Lakewood Park Manor

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christian Gutierrez conducted an unannounced Required-1 year visiting using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Cynthia Flores who assisted with today’s visit. There are currently 119 elderly residents, 60 years and older, residing in the facility. The facility is licensed for (160) residents with age range 60 and over. 160 non-ambulatory, of which (5) may be bedridden in rooms 24, 25, 26, 27, and 28. Hospice waiver for 30. This is a three-story residential care facility for the elderly (RCFE). The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, elevator, outdoor patio, dining room, and kitchen. The 2nd floor includes 40 resident rooms, laundry room, medication room, and activity room. 3rd floor has 40 resident rooms, laundry room, maintenance/storage room, and activity room. There are (2) elevators and at time of visit one is being serviced. Resident bedrooms were randomly chosen for review 2nd floor (R#7, R#31, R#18, and R#9) and 3rd floor (R#45, R#47, R#67, and R#55). Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The residents’ bathrooms have the required grabs bars and non-skid mat. The hot water was between 107.3-118.6 degrees, which is within the required 105 - 120 degrees. Fire extinguishers were observed throughout the facility. Cleaning supplies and toxic substances are inaccessible to residents in third floor storage room. Kitchen was inspected. There is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, living room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. The facility does not have a swimming pool or bodies of water on the premises. Passageways and exits are free of obstruction. LPA checked first aid kit that included all of the required items along with the manual. Six (6) staff files were reviewed and included Criminal clearance record, and health screening with TB. Six (6) residents files were reviewed and included physicians report with TB clearance. Two (2) residents were missing pre-appraisal forms, and four (4) residents were missing appraisal needs and service plan LIC 625. Last fire/earthquake drill was conducted in June of 2026. Infectious control plan was reviewed. Random resident medications were reviewed. Medications are centrally stored and locked. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights and LIC9098 was given to Administrator Cynthia Flores. .the state’s words, verbatim · CDSS document, Jun 30, 2026

The state marks this report as 9 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not ensure that facility is free of pests.

Licensing Program Analysts (LPA) Christian Gutierrez conducted a subsequent unannounced complaint visit in response to the above allegations. LPA met with Administrator Cynthia Flores who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 03/03/2026 visit LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians report, mattress inventory sheet, and pest control invoice. LPA conducted a tour of random bedrooms on second floor. LPA conducted interviews with residents 1- residents 8 (R1-R8). On today’s visit LPA interviewed Administrator, and staff#1-Staff#6 (S1-S6) and delivered findings. See LIC 9099 Substantiated In regard to the allegation” Facility staff did not ensure that facility is free of pests.”, It is alleged that R1 had a bed bug infestation due to staff replacing bedframe obtained from storage. During interviews with Administrator and staff four (4) out of seven (7) staff stated that R1’s room was treated for bed bugs. Administrator stated that R1’s headboard and mattress had been replaced but could not recall if it was before or after treatment and if that was the source of bed bugs. During interviews with residents two (2) out of eight (8) stated that they have had bed bugs in their rooms. R1 stated that as soon as headboard was brought in bugs were observed, Administrator was notified of bugs and frame was removed. LPA Gutierrez observed work order from Bug Free Central Inc service report dated 01/28/26, that indicated room BB01 was treated for bed bugs and a mattress inventory log that stated 59 A replaced mattress on 01/25/26 and 59A & B had mattresses replaced on 02/03/26. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report and appeal rights were given to Cynthia Flores. Deficiency is being cited. Exit interview was conducted and a copy of this report, 9099-D and appeals rights was provided. In regard to the allegation “Facility staff did not safeguard resident's personal belongings”, it is alleged that facility did not safeguard R1’s property while room was being fumigated and R1’ had no access to clothes or toiletries. During interviews with Administrator and staff seven (7) out of seven (7) stated that when a room is being fumigated or is being worked on a special lock is placed on door to prevent anyone from coming in and taking anything. Administrator stated that the facility has a house supply of hygiene products and clothes can be accessed for resident if asked. During interviews with residents three (3) out of eight (8) residents stated they have had items stolen from rooms, but nothing has been done about it. R1 felt it was a staff member that stole something but did not have proof. In regard to the allegation “Resident's room is malodorous”, it is alleged that R1’s room smells of urine. During interviews with Administrator and staff seven (7) out of seven (7) stated that the rooms are cleaned daily and residents with incontinence needs have their diapers changed every two hours or as needed. S2 stated that some residents do have urinals next to there beds that can sometimes cause the rooms to smell like urine, but they are not dirty. During interviews with residents seven (7) out of eight (8) residents stated they have there rooms cleaned daily and that staff does a good job at it. R1 stated only time room has odor is when roommate has diaper changed. LPA did a random room check of several bedrooms and did not smell any urine in bedrooms. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Cynthia Flores.the state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20260222191617

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 26, 2026

87303 Maintenance and Operation (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. Based on observations, interviews and records reviewed, R1's room was being treated for bed bugs on 01/28/26.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: *Facility provided proof of pest control service report dated 01/28/26 for bed bug treatment. No further action required. Administrator stated to LPA Gutierrez that the facility would inspect stored mattresses and headboards before bringing into facility.

