Ivy Park at Burbank

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst Nadia Shahbazian conducted an unannounced site visit continuation of the required annual inspection, conducted on 10/16/2025. LPA met with Angela Smith - Executive Director/Administrator and explained the purpose of this visit. The following remaining inspection domains were observed, reviewed and inspected: Medications: Facility has two Medication Rooms, one on the first floor for Assisted Living Unit, the other on the second floor for the Memory Care Unit. Medications are securely locked in medications cabinets, inaccessible to residents. LPAs reviewed Medication Administration Records (MARs) for six (6) residents and compared them to the medication count and found no discrepancies. Multiple First Aid kits and the First Aid Manual were observed in the Medication Rooms. Resident records: All records were observed as locked in administrative offices. A total of ten (10) resident files were reviewed, Records included but not limited to: current IPP and/or needs and services plans, physician reports, centrally stored medication logs and admission agreements. Resident records appeared to be complete and current. Staff records: All staff records are kept locked in the Business Office. A total of eight (8) Staff files were reviewed. Criminal record clearances were present, and Staff are associated to this facility. Staff records appear to be complete and current. Under California Code of Regulations, Title 22, Division 6, deficiencies cited during today’s visit. Exit interview conducted and copy of the report with appeal rights provided to the administrator.the state’s words, verbatim · CDSS document, Oct 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Oct 31, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor .... kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in having kitchen floors, walls, doors and kitchen appliances such as industrial oven to be clean, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: Administrator will ensure that kitchen floors, walls, doors and kitchen appliances have been professionaly cleaned and sanitized and pictures are provided to LPA by the POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst Nadia Shahbazian arrived at the facility at 10:00AM today to conduct a One (1) year Required visit. LPA met with Angela Smith-Executive Director/Administrator and explained the purpose of this visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools during today's visit. A tour of the physical plant was conducted between 12:30AM through 2:45PM with Executive Director and LPA observed the following: The facility is licensed to serve (130) elderly adults ages 60 and above, of which (100) can be non-ambulatory and (30) Bedridden. The facility has an approved hospice waiver for (12). Current census is (81) with (4) residents on hospice care. The facility is an eight story building consisting of the following: the administrative offices, main dining room, living room, main laundry room, medication room, staff room, commercial kitchen, activity room, common bathrooms, 2 patios and lobby, located on the first floor. The second floor is fire cleared for the Memory Care Unit which is equipped with a delayed egress system. Floors 3 through 8 house assisted living residents. Required postings were observed in the lobby and throughout the facility. The facility's smoke/mono-oxide detectors are hard wired, facility is equipped with fire sprinkler system. Fire drill was last conducted on October 03, 2025. There are fire extinguishers throughout the facility hallways on all floors; all extinguishers were last serviced on July 14, 2025. Continued on 809-C Bedrooms: LPA visited ten (10) random rooms from each floor. All bedrooms were observed to be appropriately furnished with required beds, chairs, chest drawers and lighting with linens and comforters on all beds. All bedrooms observed to be clean and clear from obstruction. In two (2) bedrooms LPA pulled the signal pull cord and in each occasion, staff came for assistance within 4-6 minutes. Bathroom: There are common bathrooms on multiple levels. LPA visited ten (10) bathrooms located in the bedrooms. LPA observed foldable shower chair, non-skid mats and grab bars in the showers and near the toilets. The water temperature measured in range of 106.9 to 113.5 degrees Fahrenheit. All resident bathrooms and common area bathrooms were observed to be clean and sanitary. Kitchen: Facility’s kitchen door was observed to be locked and inaccessible to residents. Facility has a walk-in refrigerator, freezer, commercial oven, ice maker, ice-cream freezer and dishwasher. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days stored in the walk-in refrigerator and walk-in freezer. Food was properly labeled and stored. Emergency food is kept in a separate locked area, in a parking storage. Knives and sharp utensils are stored in the kitchen; inaccessible to residents. Detergents and chemicals are locked in a storage room outside of the kitchen. Laundry Room: Facility has a commercial laundry room for kitchen use, located on the first floor. There are laundry rooms in fifth and sixth floors, designated for washing resident clothes. Common areas: These areas include a gym, theater, hair salon on the 8-th floor. There is a library on the sixth floor, an internet lounge on the fourth floor, a doctor's lounge on the seventh floor. There is a piano lounge/living room on the first floor and activity rooms on various floors. LPA observed two (2) outdoor patio areas, one located outside the lobby, the second behind the Private Dining Room by the kitchen and a bistro near the kitchen for daily snacks. All common areas were appropriately furnished with tables and chairs and adequate lighting and all areas were observed to be neat and clean. The facility has a fire sprinkler system, internet, cable and wi-fi access. Facility does not have a pool but has water fountains located in the patio. Due to time constraints LPA was unable to complete today's annual visit and will return on a later date to complete the annual report. Exit interview conducted, and a copy of report issued.the state’s words, verbatim · CDSS document, Oct 16, 2025

