Jasmin Terrace at El Molino

Allegation investigated: Resident wandered from the facility due to lack of staff supervision. Resident sustained a fall resulting from lack of staff supervision.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met with Virginia Garcia and explained the reason for the visit. The investigation consisted of the following: On 3/14/23 LPAs Flores and Zaragoza conducted an initial complaint investigation visit and requested a copy of the staff and resident roster, interviewed assistant administrator, reviewed Resident #1(R1)'s file and requested the following copies: incident report dated 3/7/23, identification and emergency information sheet, physician's report dated 3/7/23 and 4/28/21, individual service plan, admission agreement, hospital discharge documents dated 3/5/23. In addition, copy of warning report for staff #2(S2). LPA Flores interviewed R1. On 10/31/23 LPA Flores interviewed administrator and staff #3(S3) and S2 over the phone. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegations: Resident wandered from the facility due to lack of staff supervision and Resident sustained a fall resulting from lack of staff supervision. It is alleged R1 exited the residential care facility unsupervised and subsequently fell 3 blocks north of the location and was later transported to the hospital. Documents reviewed revealed; On 3/5/23 Pasadena Police Department officers responded to a report of an individual who had fallen on the sidewalk, upon responding the individual was identify as R1 and per protocol transported to the emergency room at Huntington Hospital for an evaluation. Incident report dated 3/7/23 notes R1 left the facility on 3/5/23 at 5:16pm and was taken to the hospital due to a fall. Physician’s report dated 2/2/23 notes R1 has dementia and cannot leave the facility unassisted. Hospital discharge dated 3/5/23 notes R1 was evaluated for brain and cervical trauma and was discharge back to the facility on 3/6/23. On 3/6/23, S2 was given a warning with a (3) three-day suspension for “danger of resident going out the front desk door”. LPA attempted to interview R1 however due to cognitive skills was not able to obtain information. Interviews with staff determined the incident did happen and corroborated that R1 fell down upon leaving the facility unassisted. Per S2, forgot to turn switch to lock the front door and did not notice when R1 left the facility. Upon caregivers inquiring S2 reviewed video footage and saw R1 leave the facility, notify other staff and went out looking for R1. S2 noticed people and police officers assisting R1, who was on the floor, and was transported to the hospital. Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are 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 was conducted with Virginia Garcia and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 28-AS-20230306144748

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 1, 2023

87468.2 Additional Personal Rights of Residents...: a)...residential care facilities ...shall ...: 4)..., supervision,... that meet... and are delivered by staff that are sufficient in..., qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 left the faciltiy unassisted and R1 obtained a fall while unsupervised which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Adminsitrator will ensure that all staff are qualify, sufficient in numbers, and competent to perform their duties and will schedule in-service training on prevention of wandering by POC due date 11/1/23. Will provide a copy of in-service with date, duration, and subject by 11/7/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(8) · Plan of correction due date: Nov 1, 2023

87705 Care of Persons with Dementia (k) The following...must be met...: (8) Delayed egress devices shall not substitute for trained staff... to meet... supervision needs of all residents and to escort residents who leave the facility. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 left the facility unassisted through the front door while a staff was at the front desk which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Adminsitrator will ensure that all staff are qualify, sufficient in numbers, and competent to perform their duties and will schedule in-service training on ensuring egress system is working and escorting residents outside the facility by POC due date 11/1/23. Will provide a copy of in-service with date,

Allegation investigated: Staff attempted to financially abuse resident while in care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Malou Bernardo and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident rosters. Interviewed administrator, staff #2-#5(S2-S5), and resident #1-7(R1-R7). Reviewed R1’s file and requested copies of physician’s report, face sheet, admission agreement, assisted living waiver(ALW) individual service plan agreement, resident’s facility invoices. LPA attempted to interview ALW’s social worker and R1’s family members. The investigation revealed the following: Regarding allegation: Staff attempted to financially abuse resident while in care. It is alleged resident was brought inside the branch in a wheelchair by two facility’s employees and stated were “here to help assist resident with getting a debit card and a cashier's check”. (CONTINUED ON LIC 9099C) Unsubstantiated Interview with Administrator and Assistant administrator revealed R1 was recently admitted to the facility and have attempted to obtain the family’s assistance but have not been able to. Facility is assisting R1 with arranging finances as currently R1 is self-responsible for own finances and recently obtained financial information from social security. Assistant administrator, driver, and R1 visited R1’s banks to assist R1 with access to accounts. Although assistant administrator spoke with bank staff, R1 provided the information for the account. Per documents reviewed R1 was admitted to the facility on 5/9/23. Physician’s Report dated 5/3/23 notes R1 has dementia and cannot handle own cash resources. However, ALW’s individual service plan notes R1 is legally self responsible. Interviews conducted with additional residents revealed the facility’s staff does not become involved in their financial decisions. Residents are taken to make purchases which they pay for on their own. Interviews conducted with staff revealed facility’s driver assist residents with going to appointments, stores to shop, bank, etc. Driver uses facility’s fund trust credit card to make purchases for residents when the residents request something and they cannot go. Although the facility did take R1 to the bank and communicated R1’s needs, the staff was not attempting to financially abuse R1. However, staff attempted to assist R1 with access to R1’s accounts in order for R1 to be able to finance R1’s current needs. The facility is currently assisting R1 with the process of guardianship or having a responsible party due to R1’s change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Virginia Garcia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 28-AS-20231024124234

Allegation investigated: Staff do not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Elizabeth Kirk and explained the reason for the visit. The investigation consisted of the following: LPA requested staff/resident rosters. Interviewed administrator, staff #1-#3(S1-S3) and residents 1-7(1-7). LPA requested a copy of physician's report, identification and emergency information sheet, admission agreement, and personal property and valuables sheet for R1. The investigation revealed the following: Regarding allegation: Staff do not safeguard resident's personal belongings. It is alleged many of resident’s personal belongings have gone missing since they were transported to the facility. Interviews conducted with residents revealed, 5 out 8 residents stated that personal belongings have not disappeared from their rooms and when they moved in all their items were provided to them. (CONTINUED ON LIC 9099C) Unsubstantiated 2 out of 8 residents stated that items have disappeared and did not know what happened to them. 1 out of 8 residents was unable to answer questions due to cognitive skills. Interviews with staff revealed, 4 out of 5 staff interviewed stated that recently they have been assisting a resident who moved-in on 8/9/23 to bring personal items from the resident’s previous residence to the facility. Per staff resident has stated that personal items have gone missing. However, the items have been found in the room or are still slowly being cleaned and provided to the resident. Assistant administrator explained that the resident requested assistance with brining items from the previous residence to the resident’s room. Upon going to the previous residence and picking up the items staff observed an infestation of bugs in the apartment. Therefore, the staff decided to continue to assist the resident but in order to prevent bringing any bugs into the facility they will clean the items first. Prior bringing the items into the resident’s room, the staff are cleaning, ensuring there are no bugs in the items, washing the clothes first. The resident was made aware about this process and explained the reason why it was being done that way. Although the items may have not been provided to the resident right away. The facility is ensuring to avoid an infestation of bugs inside the resident’s room and the items are being provided to the resident clean. Document reviewed revealed resident had 3 items listed on the personal property and valuables upon arriving at the facility. An update of the personal property and valuables is to be done upon resident has all her items in the room as the transition is still on going since the resident moved in. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20231016153749

Allegation investigated: Staff did not intervene in resident-on-resident dispute.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Alejandra Cevallos Front desk and contacted Virginia Garcia administrator via telephone and explained the reason for visit. The investigation consisted of the following: LPA requested a copy of resident/staff roster. Reviewed file for Resident #1 and #2. Requested copies of face sheet, physician's report, individual service plan, resident appraisal, clinical flex notes for R1 and R2. LPA interviewed residents #1-10 (R1-R10) and staff #1-#5(S1-S5). The investigation revealed the following: Regarding allegation: Staff did not intervene in resident-on-resident dispute. It is alleged the staff had been aware of the first verbal threat being made by R2 towards R1 about one week ago before the police were called. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 8 out of 10 residents stated to not have experience verbal arguments with other residents. Residents stated to feel safe, and that staff will aid right away to a situation like that. 1 out of 10 residents was unable to be interview due to cognitive skills. 1 out of 10 residents stated to have been verbally threaten by another resident and that initially had requested to stay in the room as did not feel the other resident could be harmful. R1 stated staff move R1 to another room the second time R1 mentioned the situation to the staff the same day. Interviews with staff revealed the following: On 7/6/23 R1 moved into room #233 and was alone until roommate returned from the hospital. On 7/27/23 R1 was moved to room #209 per R1’s request as he stated not to be able to sleep due to new roommate. R1 resided in room #209 for some weeks without concerns. About a week before 8/27/23 R1 stated to assistant administrator not being able to sleep due to R2 talking and giving verbal threats at that time R1 was giving the option of moving to another room. However, R1 stated to want to stay in that room. The second time R1 brought up the situation on 8/27/23 in the morning, staff acknowledged R1 and told R1 a different room will be assigned for R1 that night. R1 was moved to room #228 on 8/27/23 before the end of the day. Per document review, R2's physician's report dated 4/22/23 does not note any aggressive or inappropriate behaviors. Both residents have individual services plans in place. Clinical Flex notes noted incident on 8/27/23 which provide the communication between R1 and staff and the determination of moving R1 to a different room the same day before Pasadena police officer arrived at the facility the afternoon of 08/27/23. No history of previous incidents was noted on either residents file. Incident report was not available for review at the time of the visit or submitted to the department within the required 7 days. Although the situation may have happened facility staff address the situation and provided alternative room for R1 upon being presented to the staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 5, 2023 · control 28-AS-20230828111941

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding deficiencies found during a complaint investigation. LPA met with Lori Lackey and explained the reason for the visit. On 9/5/23 LPA conducted a complaint investigation visit. During file review LPA did not find or was provided a copy of incident report regarding incident occurred on 8/27/23. On 8/27/23 Pasadena Police Department conducted a visit and open case number PA23-71105. The call was made by a resident to follow up on verbal threats by another resident. The department reviewed incoming incident reports and did not find incident report on file. Deficiencies are noted on LIC 809D per Title 22 regulations. Exit interview was conducted with Lori Lackey and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 8, 2023

87211 Reporting Requirements: (a) Each licensee shall furnish... (1) A written report ... within seven days of the occurrence of any of the events... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse... This requirement is not met as evidence by: Based on document review licensee did not ensure a copy of incident report was provided during the visit or submitted to the department within 7 seven of incident occured on 8/27/23 which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2023

Plan of correction: Administrator will submit incident report for incident on 8/27/23 to the department by POC due date 9/8/23.

