out of five residents' files were missing the I.D & Emergency Information form (LIC 601) and Personal Rights form. LPA also observed four out of the five residents are on hospice care. However the facility has an approved hospice waiver for three residents. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Sep 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Sep 27, 2024

87202(a)(2) All facilities shall maintain a fire clearance approved by fire dept... Prior to accepting any of the following types of persons, licensee shall obtain an appropriate fire clearance approved by fire dept, (2) Bedridden persons. This requirement is not met as evidenced by The Licensee failed to follow Title 22 Regulations regarding approved fire clearance, by placing bedridden resident R1 to the room that had no bedridden fire clearance. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Administrator stated that R1 will be transferred to bedroom #5 by 9/26/2024 and will send a snapshot of the room change.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(j) · Plan of correction due date: Sep 26, 2024

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device…to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Due to LPA's observations, the Licensee failed to ensure the auditory devices were working at the front door and exit doors in Rooms 2 and 5the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: The Administrator will ensure the auditory devices at the front door, Room 2 and Room 5 are properly working. The Administrator will notify LPA Spaeth when the devices are repaired.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87632(a)(1) · Plan of correction due date: Sep 27, 2024

87632 Hospice Care Waiver (a) In order to accept or retain terminally ill residents & permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice waiver …(1) Specification of the maximum number of terminally ill resident which the facility wants to have…. This is evidenced by: The facility has an approved hospice waiver for three residents. However, LPA observed there are four out of five residents who are on hospice.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Administrator stated they will send a hospice waiver increase to the Woodland Hills South office.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b)(8) · Plan of correction due date: Sep 27, 2024

87506 Resident Records (b) each resident’s record shall contain….(8) names, address, & telephone numbers of resident’s representative….. This is evidenced by: LPA Spaeth observed the five residents' files did not contain a completed LIC 605 I.D. & Emergency Information and LIC 613C Personal Rights documentsthe state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: The Administrator stated they will obtain the completed/signed forms and forward copies to LPA Spaeth via email.

Type of visit: Office

An Informal Conference was conducted today in the Woodland Hills Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss the deficiencies cited at the facility during an annual visit conducted on 08/07/2024. Prior to the meeting, the Licensee was given the opportunity to review the facility file. Present at today's meeting are the following: · Nicole De La Alas, Licensee · Troy Agard, Licensing Program Manager (LPM) · Melissa Spaeth, Licensing Program Analyst (LPA) The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions. BRIEF HISTORY: Facility has been in operation since licensure on 08/26/2020, for a maximum of six non-ambulatory residents. LPM Agard discussed and expressed concern regarding the potential sale of the facility to an individual without notifying CCL. Also, LPA Spaeth discussed the citations that were issued during an unannounced annual inspection on 8/07/2024. Continued on 809-C The following deficiencies were observed: - The water temperature was tested in the resident's bathroom and was 126.6 degrees F. The deficiency was cleared during LPA’s visit. - The two caregivers working at the facility have not received the following training: 1) required eight hours of in-service dementia training, 2) the medication assistance training, and 3) CPR and first aid training. The caregivers also have not completed the health screening including the chest x-ray or an intradermal test. The deficiencies have not been cleared. During the meeting, the Licensee confirmed they have assumed responsibility of the facility as of today, 9/17/2024. The Licensee stated three previous caregivers are now working at the facility. The Licensee will resume as the Administrator. LPA Spaeth received a copy of a letter which confirms the facility is under the supervision of Nicole De Las Alas. The Licensee shall submit the following to LPA Spaeth: · Proof of liability insurance · An updated LIC 500 - Personnel Report · Staff member Raquel D'Ambrosio's health screening form completed and signed by a physician · Malina Sorrano and Reyoldo Sorrano will complete the CPR/First Aid training · The required residents' documentation will be completed. . The Licensee was informed the above documentation is due Tuesday 9/24/2024. The Licensee was also informed that Community Care Licensing (CCL) shall continue to monitor the facility with annual facility inspection visits and as often as necessary to ensure the Licensee's compliance with Title 22 Regulations. The Licensee was also informed that further citations and/or non-compliance may result in a Non-Compliance Conference with the Regional Manager. Exit interview conducted and a copy of today's report was provided to the Licensee.the state’s words, verbatim · CDSS document, Sep 17, 2024