Allegation investigated: Staff did not prevent a resident from sustaining multiple falls while in care

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced subsequent visit to this facility to further investigate the above allegation. LPA met with Operations Specialist Laura Kephart and explained the reason for the visit. LPA conducted a physical plant tour at around 10:00 AM, requested copies of facility documents relevant to the investigation at 10:38 AM, reviewed records between 10:45 AM to 11:45 AM and interviewed staff and residents between 11:45 AM to 1:45 PM. Regarding the allegation that Staff did not prevent a resident from sustaining multiple falls while in care, it was alleged that Resident #1 (R1) had two (2) falls within two (2) months, LPA's record review today revealed that R1 was hospitalized on 03/03/25 and 04/15/25 due to fall. LPA's interview with R1 today at 1:05 PM revealed that R1 was with a caregiver on both times R1 fell and on both occasions, the care staff tried to break R1's fall. LPA's interview with Staff #1 (S1) who was present during the initial incident on 03/03/25 revealed that S1 was called through the personal call button (pendant). (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) At around 5:00 PM and proceeded to assist R1 transfer to the toilet from the bed through the wheelchair, upon returning to the wheelchair from the toilet, R1's leg locked and unable to bend, a medical condition of R1 which happens from time to time. This made R1 panic so S1 sat R1 on the floor. On 04/15/25 incident, LPA's interview with Staff #3 (S3) revealed that S3 did not remember S1 falling but LPA's interview with R1's private caregiver revealed that S1 fell on 04/13/25 with S3 protecting R1. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued. (continued from LIC 9099-A-C) Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 31-AS-20250516163441

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(f) · Plan of correction due date: Aug 5, 2025

The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation, if any, of the appropriate licensed medical professional, and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident’s record. This requirement is not met as evidenced by: Based on records review and interview, there was no assessment made to R1 after 2 hospitalizations, this poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Cleared during visit. An assessment was done on 05/27/25 after CCL's initial visit on 05/21/25.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Case Management Visit to confirm the admission of Resident #1 (R1). Upon arrival at 10:00am, LPA met with Fabiola Moreno - Memory Care Director and explained the purpose of the visit. . LPA obtained copies of the LIC 500 and the Resident Roster. Admission of R1 to the facility was confirmed, date of admission was on 03/12/2025. LIC 809 signed and copy provided. Exit interview conducted.the state’s words, verbatim · CDSS document, May 6, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller conducted a Case Management Visit at the facility to follow up on two incident reports involving medication errors. The incident reports are dated 03/15/2025 and 04/04/2025. LPA/LPM met with Executive Director Brittney Buchannan. An entrance interview was conducted. LPA requested copies of the Resident Roster, LIC 500 and personnel records for Staff #1 and Staff #2, including but not limited to: Training documents. Based on interview with administrator and record reviews, it was concluded that, Staff # 1 failed to comply with the facility's plan of operation, resulting in repeated medication errors. Staff #1 was terminated, due to repeated errors. Citation issued, appeal rights provided and exit interview was conducted; copy of the LIC 809 provided.the state’s words, verbatim · CDSS document, Apr 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Apr 17, 2025

Plan of operation. In part .... The Licensee shall operate the facility in accordance with the terms specified with in the plan of operation. This requirement was not met as evidenced by: Based on information provided by the administrator during the interview S1 did not comply with the facility's medication policy, resulting in repeated medication errors, which poses/posed an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: Administrator terminated the employment of S1. POC cleared on the date of visit.