Allegation investigated: Staff not providing adequate service to resident in care.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with administrator and explained the reason for the visit. The investigation consisted of the following: On 6/8/22 LPA Flores requested a copy of staff/resident roster, conducted interviews with Assistant Administrator(S1), resident #1-11 (R1-R11), staff #2 (S2) and requested copies of the following documents: Admission Agreement, Identification and Emergency Information, Appraisal Needs and Care Plan, Flex Notes for R1 and Foot and Ankle Care logs. On 8/15/23 LPA Flores interview staff #3-#5(S3-S5) and delivered findings. The investigation revealed the following: Regarding allegation: Staff not providing adequate service to resident in care. (CONTINUED ON LIC 9099C) Unsubstantiated It is alleged R1 had two layers of clothes on, hair not combed, pressure sock put on wrong and toenails were not cut when family member visited. Interviews conducted on 6/8/22 with residents revealed 11 out of 11 residents interviewed stated staff provides assistance with changing clothes, showers, and Activities of Daily Living (ADLs). Residents also stated a podiatrist provides visits once a month to cut their toenails. 2 out of the 11 residents interview stated to not need assistance with cutting their toenails because they cut them themselves. Administrator assistant and Wellness Director stated staff provide assistance with ADLs by showering, grooming, and changing clothes in the morning. A podiatrist is in rotation who provides services for cutting toenails every 6 weeks for residents. Staff makes notes when residents refuse services. Interviews with additional staff revealed staff assist with changing clothes, showers, and that podiatrist is notified when residents need to cut their toenails. Caregiver (S3) stated to provide care for R1 consistently. Although S3 has come across R1 wearing layers of clothes. S3 has redirected R1 and assisted with removing additional layers. However, when R1 refuses S3 provides time and returns to assists with removing additional layers and R1 is compliant at the time. Document review revealed, physician's report dated: 6/22/21 notes R1 is able to communicate his/her needs and follow instructions. R1 seems to be able to perform most ADLs and needs assistance with showers. Physician's report dated: 6/2/22 notes a change in condition and R1 no longer follows instructions. No other changes were noted. Individual Service Plan dated: 3/4/22 notes staff is to assist R1 three times per week with grooming and supervisors will ensure ADLs are completed daily. It also notes staff will redirect R1 to current situations and reality as needed. Foot and Ankle Care logs dated 2/3/22, 3/3/22, 5/3/22 note R1 received services from the podiatrist on those dates. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 28-AS-20220601164319

Type of visit: Case Management - Incident

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 6/30/23. LPA met with Virginia Garcia administrator and explained the reason for the visit. On 6/30/23 facility submitted incident report regarding resident #1(R1). On 6/26/23 R1 sustained a fall during an episode of seizure while taking a shower. At the time of the incident R1 was evaluated by supervisor. After the seizure R1 was in sleep state and unable to communicate symptoms. Per wellness director, hospice was contacted. A nurse arrived to evaluate R1 within 30 minutes of incident, and verbally provided recommendations for R1. On the morning of 6/27/23 caregiver went to assist R1 and noticed R1 was moaning. Facility contacted hospice and responsible party at that time. On 6/27/23 hospice requested a x-ray. On 6/28/23 x-ray was conducted and revealed R1 sustained a subcapital fracture of the femoral neck to the right hip. Per documents reviewed, R1 was admitted to hospice after "an episode of seizure" on 2/2/23. Last physician report was conducted by hospice doctor on 6/22/23. R1 is currently on comfort care under hospice at the facility. LPA requested copies of physician's report dated 6/22/23, hospice care plan dated 2/2/23, verbal orders dated 6/27/23, physician's order dated 6/26/23 and 6/29/23, hospice communication sheet dated 6/22, 6/26,6/27,6/29/23, x-ray interpretation dated 6/28/23, hospital discharge dated 1/28/22, hospice initiation letter dated 2/2/23, and unusual incident report dated 6/29/23, appraisal/needs and service plan dated 6/22/23, advance health care directive dated 3/1/10, and medication sheet for July 2023. Facility staff is following hospice care plan and healthcare designated agent's request to provide comfort care for R1 and is currently updating appraisal/needs and service plan. No deficiencies were noted during this visit. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 6, 2023

Type of visit: Case Management - COVID-19

LPA Flores conducted an unannounced case management visit regarding COVID 19 guidelines notify to the department via email during an annual visit on 2/27/23. LPA Flores met with Lori Lackey Assistant administrator and explained the reason for the visit. On 2/6/23 LPA Flores was copy on an email and received a picture of Staff/Administration #1 - Conrad Garcia in the dining room on a phone call without a face mask. On 2/25/23 LPA Flores was copy on an email notifying staff #2 - Rocio Gonzalez Wellness Director was observed without a face mask at the facility. During an unannounced annual visit conducted on 2/27/23 LPA Flores interview staff#2 who recognize she had arrived at the facility without a mask and there were no face mask available in the front desk, leading staff to walk to her office to get a face mask. Per receptionist face mask had to be replenish the morning of 2/25/23. Deficiencies have been noted on LIC 809D. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(c)(1)(F) · Plan of correction due date: Mar 6, 2023

(c) An Infection Control Plan...shall be included in the Plan of Operation required by Section 87208.(1)... shall includ e...:(F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidence by: Based on interviews conducted Licensee did not ensure staff are following COVID 19 guidelines and supplies are replenish over night which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 27, 2023

Plan of correction: Administrator will ensure all staff are knowledge of all current guidelines regarding face mask around the facility and will ensure supplies are available at the front desk at all times. Certification in writting will be submitted to the department by POC due date 3/6/23.

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, medication, and food review. LPA Flores met with Rocio Gonzalez Wellness Director and explained the reason for the visit. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the facility. LPA Flores conducted a tour of the facility with Rocio Gonzalez Wellness Director and observed the following: Upon arriving at the facility, receptionist conducted screening of LPA and observed signing logs with COVID related questionnaires. Signs are posted throughout the common areas, social distance was observed among the residents. Staff were observed wearing face masks. Facility has a commercial kitchen. Kitchen is clean and food supplies were observed to be sufficient food for at least 2 days of perishables and 7 days of non-perishables. Facility has obtained a temporary walking freezer that is maintain outside the kitchen while repairing the indoor walking freezer. LPA observed the following rooms # 123,130, 223, 235, and 239. Each room has sufficient lighting, proper furniture, and bedding supplies. Each room has a private bathroom in working condition with grab bars, and skid strips/mats and water temperature was tested between 100.0 - 110.6 degrees F. which is not within the required 105-120 degrees F. LPA Flores checked medication for 5 residents. Administrator Certificate #6020807740 exp: 1014/24 was observed for Virginia Garcia and a copy of Liability Insurance was required. Deficiencies have been noted on LIC 809D and a copy of this report, LIC 809D, and appeal rights have been provided during exit interview with Lori Lackey Assistant Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2023

Allegation investigated: Resident suffered a fracture while in care.

Licensing Program Analyst (LPA) Mary Flores and Licensing Program Manager (LPM) Tony Vasallo conducted an informal office meeting to deliver findings for this complaint and met with Virginia Garcia Administrator. The investigation consisted of the following: On 3/4/21 LPA Flores conducted a video call which consisted of a Health and Safety check by conducting a tour of the facility. LPA observed that the facility is in good repair and clean. LPA requested staff/resident rosters and the following documents for residents #1,#2,#3,#4,#5,#6, Caregiver Logs for February 2021, Incident Reports, Face Sheet, Hospice Service Notes. On 3/4/21 the investigation was assigned to Investigator Edward Hector, who conducted interviews with Administrator, resident #1 (R1), staff members #1,#2 (S1, and S2) and collected hospice documents, physician report dated 3/2/21, facility's flex notes, hospice documents for resident #1(R1). On 2/18/22 a referral was made to the department's program clinical consultant. (CONTINUED ON LIC 9099C) Substantiated On 1/10/23 LPA requested physician's report dated and hospice documents for Grigmar Hospice Care. On 1/25/23 LPA delivered findings for the above allegation(s). The investigation consisted of the following: Regarding allegation: Resident suffered a fracture while in care. It is alleged a left hip fracture involving R1 resulted on a serious bodily injury. Interviews revealed that on 2/23/21 R1's family member visited at around 5:00pm and found R1 in gery chair with a robe on and staff was in the bathroom at the time of the visit. Family member notified administrator of incident. At 7:40pm family member informed facility staff that R1 had pain in left hip, facility staff notified family member that R1 had not have any falls or injuries. R1's physician was at the facility checking other residents and around 7:40pm was called in to check in on R1 and evaluated R1. Physician at that moment did not think there was a fracture, however physician ordered an x-ray to determine if there was a fracture. On 2/24/21 at 12:10am facility received x-ray results noting "acute left hip fracture". On 2/24/21, R1 was taken to the hospital for treatment. R1 was under Grigmar Hospice care at the time. Hospice notes dated 2/23/21 at 9:10pm note R1 had swelling of the left hip and showed facial grimace when moving or lifting left leg. Administrator conducted an internal investigation on 2/24/21 and did not find evidence that S1's neglect or actions caused R1 to sustain a hip fracture. Administrator also stated not observing any bruising or evidence of a fracture on 2/23/21. Administrator advised that staff are to conduct a 2 person assist when showering R1 and it was discovered S1 conducted the shower alone on 2/23/21. R1 was unable to be interviewed due to R1's cognitive skills. Interview with S1 revealed, S1 stated staff is to utilize a 2 person assist when showering the residents. However, on 2/23/22 S1 did not ask for assistance to provide R1's shower. Documents review revealed R1 has a history of hip fracture and osteoporosis per physician's report dated 3/2/21. Radiology report dated 2/23/21 notes an acute left hip fracture. Based on interviews and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore, the 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. ***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM*** An exit interview was conducted with Virginia Garcia Administrator and a copy of this report, LIC 809D, and appeal rights were provided. On 1/10/23 LPA requested physician's report dated and hospice documents for Grigmar Hospice Care. On 3/18/23 LPA delivered findings for the above allegation(s). The investigation revealed the following: Regarding allegation: Facility fail to notify responsible party of change in condition. It is alleged family member was not notify of fracture upon x-ray results were received. Responsible party stated that from 2/23/21 to 2/24/21 between 11:00pm to 8:30am was not notify of x-ray results or provided an update on R1's change in condition. Documents review revealed facility's flex notes dated 2/24/21- 12:10am note facility received x-ray results noting "acute left hip fracture". Upon receiving the results facility staff contacted physician to notify the x-ray results and physician requested facility notified responsible party. Per facility's notes staff left a voice message for R1's responsible party, notifying to contact the physician in the morning of 2/24/21 as requested by the physician to discuss R1's treatment options. 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. Regarding allegation: Facility has insufficient staff. It is alleged facility does not have sufficient staff to provide care to the residents. During interviews conducted administrator stated that on 2/23/21 S1 was to provide shower with a 2 person assist and staff did not requested assistance, the incident would have resulted in a third disciplinary notice if S1 had not resigned. S2 who has provided consistent care for R1 stated to have not conducted transfers for R1 around 2/23/21. However S2 stated, whenever needing to transfer R1 out of bed S2 has always provided transfer with a 2 person assist. On 2/23/21 S1 stated to have proceeded to provide shower without requesting assistance from other staff. Documents review revealed February's caregiver schedule for 2/23/21, notes 8 caregivers on duty for the morning shift, 7 caregivers on duty in the evening shift, and 4 caregivers in the night shift. Per administrator during the morning shift each caregiver was providing care for about 12 residents and during the evening shift each caregiver was assigned to at least 15 residents for care. 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 was conducted with Virginia Garcia Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 25, 2023 · control 28-AS-20210303163807