Type of visit: Required - 1 Year

On 08/07/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit. LPA Melissa Spaeth was greeted by a caregiver. LPA Spaeth spoke to the Licensee, Nicole De Las Alas by phone and the Licensee arrived at 10:20 am. The Licensee stated they have sold the facility to another individual but did not know the status of the buyer's application with CCL. The Licensee also stated the two staff members working at the facility were hired by the new owner. The Licensee stated they had a personal appointment and had to leave the facility. The Licensee left at 11:05 am. The facility is licensed as a Residential Care Facility for the Elderly (RCFE) to serve six residents of which six (6) may be non-ambulatory and one (1) may be bedridden. There is a hospice waiver for three residents. There are five residents living in the facility. At 11:15 am, a former staff member arrived and stated they had purchased the facility as of May, 2024 and they had been a previous staff member of the facility. LPA Spaeth observed the previous staff member and the two caregivers who are currently working at the facility had received criminal record clearance. LPA and the caregiver began the tour at 10:00 am until 11:00 am. LPA Spaeth observed the following: Common areas – LPA observed the family room contained comfortable seating. Dining Room/Kitchen Combination – LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food in the refrigerator. LPA Spaeth observed the kitchen knives and cleaning solutions were locked underneath the kitchen sink. The medications were safely locked in a kitchen cabinet. Backyard- LPA observed comfortable seating located in a shaded area. The gate leading from the backyard to the front yard was not locked. Continued on 809-C. Resident Bedrooms – LPA observed the five residents’ rooms were neat and clean. The bedrooms contained a bed, linens, night stand, night lamp, chest of drawers and closet. Bathrooms – The two bathrooms contained hand soap, paper towels, trash can, a slip resistant mat, and grab bars. LPA Spaeth tested the water temperature at 10:50 am in the resident’s bathroom and the water temperature was 126.6 degrees F. Hallway Closet – The closet contained clean linen and PPE supplies. Staff Room – The staff’s bedroom was locked. Garage – The garage was locked and contained the washer, dryer, laundry detergent and an additional deep freeze filled with frozen meats and vegetables. Smoke/Carbon Monoxide Detector- The detectors were tested at 11:00 am and were functional. LPA reviewed the residents’ files at 1:00 pm until 1:30 pm. LPA reviewed the staff files at 2:00 pm until 2:30 pm and observed there were no staff files for the two caregivers working at the facility. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given to the caregiver.the state’s words, verbatim · CDSS document, Aug 7, 2024

Allegation investigated: Licensee does not dispense medication as prescribed to resident in care.

On 05/19/24, Licensing Program Analyst (LPA) Ernand Dabuet made a subsequent unannounced visit to this facility and was greeted by caregiver staff #1 (S1) Jan Allen Vernon De Jesus. LPA Dabuet contacted the administrator Nicole De Las Alas who was not available for this visit. LPA explained the purpose of today’s visit is to gather information for the allegation mentioned above and deliver findings. The investigation consisted of the following: An initial 10-day visit was conducted by (LPA) Melissa Spaeth on 01/31/24 who met with caregiver Melina Serrano. (LPA) Dabuet conducted subsequent visits on 05/18/24 and 05/1924. (LPA) Dabuet requested copies of files for resident #1 (R1)’s Admissions Agreement (dated: xx xx xx), Physicians Report LIC 602A (dated: 12/20/23), Register of Facility Residents LIC 9020 (dated: 02/29/24), and other documents associated with the complaint. Interviews were conducted with residents #1-#2 (R1-R2), staff #1 (S1), and administrator #1 (A1). A tour of the facility was performed. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff abandoned resident at hospital. The details of the complaint alleged facility staff abandoned the resident at the hospital. The complainant reported resident #1 (R1) was admitted on 01/18/24 and that home care staff refused to accept (R1) back at the facility. The complainant stated that (R1) does not require additional higher level of care needs. The complainant reported when the hospital reached out to coordinate (R1) release and was informed by staff that (R1) could not return. According to resident #1 (R1)’s Admissions Agreement Residential Care Facilities for the Elderly is self-responsible and did not have a conservator, power of attorney, or guardian. Admissions Agreement revealed to be unsigned and undated by (R1) and facility representative. On 01/17/24 at 12:55 pm, Licensing Program Analyst (LPA) Melissa Spaeth interviewed resident #1 (R1). (R1) claimed to be an Assisted Living Waiver (AWL) recipient and should have not to pay anything. (R1) claimed to dispute the additional cost the administrator is charging. (R1) did not sign the Admissions Agreement due to the cost dispute. (R1) reported that the administrator issued (R1) a 30-day Eviction Notice on 01/11/24. (R1) claimed the administrator is attempting to evict (R1) based on non-payment. (R1) stated to have been placed in the facility on 12/20/24. On 05/18/24, between 02:45 pm – 03:31 pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed administrator #1 (A1) by telephone. (A1) confirmed that (R1) was a resident at the facility and the facility provided care and supervision services for approximately 29 days. (A1) reported to have issued a 30-day Eviction Notice to (R1) in person served by a care staff. (A1) claimed to have notified Community Care Licensing (CCL) of the eviction by faxing the Eviction Notice to the Woodland Hills South Adult and Senior Care Regional Office. (A1) was uncertain of the date the notice was dated and issued nor the date it was sent to (CCL). (A1) did not follow up with the (WHS) Regional office to determine if notice was received or was authorized for approval. (Evaluation Report continues LIC 9099-C) (A1) communicated that (R1) was an AWL and SSI recipient and that (R1) was evicted for non-payment and failed to adhere to the facility’s house rules and policies. (A1) confirmed to have received a payment from (ALW) in March 2024, which was deposited into the facility's account. (A1) reported that (R1) had health issues that required hospitalization in January 2024, and was hospitalized after being issued a 30-day Eviction Notice. (A1) claimed that (R1) never signed an Admissions Agreement. As a result, (R1) is not considered a resident at the facility. (A1) assumed that without an Admission Agreement, there is no valid contract with (R1). (A1) did not have an obligation to accept the resident back and the 30-day Notice was served. (A1) claimed (R1)’s belongings were picked up while the resident was still in the hospital. In (A1)'s opinion, (R1) needed a higher level of care but did not have a medical assessment from the hospital records to support the claim. (A1) agreed to provide a copy of the Eviction Notice issued to (R1) and a copy of the facsimile receipt sent to the (WHS) (CCL) Regional office to LPA Dabuet on 05/19/24. On 05/18/24, between 03:35 pm – 4:4pm, Licensing Program Analyst (LPA) Ernand Dabuet interviewed staff #1 (S1) and residents #2-#3 (R2-R3). (R2-R3) claimed they did not know about (R1)’s residency before their placement at this facility. (S1) claimed to have no knowledge of the matter concerning (R1) as (S1) is a recent hire at the facility. ( R4) was unavailable for an interview and could not give a statement. (LPA) Ernand Dabuet could not obtain additional statements related to the allegations in this complaint from (R1) due to unreturned calls. According to internal records (dated: 01/17/24, 01/18/24, and 01/23) reviewed by (LPA) Dabuet, (A1) was informed of by (CCL) Associate Government Program Analyst (AGPA) Aileen Aguinaldo, it is the responsibility of the facility despite the 30-day Eviction Notice issue to (R1), and that (A1) agreed and will allow (R1) to return to the facility. (Evaluation Report continues LIC 9099-C) This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created on 05/19/24. The documents were sent by facsimile to (CCLD) with no confirmed receipt from (A1). The (WHS) (CCL) Regional Office had no records on file. The facility failed to follow up with (CCL) for approval as written in Title 22 Regulations Section 87224 Eviction Procedures. (A1) failed to follow up and contact the Department informing that a 30-day Notice was issued to (R1). It was determined the notice was not valid. (A1) failed to provide a copy of the notice to LPA Dabuet along with facsimile receipt. Based on interviews and record reviews, there is sufficient evidence to support the allegation mentioned above. Based on the Department's observation and interviews, records reviews, and analysis, the preponderance of evidence standard has been met, therefore the allegation of “Staff abandoned resident at hospital" is Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. An exit interview was conducted with Jan Allen Vernon De Jesus. The Rights were discussed with Nicol De Las Alas by telephone, and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report.the state’s words, verbatim · CDSS document, May 19, 2024 · control 31-AS-20240124103329