Allegation investigated: Staff had an inappropriate sexual interaction with resident in care

On 02/19/25, Licensing Program Analysts (LPAs) Mariana Agban, Nadia Shahbazian, Angela Panushkina, Lesile Ngo-Castaneda, and Licensing Program Manager (LPM) Eva Miller conducted an unannounced visit to the facility to deliver the finding on the above allegation. LPAs and LPM met with the Executive Director Brittney Buchannan and explained the purpose of the visit. On October 10, 2024, the Woodland Hills South Adult and Senior Care office received a complaint alleging that staff had an inappropriate sexual interaction with resident in care. The investigation was conducted by Investigator Dennis Douglas from the Community Care Licensing Division (CCLD) Investigations Branch. The following was determined: Allegation: Staff had an inappropriate sexual interaction with resident in care. During the investigation, the Department conducted interviews with facility staff, the Burbank Police Department, the detective assigned to the case, and residents at the facility. Copies of Resident #1 (R1), Resident #2 (R2), and Staff #1 (S1) files, the incident report (SIR), the IB Investigation Report, and police investigative reports were obtained and reviewed. (Continue on 9099C) Substantiated The investigation revealed that on 09/13/2024, Staff #1 (S1) was observed kissing R1 on the lips by R2. S1 initially denied the allegation during the facility's internal investigation but later acknowledged kissing R1 on the forehead during questioning by the Burbank Police Department detective. Throughout the investigation, interviews with facility staff indicated that S1 exhibited unusual behaviors with residents, such as caressing their hands and feet. Ultimately, S1 was arrested by the Burbank Police Department and terminated on 09/23/24. It was determined that S1 sexually assaulted R1; therefore, based on the conducted interviews and the review of the investigation reports, the allegation is deemed substantiated. An immediate civil penalty of $500 will be assessed today for sexual assault. The Executive Director was informed that additional civil penalties may be applied based on Health and Safety Code 1548. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal rights were provided, and a copy of this report was issued to the Executive Director.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 31-AS-20241003120407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(1) · Plan of correction due date: Feb 19, 2025

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on the investigation conducted by the Investigative Branch, substantiating sexual assault perpetrated by staff #1 (S1) on Resident #1 (R1) which posed an immediate health and safety risk or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: S1 was terminated. An immediate civil penalty in the amount of $500 is issued.

Allegation investigated: Staff does not provide adequate supervision resulting in resident engaging in physical altercations with other residents. Staff did not seek medical attention to resident. Staff does not provide a safe environment to residents. Staff do not notify responsible parties of incidents.