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 26, 2023

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, and documents reviewed the licensee failed to ensure R1 did not sustained a hip fracture while in care which poses an immediate health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: Licensee will ensure facility's plan of operation identify the number of caregivers necessary to provide assistance with transfer and will submit a copy by 1/26/23. Number of caregivers should be identified in care plan and discuss with caregivers. Administrator will provide hoyer lift training for staff and will submit copies by 2/1/23.

Type of visit: Office

Licensing Program Analyst(s) (LPA) Mary Flores and Licensing Program Manager (LPM) Tony Vasallo conducted an Informal Office meeting at the regional office with Virginia Garcia Administrator. During the meeting the following was discussed: The purpose of the meeting was explained to the administrator Virginia Garcia. LPA Flores provided findings for complaint #28-AS-20210303163807. Findings regarding allegation resident #1(R1) sustained a fracture while in care were substantiated as there was enough evidence during interviews conducted and records reviewed. Additional staffing to ensure sufficient staffing for each shift. When hiring staff through registry facility is to ensure staff is properly trained to perform duties. Facility provides training to staff in English/Spanish. Additional deficiency is noted during this visit related to complaint investigation where it was revealed that staff #2(S2) was discovered using Resident #1's (R1) private bathroom. On 2/23/21 R1's responsible party visited R1 upon walking into the room found R1 sitting in a chair and S2 exiting R1's bathroom pulling him/her pants up. S2 confirmed he/she used R1's bathroom and it was not unusual for staff to use the resident's bathrooms. S2 had been provided two disciplinary notices prior to the incident. Disciplinary notice dated: 2/21/20 notes S2 used another resident's bathroom to shower another resident. Disciplinary notice dated: 7/13/20 notes S2 yelled at another staff who was attempting to assist S2 with resident care. S2 reassigned to the position as a caregiver after the incident. Plan of correction for deficiencies were discussed with Administrator. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Virginia Garcia Administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 25, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 21, 2023

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: Based on documents review licensee did not ensure S2 follow residents rights by using R1's private bathroom which poses a potential health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Jan 25, 2023

Plan of correction: Administrator will provide a plan with topics and identify consultant agency to provide proper personal rights training by 1/26/23 and will submit training agenda and sign-in by 2/8/23.

Allegation investigated: Facility staff did not provide resident(s) meal(s) in a timely manner. Facility staff gave resident unsanitary/dirty fruit.

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Administrator Virginia Garcia and Assistant Administrator Lori Lackey and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Administrator Virginia Garcia, Assistant Administrator Lori Lackey, Staff 1-4, and Residents 1-11 (R1-11). LPA obtained copies of Staff and Resident Rosters and facility menu including Menu Substitutions and Menu for Soups of the Day. LPA conducted a tour of enitre facility inside and out. The tour included observations of faciility kitchen, food supply and dining area(s). (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Facility staff did not provide resident(s) meal(s) in a timely manner, it is alleged that facility residents wait long periods of time for their meals. Interviews conducted with 6 out of 6 staff revealed that the facility residents are served all their meals on time. Staff stated that the facility is still providing tray service to some residents due to the COVID19 pandemic and that some residents eat in the dining room. They stated that all meals are always served and/ or delivered in a timely manner. Staff stated that residents also do not wait long when they request an alternate food item if they happen to not like what is on the menu that day. Interviews conducted with 11 out of 11 residents revealed that they are served all their meals timely and they never wait long periods of time for their food to be served and/ or delivered. 11 out of 11 residents stated they are satisfied with the food service and do not have any concerns regarding the food service or anything else. They also stated that if they request an alternate food item they do not wait a long time. During the time of the visit, LPA observed residents being served breakfast and also lunch. LPA observed the meals to be served timely and being prepared to be served in a timely manner. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. For allegation, Facility staff gave resident unsanitary/dirty fruit, it is alleged that residents are served food that does not look fresh and it is also alleged that a staff member picked up fruit from the floor and returned it to a bowl and gave back to a resident to eat. Interviews conducted with 6 out of 6 staff revealed that the facility residents are always served fresh, sanitary and clean food. Staff deny that residents are ever given anything food item that has fallen on the floor back to them to eat. Staff stated that when residents drop food they are given another serving. Staff also stated that if residents drop any silverware it is also replaced with a clean one. Staff stated that all food is always served fresh including meals that are alternates/ substitutions which are served when a resident requests it due to them not wanting to eat what is on the menu. Staff also stated that meals that are delivered via tray service are covered for delivery and uncovered when it is delivered to the residents. Interviews conducted with 11 out of 11 residents revealed that they are satisfied with the food service and do not have any complaints about it. 11 out of 11 residents stated that the food is served fresh, their fruit is fresh and clean. They stated that they are never served food that does not look fresh and are never served food that fell to the floor. 11 out of 11 residents stated that they do not have any concerns regarding the food or anything else. During the time of the visit, LPA toured the facility kitchen and inspected the food supply. LPA observed the fruit and vegetables and other fresh food items to look fresh and all food that staff was in the process of preparing for lunch delivery was covered with plastic wrap. LPA also observed an ample amount of food. There was enough food for 7 days non-perishables and 2 day perishables. Based on interviews conducted with facility staff, facility residents, and LPA observations there was not enough supportive evidence to concur with the reported allegation. 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. A copy of the report was provided to Administrator Virginia Garcia.the state’s words, verbatim · CDSS document, Jan 20, 2023 · control 28-AS-20230113110129

Allegation investigated: Facility is in disrepair Facility is unkempt

Licensing Program Analyst(LPA) Christine Wong conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Denise Miller (Office Coordinator) and explained the reason for the visit. Shortly after the assistant administrator Lori Lakcey and administrator Virginia Garcia arrived and assisted with the visit. The investigation consisted of the following: On today's date, LPA interviewed 11 residents and 6 staff and administrator, obtained staff resident and staff roster and toured the facility (1st Floor). The investigation revealed of the following: In regard to the allegation of "Facility is in disrepair" LPA interviewed 11 residents and 10 out of 11 residents reported the facility is in good condition and good repair. The residents reported they did realize there's flooding in the facility a week ago but does not affect them at all. It's only part of the area on the first floor. (See LIC 9099C for continuation) Unsubstantiated LPA also interviewed staff and reported facility is a good repair and no residents even complaint about the facility was in disrepair. Administrator reported they did have the flooding issue about a week ago but everything is dry up already. It only flooded part of the area on the first floor which included two residents room (Room#101 and #103), family room and hallway near the dining area. When the flooded came, they immediately removed those two residents' rooms to another room and administrator immediately called staff to come into the facility and helped out and pushed the water out and dry the facility by using the suction machine. After two to three hours, all water was pushed out and there were no more flooding. The plumbing company also came and assessed the problems which was the pipe issues and may have to replace it all. LPA also toured the two residents' rooms, hallway and family room and currently everything is in good condition. In regard to the allegation of "Facility is unkempt" LPA interviewed 11 residents and 10 out of 11 residents reported the facility is well kept. They have no issues with their rooms and everything is working probably in their rooms. LPA also interviewed staff and all denied the allegation. LPA also toured the facility and LPA did not observe any flooding or water traveling from shower to the toilet in residents' rooms. LPA also did not observe any hole in the ceiling in the dining room. Administrator also reported no resident ever complaint about the facility is unkempt and also they are in the process of doing different renovations in the facility which to maintain the facility to be up-to-dated. Based on the interviews conducted with residents and staff and LPA's observation, 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 conducted with Virginia Garcia Administrator and a copy of this report and appeal right was provided.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 28-AS-20230112164253

Allegation investigated: Resident was assaulted by another resident Resident care needs are not being met