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b) · Plan of correction due date: May 31, 2024

87224(b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good csafety... mental and/or physical health or safety of others in the facility.ause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or This requirement is not met as evidenced by: Based on interviews and record reviews. The facility failed to properly inform CCLD of the 30-Day Notice of Eviction for (R1) and failed to provide evidence of notice submitted. The notice is not valid unless CCLD approves. This violation posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, May 19, 2024

Plan of correction: Licensee is to review Title 22 Regulaiton Section 87244, and resubmit a written statement to CCL to indicate it was reviewed and understood. POC must be sent to LPA Dabuet at ernand.dabuet@dss.ca.gov by 05/31/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: May 31, 2024

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by Based on interviews and record reviews, the licensee did not comply with the section. The faciltiy failed to accept (R1) upon discharge from hospital. This violation which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2024

Plan of correction: Licensee will need to provide will adhere to Title 22 87468.1 and submit a written statement that to indicate it was reviewed and understood. Proof of correction must be sent to LPA by email at ernand.dabuet@dss.ca.gov by 05/31/24.

Type of visit: Case Management - Other

During Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit regarding Complaint #31-AS-20240111081949, LPA Spaeth reviewed resident's files at 11:50 am until 12:30 pm, LPA observed documents were missing from two residents' files. Based upon review of residents' records and upon Title 22 Regulations, the following deficiencies are substantiated (See 809-D page).the state’s words, verbatim · CDSS document, Jan 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Jan 26, 2024

87458 Medical Assessment (a) Prior to a person’s acceptance as a resident, the licensee shall obtain and keep on file documentation of a medical assessment, signed by a physician, made within the last year….This requirement is not met as evidenced by: Based on LPA's file review, the licensee did not comply with the section cited above in two out of four resident files which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: Administrator will provide copies of R1's and R2's records via fax or email to LPA Melissa Spaeth

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(b) · Plan of correction due date: Jan 26, 2024

87507 Admissions Agreements (b) Admissions agreements shall be signed and dated,…by the resident. This requirement is not met as evidenced by: Based on LPA's file review, the licensee did not comply with the section cited above in two out of four resident files.the state’s words, verbatim · CDSS document, Jan 17, 2024

Plan of correction: Administrator will provide copies of R1's and R2's records via fax or email to LPA Melissa Spaeth