At 9:30am, Licensing Program Analysts (LPAs) Angela Panushkina, Nadia Shahbaziana, Mariana Agban, Leslie Ngo-Castaneda and Licensing Program Manager (LPM) Eva Miller conducted an unannounced subsequent complaint visit at this facility to deliver final findings. The team met with the Executive Director and explained the reason for the visit. An initial visit was conducted by LPA Panushkina on 12/12/2024 and interviews and record reviews were made. Moreover, at 10:05am, LPA requested resident and staff roster. At 10:20am, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Appraisal Needs and Services Plan, Reporting Requirements, etc., relevant to the investigation. At approximately 10:25am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:30am – 01:30pm, LPA conducted an interview with the Executive Director, Health Services Director, Resident Care Coordinator, four (4) staff, and ten (10) residents. Continue on LIC9099-C Unsubstantiated Lastly, LPA obtained copy of a Police Report on 12/31/2024. Allegation: Staff does not provide adequate supervision resulting in resident engaging in physical altercations with other residents. It was alleged that Resident #1 (R1) was struck by Resident #2 (R2) in the dining room. To investigate this allegation, LPA conducted an interview with the Executive Director (ED) and was informed that ED was not aware of the incident until Health Services Director (HSD) received a phone call from R1's family member. Interview with the HSD revealed that on 12/05/24, HSD was scheduled to work and did not witness R2 strike R1. Interview with HSD revealed that R1 did not inform any staff members about the incident nor did R1 complain about any head injury to the facility staff. Interview with four (4) staff members corroborated the statement provided by the HSD, and all four (4) staff informed LPA that they have not witnessed R2 engaging in physical altercations with R1. During the interview with the witness (R3), LPA was informed that he/she was sitting by R1 and observed R2 approached their table but did not witness R2 engaging in physical altercation. Additionally, LPA conducted interviews with ten (10) residents and nine (9) out of ten (10) residents interviewed denied the above allegation. Lastly, a review of the Police Report revealed that an investigating officer inspected R1's head and did not observe any redness, swelling or injuries. Therefore, based on interviews, documentation received and record reviews this allegation is deemed Unsubstantiated at this time. Allegation: Staff did not seek medical attention to resident. It was alleged that R2 struck R1 and no medical attention was provided by the facility staff. To investigate this allegation, LPA conducted an interview with R1 and was informed that he/she was sitting in a dining room and around 1:00pm, R2 approached R1 from the back and hit R1 in the head with an unknown object. LPA was also informed that R1 did not inform any of the staff members, instead R1 went to R1's room and took a nap. Sometime around 4:00pm, R1 contacted the family member to inform about the incident. During the interview with HSD, LPA was informed that once the staff is aware of any incidents, it's immediately brought to her attention and if medical attention is required staff will follow the policy, Continue on LIC9099-C so that immediate assistance can be provided and an Incident Report can be completed within two (2) hours. LPA was also informed that since R1 did not inform anyone and no staff witnessed any incidents, no one was aware of any medical attention being required for R1. Interview with nine (9) out of ten (10) residents confirmed that the facility staff always provide medical attention as required. Therefore, based on interviews, record reviews and information gathered, this allegation is deemed Unsubstantiated at this time. Allegation: Staff does not provide a safe environment to residents. To investigated this allegation, LPA conducted an interview with the Executive Director (ED), Resident Care Coordinator (RCC) and Health Services Director (HSD) and was informed that prior to employment, all staff are provided with initial training on basic services and care and supervision to be able to provide a safe environment to residents. LPA conducted an interview with four (4) staff members who indicated they made sure that all residents are safe and comfortable. In addition, interview with nine (9) out of ten (10) residents expressed no concerns regarding this allegation. Residents revealed that they are happy with the facility and staff. Therefore, based on interviews and record reviews, this allegation is deemed Unsubstantiated at this time. Allegation: Staff do not notify responsible parties of incidents. It was alleged that R1's responsible party was not informed of an incident that occurred on 12/05/24. To investigate this allegation, LPA conducted an interview with the Executive Director (ED), Resident Care Coordinator (RCC) and Health Services Director (HSD) and was informed that once there is an incident, the staff immediately notifies the upper management who then contact the family/responsible party/conservator. Interviews with ED, RCC and HSD revealed that the facility staff was not aware of the incident with R1, thus there was no reason for them to contact the responsible party. Based on interviews, and information gathered, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 31-AS-20241206133513

Allegation investigated: Facility is understaff.