*This is an amended report of report provided on 8/2/22 to change finding from unsubstantiated to substantiated and provide correct deficiency for allegation Resident was assaulted by another resident, and provide additional information for allegations above.* On 8/2/22 Licensing Program Analyst(LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation(s). LPA met with Lori Lackey assistant administrator and explained the reason for the visit. The investigation consisted of the following: On 1/5/22 LPA Flores conducted a tour of rooms#130,132,138,260, and 263 with Virginia Garcia administrator, reviewed files for Resident #1(R1), #2(R2), #3(R3), #4(R4), and requested copies of the following documents for R1, R2,R3,R4: Face sheet, physician's report, preplacement appraisal information, individual service plan assisted living waiver, appraisal/needs and care plan, hospital discharge, incident reports, other reports, and facility's clinical flex notes. (CONTINUED ON LIC 9099C) Substantiated Regarding allegation: Facility is in disrepair. It is alleged the facility had a sewage leak on 11/30/21 where resident needed to be moved to another room. Interviews with residents revealed 6 out of 12 residents were unable to answer due to cognitive skills and 5 out of 6 residents stated facility is in good repair. Interviews with staff revealed 5 out of 6 staff stated facility is in good repair and 1 out of 6 staff stated that on 11/30/21 upon R1 and responsible party returning to room after being out all day, they noticed there was water in R1's room on the floor. Per Assistant Administrator R1 was moved from room #138 temporarily to room #130 on 11/30/21 and a second incident happened a week after upon returning to the R1's assigned room in which toilet overflowed on the second incident. Plumber stated that toilet overflowed both times due to paper towels being flush down the toilet. Resident was moved to a different room after the second incident and paper towels were removed to avoid other incidents. On 1/5/22 LPA Flores tour the facility and observed residents' bathrooms in five rooms, toilets, showers, and faucets were in working condition. Per administrator, plumbing assessment toilets overflowed due to excess paper towels flushed down. After the incident on 11/30/21 facility took measures to repair the toilet and redone the entire bathroom during the repairs R1 remained on room #130. Upon R1 returning to room #138 and second incident happening R1's responsible party requested R1 return and stay in room #130. Plumbing Services invoice dated 12/1/21 notes a hydro jet drain line and other bathroom related work is listed. 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 was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided. On 8/2/22 LPA Flores interviewed resident#1 (R1),#2(R2),#3(R3),#4,(R4),#5(R5),#6(R6),#7(R7),#8(R8), #9(R9),#10(R10),#11(R11 and staff #1(S1),#2(S2) #3(S3),#4(S4),#5(S5),#6(S6). The investigation revealed the following: Regarding allegation: Resident was assaulted by another resident. Based on interviews and information gathered during the investigation, it was determined that R1 has wandering behavior. On 9/4/21, R1 wandered into R12’s room which resulted in R12 assaulting R1. R1 sustained injuries including but not limited to, facial lacerations and bruises. An incident report was submitted as required, however, no plan of action was documented to address this behavior nor was R1’s needs/services plan updated to reflect R1’s change in behavior. During the interview with the wellness director, she indicated that she advised staff to provide additional supervision to R1 after this incident. A second incident occurred on 11/6/21 in which R1 walked into R12’s room resulting in R12 hitting R1. Upon review of the special incident report dated 11/6/21, the plan of action indicated R1 would be closely monitored but did not include preventative measures the facility would take to ensure the safety of the resident. After the facility informed R1’s responsible party about the incident on 11/6/21, R1’s responsible party contacted the Pasadena police department, however, no further action was taken by law enforcement. Documents review revealed R1's Assisted Living Waiver (ALW) needs and care plan dated 6/30/21 does not provide information to address wandering behaviors to prevent R1 from wandering into other residents' rooms. No other notes were found related to providing additional supervision, monitoring, or changes in activities to assist with R1's wandering behavior. An updated needs and care plan was not provided. On 11/18/22 LPA confirm with the ALW coordinator that R1 does not need a higher level of care at this time. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. The investigation revealed the following: Regarding allegation: Resident care needs are not being met. It is alleged resident was scheduled for surgery and physician's instructions were for resident to fast, staff did not pay attention to this issue, and fed resident delaying surgery. Interview with residents revealed 5 out of 11 residents stated to have their needs met by facility and staff. 5 out of 11 residents were unable to respond due to cognitive skills and 1 out of 11 residents stated not receive care from staff at the facility. Interviews with staff revealed 4 out of 6 staff stated they are familiar with the residents care plan and attempt to meet their needs. (CONTINUED ON LIC 9099C) Assistant Administrator informed LPA that R1 was schedule for surgery on 10/19/21 and there was a lack of communication with all kitchen staff the night of 10/18/21 which prevented server from retaining breakfast from resident the morning of surgery. Wellness director stated that the staff were instructed the night of 10/18/21 to prepared the resident for surgery and retain food intake in the morning of 10/19/21. However, caregiver and server did feed the resident in the morning of 10/19/21. Documents review revealed Flex notes had notes regarding surgery schedule for 10/19/21 and physician's instructions for R1 before the surgery. An internal investigation was conducted and reveal caregiver and server admitted to have not realize and fed R1 prior to the surgery on 10/19/21. An employee warning notice forms were observed dated 10/19/21 for caregiver and server. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. This deficiency was noted on LIC 9099D dated 8/2/22. Exit interview conducted with Lori Lackey Assistant Administrator and a copy of the report, LIC 9099D, appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 8, 2022 · control 28-AS-20220104133920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Dec 22, 2022

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidence by: Based on interviews and documents review licensee failed to provide adequate direct care staff to support R1's needs identify in physician's report which poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2022

Plan of correction: Licensee will ensure updated plan care for R1 is review with staff in each shift to ensure that direct care is provided to meet R1's needs. A copy of updated R1's care plan and a copy of staff's sign in log of reviewed care plan is to be submitted to the department by 12/22/22.

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained unexplained bruising while in care. Resident was handled in a rough manner while in care. Resident's Representative was not notified of resident's injury.

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Lori Lackey Assistant Administrator and explained the reason for the visit. The investigation consisted of the following: On 5/18/22 LPA FLores conducted an initial complaint investigation visit and conducted a health and safety check tour of the facility, requested staff/resident roster, and documents for resident #1(R1) physician's report, appraisal needs and care plan, preappraisal, face sheet, functional capability assessment, clinical flex notes, notification to physician and family,and incident reports. On 5/16/22 Investigation Bureau accepted complaint for full investigation of two allegations. During the investigation assigned Investigator Edward Hector from the Investigaiton Bureau (IB) contacted San Gabirel Valley Medical Center, Broadway Healthcare Center on 5/27/22. On 6/13/22 IB interviewed R1's responsible party, administrator, staff #2, #3. On 6/16/22 IB investigator reviewed documents requested. (CONTINUED LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Resident sustained unexplained bruising while in care. It is alleged that upon hospital staff uncovering R1's chest, R1 "had a very large ecchymotic (bruising) all over chest, going across, like in a "band" pattern. Facility documents reviewed revealed that on 4/26/22 notes revealed staff #3 attempted to use lift on R1, S3 decided not to use lift and called for help as R1 slipped off lift. On 6/13/22 facility's administrator stated "S3 placed R1 in the Hoyer Lift and the belt or sling kept sliding form her abdomen to her chest area." Administrator also stated that as a result of using hoyer lift R1 sustained bruises in her chest. Interview with S2 conducted on 6/13/22 revealed S2 had observed a little bruising on 4/26/22 and four days later verbally notified supervisor that bruising began to enlarge and spread across the chest. On 6/14/22 S3 stated that R1's transfer had changed as previously S3 was able to transfer with the assist of R1 standing on R1's own power. However, "currently R1 could not push or support her own weight, and R1's body is as dead weight". S3 stated R1 was been provided bed baths due to current R1's status and on 4/25/22 R1 had a "bad bowel movement that a shower was necessary". After shower S3 attempted to transfer R1 from shower chair to wheelchair with hoyer lift. S3 stated to have experience using hoyer lift and to use the hoyer lift with R1 on 4/25/22. Hospital intake documentation dated 5/6/22 noted R1 had "ecchymosis accross the chest and upper arms." No mention of suspected elder abuse was noted on intake. 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. Regarding allegation: Resident was handled in a rough manner while in care. It is alleged R1 sustained this severe bruising on chest after being handled very roughly, several times, probably while being lifted "more than once". Facility documents reviewed revealed that on 4/26/22 notes revealed S3 attempted to use the lift on R1, and S3 decided not to use lift and called for help as R1 slipped off lift. On 6/13/22 facility's administrator stated "S3 placed R1 in the Hoyer Lift and the belt or sling kept sliding from her abdomen to her chest area." Administrator also stated that as a result of using hoyer lift R1 sustained bruises in her chest. On 6/14/22 S3 stated that R1's transfer had changed as previously S3 was able to transfer with the assist of R1 by standing on R1's own power. However, currently R1 could not push or support her own weight, and R1's body is as "dead weight". S3 was providing bed baths due to current R1's status and on 4/25/22 R1 had a bad bowel movement that a shower was necessary instead of a bed bath. After shower S3 attempted to transfer R1 from shower chair to wheelchair with hoyer lift. S3 stated to have experience using hoyer lift and to use the hoyer lift with R1 on 4/25/22 for the first time as R1 did not required before. (CONTINUED ON LIC 9099C) 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. Regarding allegation: Resident's Representative was not notified of resident's injury. It is alleged responsible party was never informed by the facility that R1 had this bruising. On 6/13/22 S2 stated that after notifying administration regarding bruising S2 was notified that the bruising had been documented, family was notified, and R1's physician had been contacted. Incident Report dated 4/26/22 notes R1's physician and both family members were notified. On 4/26/22 facility notified physician via phone call and sent an email with pictures of bruises. Facility's flex notes noted that on 4/26/22 at 9:10am staff contacted family representative #1 and family member #2 was present during the call with family representative #1. Interview conducted on 6/13/22 with family representative #1 notes family representative #1 was notified on 4/26/22 of the incident and of bruising and was notified that family representative #2 was present at the facility. 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 was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 28-AS-20220516134857