Allegation investigated: Staff are mismanaging residents rent payments

Licensing Program Analysts (LPA) Christian Gutierrez conducted a subsequent unannounced complaint visit in response to the above allegations. LPA met with Administrator Cynthia Flores who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 02/19/2026 LPA obtained copies of the following documents: staff roster, resident roster, R1’s ledger report for billing, bill history for R1, and pictures of physical checks for R1’s rent. LPA interviewed Administrator and staff #1 (S1). On today’s visit LPA interviewed witness 1 (W1) over telephone, residents 1- residents 8 (R1-R8), and delivered findings. See LIC 9099 Unsubstantiated In regard to the allegation “Staff are mismanaging residents rent payments”, it is alleged that facility has had a significant delay in processing checks and has lost January’s rent payment for resident. During interviews with Administrator and staff both stated that January’s check was still not received from payee. Administrator stated that there has been lost checks in the past but that the facility has no control of where the mail gets sent to if check is not sent via certified mail. Staff one (S1) did state there was miscommunication with witness 1 (W1) and that he/she thought January’s payment was received but after speaking with home office they were informed that no payment had been received. LPA spoke to W1 and asked how payment was made for R1 and was told by ACH withdrawal. LPA obtained physical checks for the month of October, November, December of 2025, and for February of 2026 from the facility for R1. LPA contacted W1 to confirm if a check was sent to facility and was told it was under investigation with the bank. LPA contacted bank with information provided on check and was told they could not provide personal information for a customer however they were able to confirm that just because a customer sees an ACH withdrawal from there account does not mean a check is not sent to the creditor. Bank representative stated it is treated as a cashier’s check. LPA asked W1 if there has ever been a late fee and or an eviction notice for nonpayment to R1 and W1 stated no. During interviews with residents eight (8) out of eight (8) residents stated they have had no issues with rent payments. R2 stated they gave permission to take rent out of there bank and has never had any issues. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Cynthia Flores.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 28-AS-20260217123225

Allegation investigated: Facility staff retaliated against resident for filing a complaint Facility staff refused resident re-entry resulting in a forced eviction Facility staff did not ensure inventory of residents personal belongings were maintained Facility staff did not ensure residents personal items were safely secured Facility staff does not ensure communication is answered promptly and appropriately