On 2.19.2025 Licensing Program Manager (LPM) Eva Miller, Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda, Marianna Agban, Nadia Shahbazian, and Angela Panushkina arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPAs was greeted by Briittany Buchanan and was advised the reason for the visit. Entrance interview conducted. On 9/25/2024 at 11AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. Allegation #1: Facility is understaffed. Continue to LIC 9099-C Substantiated Regarding the allegation that facility is understaffed. It was alleged that the facility is understaffed, wherein facility staff are not able to attend to the residents needs in a timely manner. LPA did a record review at 10 AM and requested copies of records at 12:00 PM for R1’s physician report, appraisal needs and services, pre-placement appraisal, CSMDR, and other necessary documents. On 9.25.24 LPA interviewed twenty (20) residents out of seventy (70) and eight (8) staff between 11:08 AM to 2:30 PM. Interviews revealed residents were not being checked regularly due to being short staffed. Staff interviewed made statements to the effect that they need assistance and are short staffed. Based on the information gathered, during the course of the investigation, the allegation is deemed substantiated at this time. Exit Interview conducted. Deficiencies cited (refer to LIC 9099-D). Appeal Rights explained and provided. Copy of report provided to Executive Director (ED). Regarding the allegation that that facility did not meet resident hygiene needs. It was alleged that staff do not properly shower residents. Record review of staff training records revealed all staff had been trained on resident hygiene and bathing. Shower schedule was also given to LPA and records show that all the residents were getting their scheduled shower. On 9.25.2024 LPA interviewed twenty (20) residents out of seventy (70) and eight (8) staff between 11:08 AM to 2:30 PM. Interviews with residents revealed they receive enough assistance with showering from facility staff and an outside agency. Interviews with staff and the executive director revealed the facility revealed no shower issues were raised by residents, family, or visitors. Residents receive shower assistance twice (2x) to thrice (3x) a week. Based on record review and interviews, the facility meets residents’ showering needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 31-AS-20240920163810

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 19, 2025

Facility personnel, shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not `met as evidenced by: Based on LPA’s observations, review of facility files and information provided during interviews it was determined that the facility did not provide a sufficient number of staff to meet the needs of residents in care including but not limited to incontinent care, resulting in the risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: Administrator will provide sufficient staff to meet resident needs as per CCR 87411(a) and will give LPA copies of staff schedules documenting sufficient personnel to meet the resident needs and copies of required documentation of staff training for existing personnel and any newly hired for the purpose of correcting this deficiency..

Allegation investigated: Facility retained resident with prohibited health condition.

Licensing Program Analysts (LPA) Abeye Duguma, Angelica Segovia and Nadia Shahbazian conducted an unannounced subsequent complaint visit to the facility. LPA met with Executive Director, Brittney Buchannan, and explained the reason for the visit. ---Facility retained resident with prohibited health condition. It was alleged that facility retained a resident with mrsa and did not prevent mrsa outbreak. To investigate the allegation, on 03/06/2024 LPA Antonia Alvizar- Ettima requested pertinent documents at around 12:25p.m. and interviewed four (04) staff from around 12:40p.m. to 1:35p.m. A review of the Pristine Home Health Physician's Orders, MS Diagnostic Laboratories LLC, and Resident Care Notes revealed that resident tested positive for mrsa on 02/23/2024 and was transferred to Glendale Care Center on 02/27/2024. (CONT. on LIC9099-C) Unsubstantiated During interviews with staff, all staff stated once facility received the positive results for Resident #1 (R1) on 02/25/2024, they isolated R1, immediately contacted R1's physician and, per physician's orders, R1 was transferred to Glendale Care Center on 02/27/2024. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 31-AS-20240226110712

Allegation investigated: Facility staff are not responding to the residents setting off the beeper system at the main entrance of the facility. Facility staff do not respond to the residents calls for assistance in a timely manner. Facility staff are not qualified.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Beatriz Martinez and explained the reason for the visit. --- Facility staff are not responding to the residents setting off the beeper system at the main entrance of the facility. It was alleged that residents with memory loss wander the ground floor and set off beeper system at main entrance, then nobody responds to help. To investigate the allegation, LPA conducted a physical plant tour at around 11:00a.m. and interviewed four (04) staff. During the physical plant tour, LPA observed two (02) delayed egress doors on opposite ends of the second floor. (CONT. on LIC9099-C) Unsubstantiated To test staff response time, LPA triggered delayed egress alarms multiple times and observed an average response time of fifteen (15) seconds. LPA also observed three (03) caregivers and one (01) MedTech providing care to seventeen (17) memory care residents. During interviews with staff, all staff stated they respond to the delayed egress alarm within five (05) to fifteen (15) seconds. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff do not respond to the residents calls for assistance in a timely manner. It was alleged that help calls taking twenty (20) to thirty (30) minutes to get to residents’ rooms. To investigate the allegation, LPA conducted a physical plant tour at around 11:00a.m. and interviewed four (04) staff. During the physical plant tour, LPA selected six (06) rooms at random, used the call button system and observed an average response time of five (05) minutes. LPA also observed three (03) caregivers and one (01) MedTech providing care to seventeen (17) memory care residents. During interviews with staff, all staff stated they respond to the resident call buttons within three (03) to six (06) minutes. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Facility staff are not qualified. It was alleged that there is a lack of a qualified manager to handle the safety of confused elderly. To investigate the allegation, LPA requested records at around 12:00p.m. A review of staff files revealed that the manager at the time the complaint was filed had all required training, including Elopement Response Plan, CPR, First Aid and Service Excellence with Residents and Families training. Based on record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 31-AS-20240116093357