Type of visit: Case Management - Incident

Licensing Program Analyst(s) Mary Flores conducted a case management visit to follow up on an incident report send to the department on 11/4/22. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason for the reason. On 11/4/22 LPA Flores reviewed incident report regarding Resident #1(R1). Incident report notes that on 10/31/22 R1 was not found in her room at around 7:30pm. Caregiver made facility administration aware and upon checking facility's cameras it was discovered R1 had left the facility around 6:00pm when a delivery driver opened the door. Last caregiver check on 10/31/22 was conducted at 5:26pm and R1 was seen then. Facility contacted Pasadena Police Department(PPD) and (2) two staff went out looking for R1. During the course of the report intake with PPD they were notify that R1 was found. Pasadena Police department officer returned with R1 at 9:52pm. On 11/29/22 LPA Flores conducted a file review of R1's personal file at the facility. The following was observed: Physician's Report dated 7/6/22 notes R1's primary diagnosis is Dementia and notes R1 has wandering behavior and is not able to leave the facility unassisted. Face Sheet notes R1's date of admission was 2/15/21. R1 is under conservatorship, appointed person is to make person and estate decisions for R1. During the visit LPA was notified that a second incident happened on 11/27/22 a copy of the internal incident report was provided to LPA which notes R1 left the facility unassisted on 11/27/22 at 11:30am after a family entered the facility, staff noticed she was no longer in the lobby's sofa and went to look for R1. R1 returned to the facility at 1:20pm. On 11/29/22 LPA Flores was allowed entry to the facility through the main door after ringing the bell, door did not lock behind LPA. LPA observed one receptionist was on a phone call and there were around 7 residents in the lobby, LPA followed to check the door to see if it locked, door continue to be unlocked and after LPA's attempt, receptionist followed to lock the door. Per Assistant administrator staff have to flip switch for door to lock after an entry to lock the door. (CONTINUED ON LIC 809C) LPA reviewed facility's video on 11/27/22 at 11:19:03am two visitors enter the facility the door closes behind them and at 11:19:26am R1 opens the door and exits the building. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 29, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Nov 30, 2022

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) ... Section 87468.1, Personal Rights of Residents...(4) To care, supervision,... meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on documents review facility did not ensure R1 did not leave the facility unattended which is an immediate risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Nov 29, 2022

Plan of correction: Licensee will create a plan to ensure that activities and proper steps are taken to prevent R1 from leaving the facility and will submit a copy of this plan to the department by POC due date 11/30/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(a) · Plan of correction due date: Dec 6, 2022

87411 Personnel Requirements - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidence by:the state’s words, verbatim · CDSS document, Nov 29, 2022

Plan of correction: Licensee will provide in-service training to staff regarding wandering behaviors and steps to take prevent and after a resident has exit the facility by POC due date 11/30/22.

Allegation investigated: Facility failed to report resident with scabies to local public health department.

***THIS IS AN AMENDED REPORT***Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Malou Bernardo, Business Office Manager); as Administrator (A1: Virginia Garcia) was unavailable, but, LPA/RA was later met by Asst. Administrator (A2: Lorie Lackey). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility had a positive COVID case by a staff member on 08/05/22; however, no new cases at this time nor any residents or staff members have symptoms. An initial 10-Day virtual visit was conducted by LPA Angelica Rea on 06/24/20 (via telephone) with Administrator Garcia due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. The purpose of this visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. LPA/RA interviewed Asst. Administrator (A2: Lorie Lackey), Staff #1 (S1: Malou Bernardo, Business Office Manager), Staff #2 (S2: Elizabeth Kirk, Nursing Supervisor), and Staff #3 (Manuel "Tony" Ardon, former A.M. Nursing Supervisor) between 9:00 a.m. - 10:00 a.m. LPA/RA could not Unsubstantiated interview (former) Resident #1 due to the resident's passing on 07/14/22. LPA/RA reviewed (former) R1's records between 10:00 a.m. - 11:00 a.m. and obtained copies of pertinent documents: Physician’s Report, Admissions Agreement, Emergency I.D. & Information, Appraisal Needs and Services Plan, Clinical Flex Notes, and Dermatologist Notes; Staff and Resident rosters. Regarding Allegation #1: this investigation revealed concerns of unreported scabies had been diagnosed to Resident #1 on 06/05/20 and not reported to the Public Health Department. Resident #1's skin condition was discussed with Administrator Garcia, Asst. Administrator Lackey, and Staff #3 relating to Resident #1's scabies treatment. Administrator Garcia stated that Resident #1 had been in isolation (in a private room) since the day of the "suspected" (not confirmed) scabies diagnosis, effective 06/05/20. Resident #1's responsible persons were informed by Staff #3 that facility staff monitor the resident during showers and a "fully body skin check" is conducted on a monthly basis. A review of Resident #1's Physician's Report (dated 07/14/21) documented under, "Physical Health Status" that Resident #1 had no history of skin condition or breakdown. A review of Resident #1's Appraisal/Needs and Services Plan (dated 01/14/22) documented under, "Physical Health" that Resident #1 was at risk for skin breakdowns due to incontinence and immobility. A review of Resident #1's "Clinical Flex Notes" (dated 06/05/20) documented the onset of "suspected" scabies diagnosis by the resident's Dermatologist and reported "just based on clinical presentation - did not do biopsy to confirm" scabies. When facility reported it to the Public Health Department, two (2) nurses came on the phone who said that it wasn't necessarily being lodged against the facility; as no other residents had scabies. This is a precaution. If only one (1) incident of scabies can be documented then the facility did not have an obligation to report it. Asst. Administrator Lackey indicated that it's been reported by the home health nurse (dated 07/22/22) that Resident #1 had been diagnosed with Bullous Pemphigoid. Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation of OTHER: Facility failed to report resident with scabies to local public health department is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to Asst. Administrator (Lorie Lackey).the state’s words, verbatim · CDSS document, Aug 10, 2022 · control 28-AS-20200619080818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Aug 24, 2022

Reporting Requirements: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This This requirement is not met as evidenced by: Dermatologist reported "suspected scabies just based on clinical presentation - did not do biopsy to confirm"; therefore, facility did not report it to the Public Health Department.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Licensee/Administrator shall read Title 22, Section "Reporting Requirements" and send a written statement to CCL by the POC date - no later than 08/24/22.

Allegation investigated: Resident care needs are not being met

Licensing Program Analyst(LPA) Mary Flores conducted an unonnounced complaint investigation visit regarding the above allegation(s). LPA met with Lori Lackey assistant administrator and explained the reason for the visit. The investigation consisted of the following: On 1/5/22 LPA Flores conducted a tour of rooms#130,132,138,260, and 263 with Virginia Garcia administrator, reviewed files for Resident #1(R1), #2(R2), #3(R3), #4(R4), and requested copies of the following documents for R1, R2,R3,R4: Face sheet, physician's report, preplacement appraisal information, individual service plan assisted living waiver, appraisal/needs and care plan, hospital discharge, incident reports, other reports, and facility's clinical flex notes. On 8/2/22 LPA Flores interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10),#11(R11) and staff #1(S1),#2(S2) #3(S3),#4(S4),#5(S5),#6(S6). Substantiated The investigation revealed the following: Regarding allegation: Resident care needs are not being met. It is alleged resident was scheduled for surgery and physician's instructions were for resident to fast, staff did not pay attention to this issue, and fed resident delaying surgery. Interview with residents revealed 5 out of 11 residents stated to have their needs met by facility and staff. 5 out of 11 residents were unable to respond due to cognitive skills and 1 out of 11 residents stated not receive care from staff at the facility. Interviews with staff revealed 4 out of 6 staff stated they are familiar with the residents care plan and attempt to meet their needs. Assistant Administrator that there was a lack of communication with all kitchen staff which prevented server from retaining breakfast from resident the morning of surgery. Wellness director stated that the staff were instructed the night before to prepared the resident for surgery and retain food intake in the morning. However, caregiver and server did feed the resident in the morning. Document review revealed Flex notes had notes regarding surgery and instructions for R1. During internal investigation caregiver and server admitted to have not realize and fed R1 prior to the surgery. An employee warning notice forms were observed dated 10/19/21 for caregiver and server. Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited. Exit interview conducted with Lori Lackey Assistant Administrator and a copy of the report, LIC 9099D, appeal rights were provided. The investigation revealed the following: Regarding allegation: Resident was assaulted by another resident. It is alleged R1 wandered into R12's room on 9/4/21 and 11/6/21 was assaulted because R1 did not know which room R1 was in. R1 had facial lacerations, a busted lip, bruises on neck and arms. Interviews with residents revealed 7 out of 11 residents stated to have not been threaten by residents physically or observed residents in altercations. 2 out of 11 residents stated that there has been incidents when a resident walks into their room but has not been aggressive and leaves prior staff arriving to assist. 2 out of 11 residents were unable to answer due to cognitive skills. Interviews with staff revealed 2 out of 6 staff interview stated incidents did take place, and steps were taken to prevent other incidents from happening after the initial incident. 2 out of 6 staff stated not to be familiar with those incidents, however R1 may have some aggressive behaviors from time to time in which resident needs to be provided space. 2 out of 6 staff interview stated not to be familiar with the incidents. Documents review revealed incident reports were noted and submitted to the department for incidents on 9/4/11 and 11/6/21, in addition to incident report a report of suspected abuse (SOC 341) and an email to the local ombudsman (LTCO) was submitted on 11/8/21 to the proper agencies regarding incident. R12 was admitted to the Geriatric Psych Unit after the incident on 11/6/21 and had previously been admitted on 7/1/21 due to aggressive behaviors. R12 was under care of primary physician and psychiatric. Picture dated 9/4/21 provided by the facility shows redness on left cheek, no bruises or lacerations were observed. No other pictures were provided. Police was contacted on 11/6/21 by R1's responsible party and a report was created, however police officer stated no action can be taken due to R12's cognitive skills. 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. Regarding allegation: Facility is in disrepair. It is alleged the facility had a sewage leak 11/30/21 where she needed to be moved to another room. Interviews with residents revealed 6 out of 12 residents were unable to answer due to cognitive skills and 5 out of 6 residents stated facility is in good repair. Interviews with staff revealed 5 out of 6 staff stated facility is in good repair and 1 out of 6 stated on 11/30/21 upon R1 and responsible party returning to room after being out all day noticed there was water on R1's room floor, R1 was moved temporarily to another room and a second incident happened a week after returning to the same room in which toilet overflowed. Plumber stated that toilet overflowed both times due to paper towels being flush down the toilet. Resident was moved to a different room after the second incident and paper towels were removed to avoid other incidents. On 1/5/22 LPA Flores tour the facility and observed residents' bathrooms in five rooms working properly. The toilet flooded due to paper towels and facility took measures to repair the toilets and provided a different room while bathroom was being redone after the first incident and a different room was provided as requested by R1's responsible party after the second incident. 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 was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 2, 2022 · control 28-AS-20220104133920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Aug 2, 2022

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... for assistance in obtaining such care, by compliance with the following:(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee failed to ensure R1 did not have food intake in the morning prior to surgery which poses a potential health, safety or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Aug 2, 2022

Plan of correction: Administrator conducted internal investigation and wrote warning notice form to staff responsible for not meeting R1's needs on 10/19/21. Deficiency cleared.