**This report supersedes report dated 01/17/2026. The purpose of this report is to include additional information that was not included on 01/17/2026. All findings remain the same. Licensing Program Analyst (LPA) Gutierrez met with Cynthia Flores and explained the purpose of this visit. ***** Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Ariadna Flores who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 12/18/2025 LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, identification information (LIC 601), conservatorship paperwork, preplacement appraisal, admission agreement, and inventory sheet. On 01/12/2025 visit LPA Gutierrez interviewed Administrator, staff 1-staff 6 (S1-S6), and residents 2-residents 10 (R2-R10). LPA made several attempts to contact R1 and was unsuccessful. On today’s visit LPA Gutierrez delivered findings. See LIC 9099C Unsubstantiated In regard to the allegation “Facility staff retaliated against resident for filing a complaint”, it is alleged that R1 was put on a 5150 hold for making a complaint against facility. During interviews with residents nine (9) out of ten (10) residents stated staff has never retaliated or treated them poorly for filing a complaint or doing something staff doesn’t agree with. During interviews with staff six (6) out of six (6) stated they have never retaliated against residents for filing a complaint. Administrator stated that a 5150 hold was placed on R1 because of aggression only after being evaluated by the clinician. In regard to the allegation “Facility staff refused resident re-entry resulting in a forced eviction”, it is alleged that when R1 was released from hospital R1 was refused entry to facility. During interviews with residents nine (9) out of ten (10) residents stated that they have never been denied re-entry into the facility. During interviews with staff six (6) out of six (6) staff stated R1 was not denied re-entry to facility. Administrator stated that R1 is conserved and conservator made the decision to move R1 to another facility. R1 was never evicted. LPA obtained a copy of Acknowledgment of Discharge signed 10/31/2025 by R1’s conservator. No evection letter was ever issued to R1. In regard to the allegation “Facility staff did not ensure inventory of residents personal belongings were maintained”, it is alleged that R1 had accumulated more inventory and inventory was never taken. During interviews with residents nine (9) out of ten (10) residents stated staff does ask residents to update inventory list when new items are brought in. Residents stated that staff helps them to update list. During interviews with staff six (6) out of six (6) stated they remind residents that inventory list needs to be updated. S3 stated that front desk will stop residents if they see them coming in with something to update their list. Staff stated that it is both the responsibility of staff and residents to ensure the list is updated. During record review LPA obtained copies of inventory list of R1’S belongings. LPA obtained pictures of R1’s belongings packed in multiple black trash bags and a signed letter of personal belongings being removed by R1’s conservator dated 10/31/2025. SEE LIC 9099C In regard to the allegation “Facility staff did not ensure residents personal items were safely secured”, it is alleged that items were missing from R1’s belongings when delivered to new facility. During interviews with residents nine (9) out of ten (10) residents stated that nothing has been missing from their rooms due to staff neglect. During interviews with staff six (6) out of six (6) staff stated they take inventory of every item they pack and take pictures before items are delivered or released to residents. Administrator provided inventory list and pictures of R1’s items that were packed. S2 stated they never throw items away and even still have items from three months ago because a resident has not been able to pick them up. In regard to the allegation “Facility staff does not ensure communication is answered promptly and appropriately “, it is alleged that R1 has been contacting facility and staff won’t return phone calls. During interviews with residents eight (8) out of ten (10) residents stated staff does their best to answer them promptly. R2 stated there so busy but they always come to check on me. During interviews with staff six (6) out of six (6) staff stated they have not heard from R1 since he/she has left the facility except when he called to wish the staff a happy new year. Administrator stated R1 has not left any messages. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Cynthia Flores.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 28-AS-20251215144131

Allegation investigated: Facility staff retaliated against resident for filing a complaint Facility staff refused resident re-entry resulting in a forced eviction Facility staff did not ensure inventory of residents personal belongings were maintained Facility staff did not ensure residents personal items were safely secured Facility staff does not ensure communication is answered promptly and appropriately

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Ariadna Flores who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 12/18/2025 LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, identification information (LIC 601), conservatorship paperwork, preplacement appraisal, admission agreement, and inventory sheet. On 01/12/2025 visit LPA Gutierrez interviewed Administrator, staff 1-staff 6 (S1-S6), and residents 2-residents 10 (R2-R10). On today’s visit LPA Gutierrez delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Facility staff retaliated against resident for filing a complaint”, it is alleged that R1 was put on a 5150 hold for making a complaint against facility. During interviews with residents nine (9) out of ten (10) residents stated staff has never retaliated or treated them poorly for filing a complaint or doing something staff doesn’t agree with. During interviews with staff six (6) out of six (6) stated they have never retaliated against residents for filing a complaint. Administrator stated that a 5150 hold was placed on R1 because of aggression only after being evaluated by the clinician. In regard to the allegation “Facility staff refused resident re-entry resulting in a forced eviction”, it is alleged that when R1 was released from hospital R1 was refused entry to facility. During interviews with residents nine (9) out of ten (10) residents stated that they have never been denied re-entry into the facility. During interviews with staff six (6) out of six (6) staff stated R1 was not denied re-entry to facility. Administrator stated that R1 is conserved and conservator made the decision to move R1 to another facility. R1 was never evicted. In regard to the allegation “Facility staff did not ensure inventory of residents personal belongings were maintained”, it is alleged that R1 had accumulated more inventory and inventory was never taken. During interviews with residents nine (9) out of ten (10) residents stated staff does ask residents to update inventory list when new items are brough in. Residents stated that staff helps them to update list. During interviews with staff six (6) out of six (6) stated they remind residents that inventory list needs to be updated. S3 stated that front desk will stop residents if they see them coming in with something to update their list Staff stated that it is both the responsibility of staff and residents to ensure the list is updated. In regard to the allegation “Facility staff did not ensure residents personal items were safely secured”, it is alleged that items were missing from R1’s belongings when delivered to new facility. During interviews with residents nine (9) out of ten (10) residents stated that nothing has been missing from their rooms due to staff neglect. During interviews with staff six (6) out of six (6) staff stated they take inventory of every item they pack and take pictures before items are delivered or released to residents. Administrator provided inventory list and pictures of R1’s items that were packed. S2 stated they never throw items away and even still have items from three months ago because a resident has not been able to pick them up. In regard to the allegation “Facility staff does not ensure communication is answered promptly and appropriately “, it is alleged that R1 has been contacting facility and staff won’t return phone calls. During interviews with residents eight (8) out of ten (10) residents stated staff does their best to answer them promptly. R2 stated there so busy but they always come to check on me. During interviews with staff six (6) out of six (6) staff stated they have not heard from R1 since he/she has left the facility except when he called to wish the staff a happy new year. Administrator stated R1 has not left any messages. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Ariadna Flores.the state’s words, verbatim · CDSS document, Jan 17, 2026 · control 28-AS-20251215144131