Type of visit: Required - 1 Year

On 10/5/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Beatriz Martinez/Health Services Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (130) elderly adults ages 60 and above, of which (100) can be non-ambulatory and (30) Bedridden. The facility has an approved hospice waiver for (12). The facility is an 8-story high rise consisting of the following: the administrative offices, main dining room, main laundry room, medication room, staff room, commercial kitchen, activity room, common bathrooms and lobby are located on the first floor. The second floor is fire cleared for the Memory Care Unit which is equipped with a delayed egress system. Floor #3 through floor #8 houses the rooms for the assisted living residents. LPA Iniguez and the Health Services Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (7) bedrooms and (7) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 115.5°F to 117.2°F, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 3/25/24. A review of (6) residents' service files and (6) staff personnel files was maintained in order. LPA reviewed (6) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance was emailed to LPA. Facility Annual Fess current. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below: -See D pages for more details. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to / Administrator.the state’s words, verbatim · CDSS document, Oct 5, 2024

Allegation investigated: Staff is not able to meet resident's needs due to inadequate staffing.

On 07/23/24, at 10:00 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced, initial complaint visit. At approximately 10:10 a.m. LPA met with the Executive Director, Britney Buchannan, the Health Services Director, Beatriz Martinez, the Memory Care Director, Ethan Reid and the Business Director, Leigh Ikeda. LPA explained the purpose of the visit. An entrance interview was conducted. LPA was provided copies of the resident roster, staff schedule and staff assignments. At approximately 10:30 a.m. while waiting to conduct a physical plant tour LPA interviewed two (2) residents. At approximately 10:40 a.m. LPA along with the Health Services Director and the Memory Care Director, conducted a physical plant tour to ensure the health and safety of the residents in care. From 10:51 a.m. to 2:06 p.m., LPA interviewed eight (8) out of (9) residents with one (1) resident refusing to be interviewed and eight (8) staff, four (4) of which provide direct care to residents as caregivers. From 2:45 p.m., LPA reviewed four (4) resident files. LPA reviewed and obtained copies of residents' physician's reports, appraisals, service plans and assessments. (Continue to LIC9099-C) Substantiated Allegation: Staff is not able to meet resident's needs due to inadequate staffing. In regards to the allegation it is alleged that over the past 30 to 40 days there is not enough staffing at the facility to assist residents. Interview with the Executive Director revealed caregiver assistance is dependent on the level of care a resident may need or requires. Caregivers are provided assignment sheets with residents names to provide assistance to. Assistance with activities of daily living is dependent on what level of care the resident was assessed for. Caregivers are still required to respond to call button alerts from residents not on assignment sheet. Review of two (2) assignment sheets for the assisted living unit provided revealed 31-36 names with residents requiring varying degrees of assistance with toileting, transfer, bathing, dressing, grooming , escorting or status checks. For the assisted living unit there are three (3) shifts with three (3) to four (4) caregivers and one (1) to two (2) med-techs per shift with exception to the overnight shift. Interviews with staff and residents revealed on Wednesday, July 17, 2024 at 6 a.m. the Wellness Nurse at the time received a call from a med-tech informing her the only two (2) caregivers on site for the assisted living unit of the facility were threatening to walk out if they did not have a third caregiver on site. Both caregivers, Staff #1 (S1) and staff #2 (S2) confirmed in interviews they had been working with only two staff on most days for about two weeks and had gone from four caregivers to three caregivers prior to the two weeks. Interview with Health Services Director corroborates on the day at 6 a.m. staff threatened to walk out and were not performing their usual duties if a third caregiver did not arrive. Staff walked out at approximately 6:45 a.m. - 7 a.m. without having provided care to residents in the assisted living unit. Health Services Director, states the Wellness Nurse at the time called a caregiver from the Memory Care unit to cover until more staff arrived. LPA was able to confirm with memory care staff they received a call from the Wellness Director at 6:55 a.m. to assist. Three other staff arrived and were able to provide assistance to residents some time around 7:30 a.m. Interviews with five (5) out of the eight (8) residents interviewed revealed they have waited over 30 mins to receive assistance with four (4) of those residents citing the specific incident that occurred on Wednesday as one of the days they waited over 30 minutes. One (1) out of the eight (8) residents indicated that they have only heard from other residents concerns about response time. Seven (7) out of eight (8) residents interviewed are satisfied with the care being provided only citing the wait time to receive the assistance as a concern. Interviews indicate Wednesday was an Isolated incident, however, interviews indicate staffing has been a concern prior to the incident. Therefore the allegation is deemed Substantiated at this time. Exit Interview conducted. Deficiencies cited (refer to LIC 9099-D). Appeal Rights explained and provided. Copy of report provided Executive Director via email.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 31-AS-20240719164328