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management visit -COVID 19 to follow up on recommendations. LPA Flores met with Lori Lackey assistant administrator and explained the reason for the visit. LPA conducted a tour of the facility with Lori Lackey assistant administrator and observed the following: Screening logs are located in the front desk and have record of signing in for staff, family, and other agencies for the past week, including temperature record, and questionnaire. Staff were observed wearing face masks throughout the facility. Staff were inquired about hand sanitizer accessible in their pockets. Residents were observed six feet apart and encourage to wear a face mask during cards activity. Red Zone available in the first floor, and quarantine area in the second floor, closed lid trash cans observed, PPE supplies observed outside the quarantine/yellow zone area. Staff reminded visitor to keep face mask on during the visit. No deficiencies given during this visit. Exit interview conducted with Lori Lackey assistant administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 6, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on incident report and adult abuse report (SOC 341) faxed to the department on 4/6/22. LPA met with Lori Lackey assistant administrator and explained the reason for the visit. LPA Flores reviewed staff's file and requested a copy of staff roster, incident report, SOC 341, staff #1(S1) and #2(S2)'s training, personnel record, criminal background clearance,termination letter for S1 and resident #1(R1)'s identification and emergency information sheet, admission agreement, individual service plan, physician's report and resident appraisal. LPA Flores interview staff #2. Incident report dated 4/6/22 reports that on 4/3/22 S2 requested assistance with R1 over the radio and S1 was responded to the call. R1 "suddenly struck S1 in the face and S1 hit her back in the face. S1 stated first instinct was to hit back. R1 was observed for injuries and no injuries were observed. After internal investigation facility concluded to terminate S1. S1 Document's review for R1 show no history of aggressive behaviors recorded, R1 is non-ambulatory. Individual Service Plan does not have any notes regarding providing assistance for behaviors. Further investigation is required. No deficiencies were given during this visit. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 6, 2022

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) Mary Flores conducted a case management visit COVID 19 to follow up with guidance and recommendations regarding infection control. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason of the visit. LPA Flores conducted a tour with Lori Lackey assistant administrator and observed the following: Screening upon arrival for visitors, front lobby staff screens for temperature visitor's log, family log, and staff log available. Screening logs were reviewed for staff signing in for 3/28/22. Quarantine/Isolation areas were observed PPE supplies were observed in cabinet outside the room. Social distancing in dining room and activity areas, residents observed having breakfast and having exercises with proper distance from each other. Staff were observed wearing a face mask and face shield at all times. Cleaning logs are posted. Posters in quarantine area are posted. No deficiencies cited during this visit. Exit interview conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 28, 2022

Type of visit: POC

Licensing Program Analyst(s) (LPA) Mary Flores conducted a plan of correction (POC) visit to follow up on deficiencies given on 3/11/22. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason of the visit. The following deficiencies were observed during the annual visit on 3/11/22: Section 87555(b)(21) General Service Food Requirements - On 3/11/22 Freezer's temperature was observed at 10 degrees which is not within the required temperature of 0 degrees. On 3/28/22 LPA Flores observed freezer thermometer at 0 degrees, on 3/18/22 LPA Flores received invoice for services provided by Heating and Air Conditioning contractor provided on 3/14/22. Deficiency is cleared. Section 87465(d)(3) Incidental Medical and Dental Care - On 3/11/22 during medication review medication was reviewed and medication sheets were not initial upon providing medication to residents. On 3/28/22 LPA Flores reviewed medication and medication sheets for resident #1,#2,#3,#4. Deficiency has been cleared. Exit interview was conducted with Lori Lackey assistant administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 28, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Mary Flores and Deputy Director Kevin Gains conducted an unannounced annual visit at the facility with focus on the infection control domain, food and medication review. LPA and Deputy Director met with Malou Bernardo Business Office Manager and explained the reason for the visit. Rocio Gonzalez Wellness Coordinator arrived 20 minutes later. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the facility. LPA, Deputy Director and Malou Bernardo Business Office Manager conducted a tour of the facility and observed the following: All common areas are clean and in good repair. Kitchen was observed clean, food was reviewed and sufficient for at least 2 days of perishables and 7 days of non-perishables. Freezer's temperature was observed at 10 degrees F. which is not within the required temperature of 0 degrees F. Resident's bedrooms #110,116,119, 138,245,248,252,255,259,263 were observed, all bedrooms have sufficient lighting, furniture, and bedding; room #110 - has a broken bed frame. Bathrooms were observed in each room and each has the required grab bars, bathroom #3 next to vent water damage was observed of about the size of a pen. bathroom #3, 7, 9 were missing a skid mat in the shower. Water temperature was tested in each resident's bathroom and tested between 99.1 - 109.5 degrees F. which is not within the required 105-120 degrees F. Medication and files were reviewed for resident #1,2,3,4,5,6,7,8,9,10,11, for resident #2,4,6,7,9,10 medication sheet was missing staff's initials next to dose provided for March 10th and 11th. files for staff #1,2,3,4,5,6 were reviewed. (CONTINUED ON LIC 809D) Facility is following infection control recommendations and guidelines, except for screening residents upon returning from outings. Deficiencies will be noted on LIC 809D per Title 22 Regulations Chapter 6 Division 8. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report, LIC 809D, Technical Advisory, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Mar 11, 2022

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management visit regarding COVID 19 recommendations and guidelines. LPA Flores met with Rocio Gonzalez Wellness Coordinator and explained the reason for the visit. LPA Flores conducted a tour of the facility with Rocio Gonzalez Wellness Coordinator and observed the following: Facility is currently following COVID 19 (infection control) recommendations. Staff were observed wearing face mask and googles. Residents were observed maintaining social distancing. Facility has signs throughout the facility in Spanish and English. PPE supplies were observed for at least 30 days. Facility has a yellow and red zone designated areas to assist with isolation and quarantine when necessary. Sufficient food was observed. No deficiencies were given during this visit. Exit interview was conducted with Malou Bernado Business Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 3, 2022

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management COVID 19 visit to follow with COVID 19 recommendations. LPA Flores met with Virginia Garcia administrator and explained the reason for the visit. LPA Flores and Virginia Garcia administrator conducted a tour of the facility at around 1:20pm: Screening list were observed for visitors, other agencies, and staff in the front desk. Receptionist was observed taking temperature of a visitor. Social distance was observed among the residents. Some residents were observed wearing surgical mask. Staff was observed wearing surgical or N95 mask and googles. Random staff was asked to reach for hand sanitizer in pocket. Kitchen staff were observed wearing mask while performing their duties, and preparing meals. Sufficient food was observed. Three (3) sanitizer prepared buckets were observed throughout the kitchen. Signs were observed in the front lobby, throughout the facility, and near hand washing sinks. Break room was observed with set up for 2 staff per use, signs, and sanitizing wipes available. Medication staff, showed LPA hand sanitizer, and sanitizing spray, and explained to be disinfecting after providing medication to each resident. Housekeeper showed LPA labeled disinfecting spray. Facility is cleaning and disinfecting every shift. A wing in the first floor has been designated as the red zone with an entrance through the patio, there are PPE supplies set up in the patio entrance, and three covered trash cans. No deficiencies were given during this visit. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2022

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores, Pasadena Department of Public Health Nurse Consultant (HFEN) Sharon Evangelista, and HFEN -Jonah Nugraha conducted an unannounced case management visit regarding COVID 19 guidelines. LPA and HFENs emt with Rocio Gonzalez and explained the reason of the visit. Virginia Garcia administrator arrived 20 minutes later. LPA Flores and HFENs conducted a tour of the facility with Rocio Gonzalez and observed the following; Screening books, COVID questionnaire, and temperature check were in place upon arrival. Staff were observed wearing N95 mask and googles or face shields. HFEN Evangelista advise surgical mask may be wear in the green zone. Staff was observed disinfecting high touch areas and logs are maintain. Kitchen was observed staff showed HFENs cleaning and disinfecting supplies. Residents with booster vaccine and negative test results were observed performing activity's. Facility has set up red zone at the end of hall in rooms # 138 and 137. PPE supplies are set up outside the exit door with entrance through the patio, additional trash cans were placed next to PPE supplies. LPA reviewed administrator Virginia Garcia' s email to LPA, Licensing program manager, regional manager, Pasadena department of Public Health LTCF support and local ombudsman received on 1/12/22 notifying of positive cases along with line list. No deficiencies were given during this visit. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was email for signature. *This is an electronic copy of written report provided on 1/19/22 during the visit and supersedes written report.*the state’s words, verbatim · CDSS document, Jan 19, 2022

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on facilities COVID 19 recommendations and guidelines. LPA Flores met with Virginia Garcia and explained the reason for the visit. LPA Flores conducted a tour with Virginia Garcia administrator and observed the following: One entry point with screening logs for visitors with all screening questions. Signs posted in the lobby, bathrooms, and throughout the facility. Social distancing was observed in dining room, activity room. Staff were observed in dining/activity room, and throughout the facility wearing surgical mask and googles or face shield. Four random staff were asked to show personal hand sanitizer kept in their pocket. Cleaning logs were observed up to date with 3 - 6 entries per day throughout the facility. Facility is being clean and disinfect at least each shift, facility has 3 shifts. Some residents were observed wearing face mask in activity/dining room. Break room, medication room, and clock in area were observed to have disinfecting wipes available. LPA Flores observed two caregivers conduct donning and doffing of full PPE supplies and conduct proper hand washing. Administrator inquire regarding visitation guidelines. LPA advice administrator to follow visitation guidelines per PIN 21.40ASC. Facility is currently following all COVID 19 recommendations. No deficiencies were given during this visit. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 5, 2022

Allegation investigated: Resident sustained injury while in care due to lack of supervision.