Allegation investigated: Staff do not ensure residents are spoken to in a respectful manner Staff do not ensure all residents are provided meals Staff does not ensure medications are dispensed as prescribed

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Business Office Manager Lauren Cabaron who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 11/04/2025, LPA interviewed Administrator, staff 1- staff 3 (S1-S3) and residents 2 - residents 10 (R2-R10). LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports, identification information (LIC 601), face sheet, preplacement appraisal (LIC 603), appraisal needs and service plan (LIC 625), and physicians order. During today’s visit LPA Gutierrez interviewed staff 4-staff 7 (S4-S7) reviewed random residents’ medication and delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff do not ensure residents are spoken to in a respectful manner”, it is alleged that staff are speaking to residents in a rude and disrespectful manor sometimes even cursing at residents. During interviews with Administrator and staff eight (8) out of eight (8) stated that they do not speak to any residents in a rude or disrespectful manor. Administrator stated that R1 has never had any issues with staff until recently. All staff stated they have never cured at a resident. During interviews with residents nine (9) out of ten (10) residents stated that staff have never spoken to them in a rude or disrespectful way. Nine residents stated that staff has never cursed them. In regard to the allegation “Staff do not ensure all residents are provided meals”, it is alleged that staff do not provide meals and drinks to residents if staff does not like them. During interviews with Administrator and staff eight (8) out of eight (8) stated that all residents receive three meals a day. All staff stated they never withhold food or drinks from any residents regardless of how they felt about them. S6 stated that R1 would bring a container for second servings and was never denied. During interviews with residents nine (9) out of nine (9) residents stated that they all receive three meals a day and have never been denied food or water by staff. R4 stated the kitchen has gotten so much better over the last year. In regard to the allegation” Staff does not ensure medications are dispensed as prescribed”, it is alleged that staff is giving out the wrong dosage of medication. During interviews with Administrator and staff eight (8) out of eight (8) staff stated that to their knowledge medication is given correctly as prescribed by physician. LPA did random medication checks on residents and found no discrepancies. During interviews with residents nine (9) out of ten (10) residents stated they have had no problems with there medication. Nine (9) residents stated that they are given the correct dosage as prescribed by the physician. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Lauren Cabaron.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 28-AS-20251027082759

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christian Gutierrez conducted an unannounced Required-1 year visiting using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Cynthia Flores who assisted with today’s visit. There are currently 122 elderly residents, 60 years and older residing in the facility. The facility is licensed for (160) residents with age range 60 and over. 160 non-ambulatory, of which (5) may be bedridden in rooms 24, 25, 26, 27, and 28. Hospice waiver for 30. This is a three-story residential care facility for the elderly (RCFE). The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, elevator, outdoor patio, dining room, and kitchen. The 2nd floor includes 40 resident rooms, laundry room, medication room, and activity room. 3rd floor has 40 resident rooms, laundry room, maintenance/storage room, and activity room. There are (2) operable elevators. Resident bedrooms were randomly chosen for review on 2nd and 3rd floor. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 109.4-115.3 degrees which is within the required 105 - 120 degrees. Fire extinguishers were observed throughout the facility. Cleaning supplies and toxic substances are inaccessible to residents in third floor storage room. Kitchen was inspected. There is a sufficient supply of 2-day perishable and 7-day non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, living room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. Evacuation chairs were observed at each stairwell. All required postings were observed throughout the facility. Sufficient additional linens/towels were observed. The facility does not have a swimming pool or bodies of water on the premises. Passageways and exits are free of obstruction. Five (5) staff files were reviewed and included Criminal clearance record, and health screening with TB. Five (5) residents files were reviewed and included physicians report, TB clearance, and needs and service plan. Last fire/earthquake drill was conducted in May of 2025. Infectious control plan was reviewed. Two (2) staff, and four (4) residents were interviewed. Random resident medications were reviewed. Medications are centrally stored and locked. No deficiency was observed during today’s visit. Exit interview was conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2025

Allegation investigated: Facility staff do not ensure residents have access or assistance to required medical appointments.