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 25, 2024

(a)Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports....This requirement is not met as evidence by: Based on interviews conducted, residents and staff revealed, residents have waited an unreasonable amount of time to receive assistance citing the number of staff on shift to provide care, which posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: Executive Director (ED) stated a job fair is being held July 31st. Facility has hired two caregivers. ED also states staff involved on Wednesday were given final write ups. Facility provided copies of in-service held on various topic including but not limited to individualize service plans and status checks. POC cleared today.

Allegation investigated: Memory care unit is in unsanitary condition. Facility has shortage of cleaning supplies. Facility has insufficient staffing to meet the needs residents. Facility has roaches.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Memory Care Director, Ethan Reid, and explained the reason for the visit. ---Memory care unit is in unsanitary condition. It was alleged that Resident #1 (R1) is in unsanitary condition, the odor in the room is very bad and has bowel movement in fingernails and carpet. To investigate the allegation, on 02/22/2024 LPA conducted a physical plant tour of memory care unit (Evergreen) at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. LPA was unable to interview residents. During the physical plant tour, LPA observed that all residents were clean and well groomed. LPA selected six (06) rooms at random, including R1’s room, and did not observe any stains on the carpet or experience any malodor. (CONT on LIC 9099-C) Unsubstantiated During interviews with staff, all staff stated the residents, and their rooms are always clean, and staff have never been witnessed residents with bowel movement under their fingernails. Staff stated the only time malodor is present is when residents has had a movement and when they are being changed. Staff added that residents are checked on every one (01) to two (02) hours or as needed. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Facility has shortage of cleaning supplies. It was alleged that staff bring cleaning supplies from home because manager told them that heavy duty cleaning supplies are not within the facility budget. To investigate the allegation, on 02/22/2024 LPA conducted a physical plant tour of memory care unit (Evergreen) at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. During the physical plant tour, LPA observed an overabundance of cleaning supplies. The cleaning supplies are refilled by a third-party agency as part of a subscription. During interviews with staff, all staff stated that they have never purchased cleaning supplies with their own money and that the facility has plenty of cleaning supplies available. Staff #1 added that a former staff once purchased a preferred cleaning supply but was immediately refunded and asked not to do it again. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Facility has insufficient staffing to meet the needs residents. It was alleged that residents require extensive care and supervision and are left in bed. To investigate the allegation, on 02/22/2024 LPA requested documents at around 5:15 PM, conducted physical plant tour of memory care unit (Evergreen) at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. LPA was unable to interview residents. A review of the staff roster and schedule shows that there are three (03) caregivers and one (01) MedTech during each shift. During interviews with staff, all staff confirmed that there are three (03) caregivers and (01) MedTech during each shift. (CONT. on LIC 9099-C) Staff added they are each assigned up to six (06) residents and that of the six (06), one (01) to two (02) residents are scheduled for showering and that between four (04) to five (05) residents require assistance with activities of daily living such as bathing, toileting and dressing which can take up to thirty (30) minutes per resident. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Facility has roaches. It was alleged that there are roaches and bugs in the facility caused by leftover food in the cabinets and counter tops. To investigate the allegation, on 02/22/2024 LPA conducted physical plant tour of memory care unit, Evergreen, at around 5:20 PM and interviewed four (04) staff between 6:00 PM to 07:00 PM. LPA was unable to interview residents. During the physical plant tour, LPA checked every counter top, drawer, cabinet, under the refrigerator, and cabinets and did not observe any leftover foods, roaches or signs of roach excrement. During interviews with staff, all staff stated they do not leave food on the counter tops and have never witnessed roaches in the facility. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 16, 2024 · control 31-AS-20240216140950