Licensing Program Analyst (LPA) David Sicairos conducted an initial complaint investigation regarding the allegation listed above. LPA met with Malou Bernardo Business Office Manager and explained the reason for the visit. Administrator Virginia Garcia arrived shortly thereafter. The investigation consisted of the following: during today's visit, LPA toured the facility which included a random sample of resident rooms and common areas. LPA reviewed Resident #1 (R1) file and obtained copies of the following documents: FACE Sheet, Physician's Report, Assisted Living Waiver ISP, Discharge Summary, Incident Report, and Clinical Notes. LPA also obtained copies of Staff & Resident Rosters. LPA interviewed Resident #2 - Resident #6 and Staff #1 - Staff #6 . R1 was not interviewed during today's visit as R1 is currently at a Skilled Nursing Facility and will not be returning to the facility, however LPA interviewed R1's Family Member. The investigation revealed the following: in regards to the allegation "resident sustained injury while in care due to lack of supervision", it is alleged that on 12/10/21 R1 was found laying on the hallway floor of the facility. (CONTINUED ON 9099C) Unsubstantiated R1 was taken to the hospital and was diagnosed with a brain bleed injury. Since October 2021, R1 was residing at a Skilled Nursing Facility for walking rehabilitation. R1 then returned to the facility on 12/09/21. R1 is ambulatory and did not have an assigned one on one caregiver while a resident of this facility. Interview conducted with Administrator revealed that on 12/10/21 R1 suffered an unwitnessed fall around 11:35am. A housekeeper heard a noise in the hallway and saw R1 on the floor. Housekeeper called for help and 911 was immediately called. R1 was transported to the hospital. Interviews with staff members revealed that residents are checked on at least every 2 hours. 5 out of 5 residents interviewed indicated that staff members will assist them with their activities of daily living within a reasonable amount if time. 5 out of 5 residents interviewed indicated that they feel that there is a sufficient amount of staff available at the facility to meet their needs. LPA pulled emergency cord in a random resident room during tour and observed staff responded to the call in less than 5 minutes. LPA did not obtain any evidence during investigation indicating that R1's fall was due to staff neglect or as a result of lack of supervision. 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 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.the state’s words, verbatim · CDSS document, Dec 17, 2021 · control 28-AS-20211213131957

Allegation investigated: The alarm batteries were dead. Facility has pest infestations.

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. The investigation consisted of the following: On 12/1/LPA Flores requested staff/resident roster. LPA and administrator conducted a tour of the facility and check each emergency exit doors and exit door on the second floor which exits the patio. LPA and administrator toured the kitchen and common areas in the first floor. LPA requested copies of incident reports submitted to the department regarding pest in the last year and pest control reports for the last six months. On 12/6/21 LPA Flores interview pest control agency expert. 12/14/21 LPA interview staff #1,#2,#3,#4,#5 and residents #1,#2,#3,#4,#5 The investigation revealed the following: Regarding allegation: The alarm batteries were dead. It is alleged that appears to be no functioning alarm system in place. Interview with administrator revealed the batteries of the alarm in the door leading to the courtyard needed to be change and found they were not working during a visit from the local ombudsman. (CONTINUED LIC 9099) Substantiated Janitor stated that the batteries were recently replaced after realizing batteries were not working during a visit from the local ombudsman. Interviews with staff revealed 2 out of 5 staff interview stated that batteries do not work sometimes. 2 out of 5 have not notice if batteries are not working, and 1 out of 5 staff stated batteries always work. Interviews with residents revealed 2 out of 5 residents have noticed the alarms go off and 1 out of 5 residents stated to not have heard the alarms for the doors go off at any time. 2 out of 5 residents were unable to respond due to cognitive skills. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Substantiated. Regarding allegation: Facility has pest infestation. It is alleged facility has an infestation of mice/rats, and bed bugs. On 12/6/21 LPA Flores interviewed pest control expert at Dewey Pest Control who stated the facility has had continue services for pest control with their agency for many years. Around June facility had observed a few rats and inquired services. However, the expert does not consider rats/mice to be an infestation, as rodents reside in the neighborhood and facility has bite stations throughout. Regarding Bed bugs the facility is currently going under treatment and there is currently an infestation as live bed bugs were found in 9 rooms of the facility. LPA review pest control invoices for the month of November 2021. Interviews with staff revealed 3 out of staff have not observed rats/mice at the facility and 2 of the 3 have not observed bed bugs, however 1 out of the three has heard that there are bed bugs in rooms. 2 out of 5 staff stated to have observed rats inside and in the patio of the facility. Interviews with residents, 3 out of 5 residents stated to have not observed any pest at the facility. 1 out of 5 residents stated to have observed mice a while back. 1 out of 5 residents were not able to respond due to cognitive skills. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Substantiated. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Immediate Civil Penalties have been assess for Repeat Violation within 12 months for $250. Exit interview was conducted with Virginia Garcia administrator and a copy of the report, LIC 9099D, and Appeal Rights was provided and leads to the facility's courtyard. Interview with administrator revealed the emergency exit door is under egress system however the batteries for the alarm were not working. The door at the bottom of the staircase of that emergency door is to be kept unlock as requested by fire department. Egress system is attached to a signal system in the front desk which alerts the staff at the front desk and staff notifies caregivers via radio. Interviews with staff revealed 4 out 5 stated residents are check every two hours, they respond to alarm at emergency doors right away, and 2 out of the 4 stated staff get notify via radio regarding residents observations on cameras. 1 out of 5 staff stated when alarms go off staff respond timely. Interviews with residents revealed 3 out of 5 residents stated staff check on them regularly throughout the day. 2 out of 5 residents were not able to respond due to cognitive skills. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Regarding allegation: Facility is not reporting infestations to appropriate agencies. It is alleged facility did not reported rat/mice infestation to Community Care Licensing and/or Pasadena Public Health as facility did not consider it to be an issue. On 12/6/21 LPA Flores interviewed pest control expert at Dewey Pest Control who stated the facility has had continue services for pest control with their agency for many years. Around June facility had observed a few rats and inquired services. However, the expert does not consider rats/mice to be an infestation, as rodents reside in the neighborhood and facility has bite stations throughout. Regarding bed bugs on 12/3/21 service agreement was created to treat 9 rooms out of 94 LPA review pest control invoices for the month of November and December 2021 and emails send to Department of Public Health and Community Care Licensing representatives on 11/24/21 and 11/26/21 regarding pest control visit and treatment plan. Facility provided hard copy of incident report dated 11/16/21 during the initial visit however no transmission report was provided. Although the facility did not provided a hard copy of incident report to the department. There are email communication regarding bed bug findings and treatment. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2021 · control 28-AS-20211129154345

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 14, 2021

87303 Maintenance and Operation: (a) (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on interviews conducted Licensee did not ensure facility was free of bed bugs in 9 rooms, which poses an immediate Health, Safety, or Personal rights risk to person in care. *Immediate Civil Penalties assess for repeat violation of $250.*the state’s words, verbatim · CDSS document, Dec 14, 2021

Plan of correction: Licensee will ensure pest is under control at all times and to maintain professional pest control services as necessary. Licensee provided copies of pest control service and pest control infection sheet dated 12/13/21 clearing the facility of bed bugs. Deficiency cleared on 12/14/21.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Dec 14, 2021

87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidence by: Based on interviews Licensee did not ensure exit door's (to courtyard) alarm batteries were working properly which poses an immediate Health, Safety, or Personal risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 14, 2021

Plan of correction: Licensee will ensure alarm system is in working condition. Administrator will maintain a log to track batteries live and will submit log to the department in 7 days. During the visit of 12/1/21 LPA observed alarm working.

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on COVID 19 guidelines. LPA Flores observed the following: Screening questionnaire and temperature check at front desk. Residents having lunch and sitting one per table and larger tables 2 residents per table. Staff providing meals and supervising. Signs are posted throughout the facility. Staff were observed disinfecting sign-in machine and table used by staff in the family room. No deficiencies were observed during this visit. Exit interview was conducted with Virginia Garcia Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2021

Type of visit: Case Management - Incident

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit regarding incident report fax to the department on 12/7/21.LPA met with Virginia Garcia administrator. On 12/7/21 LPA Flores reviewed incident report stating Resident #1 (R1) was noted missing around 6:00pm. Facility found out R1 left the facility by patio door at 1:30pm. Patio door was open as plumbing contractors were using door to come into the facility and conduct repairs. Facility contacted responsible party and Police Department on 12/2/21. On 12/7/21 LPA Flores requested physician's report, admission agreement, pre-appraisal agreement, needs and care plan, and medication sheet. LPA reviewed R1 physician's report which notes resident is able to leave the facility unattended. During today's visit LPA requested a copy of the police reference number/contact, employee warning notice form for staff #1, and #2, and observed the patio door. Patio door is located to the left of the main entrance, there is a blocked patio with no access to the door and it has a working egress system. Per administrator access was provided to contractors by removing planters and overriding egress system to allow contractors access with equipment on 12/2/21. Per mitigation plan and current COVID guidelines one entry point must be designated for screening, sign in and out. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights have been provided.the state’s words, verbatim · CDSS document, Dec 8, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Dec 9, 2021

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on documents review and interview conducted Licensee did not ensure to maintain one entrance point at the facility which poses an immediate health, safety, or personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2021

Plan of correction: Administrator will ensure to maintain one entry point to the facility at all times. In-service training to be provided to staff and submitted to the department on 12/9/21. LPA observed door is closed and inaccessible.