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Antonia Alvizar and Gary Tan arrived at the facility at 9:00 AM today to conduct a One (1) year Required visit. LPAs initially met with Activity Director, Krista Cheshire, later joined Administrator, Dawn Smith and explained the purpose of this visit. The facility has an approved mitigation and infection control plan on file. LPA Alvizar and LPA Tan utilized the Compliance and Regulatory Enforcement (CARE) tools, and a tour of the physical plant was conducted at 11:00 AM with Krista Cheshire and Keith Bernabe during today visit and observed the following: The facility has a fire clearance for one hundred (100) non ambulatory of which, 30 maybe bedridden. Hospice waiver for twelve (12) residents. Delayed egress is approved for Dementia Unit on second floor. Required postings were observed in the entry area. The facility's smoke alarms are hard wired as back up and tests are done on a monthly basis. Fire drill was last conducted on September 03, 2023. There are fire extinguishers throughout the facility hallways on all eight (8) floors, all extinguishers were last serviced on January 05, 2023. The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE supplies is located at the Executive Director office and Medication Room upon entry there is hand sanitizers by the elevator and sign in sheet at the time of visit. The facility maintains a temperature of 75 degrees Fahrenheit. All eight (8) floors have a mini activity room located at the end of each floor. Continued on LIC809C Bedrooms: At 11:30 AM LPAs were able to observe ten (10) random rooms from each floor. All bedrooms observed to be appropriately furnished with sufficient lighting. LPAs observed appropriate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction. Bathroom: At 11:30AM LPAs observed ten (10) bathrooms located in the bedrooms. LPAs observed appropriate grab bars located in the shower and around the toilet. The water temperature measured in range of 113.7 between 118.0 degrees Fahrenheit. Non-skid mats were located in the shower. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared. Laundry Room: At 11:10 AM LPAs observed the laundry rooms located on the and first floor for commercial laundry, fifth and sixth floors for resident clothing residents have access to the laundry area to do their own laundry, clean and clear from obstruction and storing laundry supplies. Medications: LPA observed two (2) medication carts at 11:15 AM stored in the medication room on the first floor to be locked and storing medication and inaccessible to residents. The refrigerator was observed to be doubled locked storing narcotic medications. The facility has first aid kits located in the medication room. Theater room, living/game room on each floor, and common areas: At 11:45 AM LPAs observed these areas to be appropriately furnished with tables and chairs and adequate lighting. Observed to be neat and clean. The facility has a gym on the eighth (8) floor currently being used by a resident at the time of inspection. The theater room is located on the 8th floor and was unoccupied at the time of inspection. LPAs observed two (2) outdoor patio areas, one located outside the lobby, the second behind the Private Dining Room, and the surrounding grounds of the facility which were clean and clear from debris and obstruction. These areas are equipped with owing and tables with chairs for seating and additional tables and chairs for lounging. LPAs observed a Fire Department Fire Protection Equipment Performance Report dated 03/24/2023 to have passed, the fire alarm system are hard wired and interconnected throughout facility and tested internally every month. The facility has a fire sprinkler system. No body of water was observed or located on the premises. No deficiencies cited, exit interview conducted, and a copy of report issued.the state’s words, verbatim · CDSS document, Oct 14, 2023