Type of visit: Case Management - COVID-19

icensing Program Analyst(s) Mary Flores conducted a case management COVID 19 visit regarding facility following all CDC, department of public health and department recommendations. LPAs met with Lori Lackey Assistant Administrator and explained the reason fro the visit. LPA toured the first floor with Rocio Gonzalez wellness director and observed the following: Screening logs were observed and desk front staff took visitors temperature. The following screening logs were observed; outside agencies, family sign, and staff with the following questions: Name, Temp, Fever/chills, coughing, shortness of breath/difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat, congestion/runny nose, nausea/vomiting, diarrhea, outside the U.S. in the last 14 days within the last 48 hours. LPA observed staff present in the dinning room, activity room, and patio and one resident was observed sitting at each table. Signs are posted throughout the facility in English and Spanish side by side. Break room was observed with only two chairs. Clock in machine was observed been disinfected before and after use. No deficiencies were observed during this visit. Exit interview was conducted with Rocio Gonzalez wellness director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2021

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a case management COVID 19 visit regarding facility following all CDC, department of public health and department recommendations. LPAs met with Virginia Garcia administrator. LPAs toured the facility and observed the following: Screening logs were observed and desk front staff took visitors temperature. The following screening logs were observed; outside agencies, family sign, and staff with the following questions: Name, Temp, Fever/chills, coughing, shortness of breath/difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat, congestion/runny nose, nausea/vomiting, diarrhea, outside the U.S. in the last 14 days within the last 48 hours. LPA observed staff floating in the dinning room, activity room, and patio and one resident was observed sitting at each table. Signs are posted throughout the facility in English and Spanish side by side. Disinfectant spray has been updated to a 1 minute contact to wipe, 2 housekeepers were asked regarding disinfecting and process. Logs were noticed throughout the facility with disinfecting times at least 3 times a day, which are being done once per shift, or as needed. 2 Med Techs, 1 kitchen staff were observed holding a small bottle of hand sanitizer in their pockets. Emergency exits were cleared. LPAs observed 1 kitchen staff verbalized and model hand washing procedure and 1 caregiver model donning and doffing. LPAs observed ice machine cleaning log on ice machine lid. Break room was observed with only two chairs. Clock in machine was observed been disinfected before and after use. No deficiencies were observed during this visit. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 12, 2021

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management - annual continuation visit with focus on Disaster Preparedness, Residents with Special Health Needs, and Residents Rights Information domains. LPA Flores met with Lori Lackey assistant administrator and explain the reason of the visit. LPA conducted a tour with Lori Lackey and observed 3 stairways/emergency exits each staircase has an evacuation chair on the second floor, LPA observed oxygen signs posted outside the door in rooms #205,228,230,233,243,252,258,126,130,131,110 and enter rooms #126, 130,131,110 and observed oxygen tanks in stands. LPA observed a storage closet with a substantial amount of water jugs in the first floor, fire extinguishers are located in each floor throughout the floor plan and tags were observed to be check at least once a month. LPA observed emergency food supplies in kitchen's pantry with an expiration date of 2/20/41. LPA Flores interviewed five staff, and six residents, and reviewed emergency disaster plan binder. This concludes annual visit for the facility. LPA observed facility is following current COVID 19 guidelines and recommendations per PINs and CDC guidelines. No deficiencies were found during this visit. Technical assistance were provided. Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 4, 2021

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(s)(LPAs) Mary Flores and Jewel Baptiste conducted a case management continuation annual visit focus on domains Personnel Records/Staff Training, Operational Requirements, Staffing, and Planned Activities. LPAs met with Lori Lackey assistant administrator and explained the reason for the visit. During this visit LPAs toured the facility to follow up with Infection Control guidance. LPAs observed English and Spanish signs throughout the facility, closed trash cans in common areas, disinfection time sheets throughout the facility with logging times for every shift. Staff were observed wearing surgical mask, one person per table was observed in dining room, disinfecting spray bottles have been updated. LPA observed a staff washing hands and a staff donning and doffing were done properly. LPAs reviewed staff files for staff #1(S1), #2(S2), #3(S3), #4(S4), #5(S5), #6(S6), #7(S7), #8(S8), #9(S9), facility's plan of operation, facility's activity calendar for 3 months, and in service training which total approximately 4 hours between 12/24/20 - 5/10/21. LPAs observed S1, S2,S5,S9 do not have a current First Aid/CPR training and S6 did not have a health screening/TB test. LPAs observed Administrator Certificate # 6020807740 expiration date: 10/14/22 for Virginia Garcia Administrator and obtained a copy of insurance bond with expiration date of 1/31/22. Deficiencies were given under Title 22 Regulations Division 6 Chapter 8 and noted on LIC 809D. Exit interview was conducted with Virginia Garcia, administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 27, 2021

Type of visit: POC

Licensing Program Analyst(s)(LPA) Mary Flores and Jewel Baptiste conducted a plan of correction visit for deficiency given on 10/19/21. On 10/19/21 LPAs gave a deficiency: 87465(e) Incidental Medical and Dental - LPAs observed PRN medication provided to residents without labels. During today's visit LPAs observed labels on PRN medication. Deficiency has been cleared. Exit interview was conducted with Virginia Garcia administrator and a copy of this report and deficiency clear letter was provided.the state’s words, verbatim · CDSS document, Oct 27, 2021

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a case management - annual continuation visit with focus on Incidental Medical and Dental, Residents Records/Incident Reports. LPAs met with Virginia Garcia - Administrator and explained the reason for the visit. During today's visit LPAs reviewed medication and resident files for residents #1(R1), #2(R2) , #3(R3), #4(R4), #5(R5), #6(R6), #(7(R7), #8(R8), #9(R9), #10(R10), #11(R11), #12(R12). LPAs observed non prescription medication (PRN) for R3,R4,R8,R11 did not have label. Per Title 22 Regulations deficiencies were cited today under section 8 chapter 6 and noted on LIC 809D. Exit interview conducted with Virginia Garcia administrator and a copy of the report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 19, 2021

Type of visit: POC

Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a plan of correction visit (POC) for deficiencies given on 10/11/21. LPAs met with Virginia Garcia Administrator and explained the reason for the visit. On 10/11/21 LPAs gave the following deficiencies: 87303(i)(1)(B) - Maintenance and Operation - Facility staff did not responded to emergency call respond in rooms #134, 239, 217. During today's visit LPA Baptiste tested the emergency call service in rooms #134, 239, 217 and a caregiver responded within 3 minutes. Deficiency has been cleared on 10/19/21. LPAs observed the following Infection control corrections: Visitors Log had additional questions per CDC guidelines. Signs are posted in English and Spanish throughout the facility. Disinfecting wipes were placed next to staff sign-in machine. Closed lid trash cans were observed in the common restrooms. Staff were present in the common areas. Exit interview was conducted with Virginia Garcia - Administrator a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an unannounced annual visit using the inspection tool. LPAs met with Rocio Gonzalez Wellness Director and explain the reason for the visit. Pasadena Department of Public Health Nurses Whitney Frame and Kevin Grellman join LPAs at 10:30am. The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. LPAs conducted a tour of the facility with Rocio Gonzalez and observed the following regarding Physical Plant and Food Service Domain: Resident rooms were randomly chosen #209, 214, 217, 220, 223, 232, 239, 256, 122, 125, 130, 134, 136, LPAs observed all required furniture, bedding items, sufficient lighting, in each bedroom and resident's bathrooms were observed with skid mats/skid strips, grab bars, and water was tested between 98.5 and 114.5 degrees F which is not within the required range of 105 - 120 degrees F. The large commercial kitchen was toured, sufficient food was observed, refrigerators' temperature was observed at 40 degrees and freezer's temperature was observed at 0 degrees. LPAs tested emergency call light in room #217, 239, 134 caregivers did not responded to call, LPAs and wellness director waited for 5 minutes. Infection Control Domain: LPAs observed updated COVID signs around the facility, screening questionnaire was updated, in service training were provided to staff regarding proper hand washing, face covering, social distancing, proper disinfecting, donning and doffing. Staff had individual hand sanitizers. It was recommended that all disinfected bottles are label and dated, and that additional closed lid trash cans are provided in the restrooms. As well as further in service training for staff regarding COVID 19 recommendations and guidelines. Deficiencies were given during this visit under Title 22. Exit interview was conducted with Virginia Garcia administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 11, 2021

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - COVID-19

Licensing Program Analyst(s) (LPA) Mary Flores, Program Regional Manager (RM) Araceli Ramirez, and Pasadena Department of Public Health Nurse(s) (PDPH -HFEN) Sharon Evangelista and Whitney Frame conducted an unannounced case management COVID 19 visit. LPA, RM, and PDPH-HFEN met with Lori Lackey assistant administrator and explained the reason of the visit. LPA, RM, PDPH-HFENs assistant administrator, and wellness coordinator conducted a tour of the facility and observed the following: Facility has one entry point, and screening was conducted upon entering the facility. Screening questionnaire needs to be updated to show current symptoms. COVID 19 Signage must be updated to show current symptoms in languages applicable for current population of residents/staff and must be posted throughout the facility. Hand washing sign must be updated and posted in all common sinks where hand washing is conducted with the proper steps. Social distancing must be observed in the dinning areas and alternative options may be put in place to ensure 6 feet distance is kept within residents. Staff were observed wearing a face covering and facility is to ensure staff wear the proper face mask of a surgical mask, N95 when necessary and staff are aware of proper usage. PPE supplies were observed, facility has 60 days of gowns and gloves. Facility needs to ensure all PPE supplies including but not limited to surgical mask, N95s, face shields, gowns, gloves, hand sanitizer, and disinfectant spray are provided. Logs for disinfecting were observed. Facility will ensure staff maintain log current after disinfecting surface areas. Residents were observed without face masks. Facility will provided updates to residents and will encourage residents to wear a surgical mask when residents are in the common areas. Closed lid trash cans were observed, trash can in dinning room next to sink was not working and trash cans in yellow zone were not label. Facility will ensure trash cans are working and label in the yellow area. Break room was observed, no disinfecting was observed. It was recommended to provide disinfecting wipes to clean down surfaces used after each use. RM Ramirez, LPA and PDPH-HFENs discussed the items above and recommended in service training to be provided to all staff regarding the items discuss. Technical advisories were given during this visit under COVID 19 recommendations. Exit interview was conducted with Lori Lackey and a copy of this report and technical advisories were provided.the state’s words, verbatim · CDSS document, Oct 4, 2021