***This LIC 9099/LIC 9099C supersedes the LIC 9099/LIC 9099C that was issued on 06/05/2025 *** Licensing Program Analyst (LPA) Nicol Wesley conducted a 10 day complaint visit at the facility and met with Administrator Cynthia Flores to discuss the purpose for todays visit. Investigation consisted of: staff roster, resident roster, interviewed staff #1-3, interview residents #1-13 Investigation revealed; Regarding allegation:Facility staff do not ensure residents have access or assistance to required medical appointments. LPA interviewed residents 1-13 who stated the facility nurses all help when they request assistance and If they had to go to the doctor the resident service directors help them by scheduling their appointment to go to a location outside of the facility when needed. If they need transportation they use continued on LIC9099C. Continued LIC 9099C Unsubstantiated access, the facility transports them or their loved one takes them to their appointment. Staff 2 and 3 were interviewed and said they always schedule appointments and arrange transportation for residents upon their request. 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. A copy of this report was given to the Administrator Cynthia Flores. Exit interview conducted.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 28-AS-20250529154501

Allegation investigated: Facility staff do not ensure residents have access or assistance to required medical appointments.

Licensing Program Analyst (LPA) Nicol Wesley conducted a 10 day complaint visit at the facility and met with Administrator Cynthia Flores to discuss the purpose for todays visit. Investigation consisted of: staff roster, resident roster, interviewed staff, interview residents, Investigation revealed: Regarding allegation:Facility staff do not ensure residents have access or assistance to required medical appointments. LPA interviewed residents 2-13 who stated the facility nurses all help when they request assistance and If they had to go to the doctor the resident service directors help them by scheduling their appointment to go to a location outside of the facility when needed. If they need transportation they use access, the facility transports them or their loved one takes them to thier appointment. LPA interviewed Continued LIC 9099C Unsubstantiated Resident 1 who also stated the people at the facility are nice and meets all of their needs. Resident 1 also stated their appointment has been scheduled since they called the Department of Social Services. Staff 2 and 3 were interviewed and said they always schedule appointments and arrange transportation for residents upon their request. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). Although the allegation(s), may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was given to the Administrator Cynthia Flores. Exit interview conducted.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 28-AS-20250529154501

Allegation investigated: Staff did not return resident’s belongings in a timely manner.

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Assistant Administrator, Cynthia Flores. The purpose of the visit was discussed. During the visit today, LPA obtained copies of the staff roster and resident roster. Interviews with Assistant Administrator and Staff S1-S3 were conducted. Interviews were conducted with Residents R2-R7. File for Resident R1 was reviewed and Resident Inventory List, Physician's Report and ID Face Sheet were submitted. In regards to the allegation Staff did not return resident’s belongings in a timely manner, based on interviews conducted and information gathered Assistant Administrator stated that no individuals had come 3 times for Resident R1's belongings. When they said he'd be long term at skilled nursing they packed all his belongings to be ready for pick up. Staff S1- S3 all stated that Resident R1's belongings were packed up and given to a staff from skilled nursing. Unsubstantiated All stated wallet was not on the Resident Inventory List. Staff also stated that the Assistant Manager told them to go check for a wallet in Resident R1's room and nothing was located there. Interviews with Resident's R2- R7 who have resided at the facility ranging between 1 to 5 years.all stated that they had filled out the Resident Inventory List and have never had anything missing. Also stated they had not heard of anyone elses belongings missing. All stated that staff treat them well. LPA observed the Resident Inventory List For Resident R1 which totaled 9 pages and included phone, cassettes and CD player, hats and clothes and was initialed by Resident R1 as being received on 05/09/25. It should be noted that Resident R1's last day at the facility was 03/04/25. 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 conducted.the state’s words, verbatim · CDSS document, May 27, 2025 · control 28-AS-20250522145901

Allegation investigated: Staff did not ensure that resident was transported to dialysis appointments.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with Aracely Curiel and explained the purpose of today's visit. The investigation consisted of the following: On 2/4/25 LPA obtained copies of staff & resident rosters, copy of transportation log from December 2024 - January 2025, obtained copy of Resident #1's (R1) Physician Report, R1's charting notes, copy of Unusual Incident Report (UIR), Interviewed 5 Staff (S1-S5) and 10 Residents (R1-R10). On 3/28/25 LPA interviewed R1. During todays visit 3/29/25 LPA delivered findings. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure that resident was transported to dialysis appointments. It is alleged that R1 was missing appointments to their dialysis treatments due to facility not providing transportation. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation stating that transportation is never denied to residents, residents have the option of using the facility van for transportation if it’s communicated with staff that they need it. Interviews with S1-S3 revealed that R1 did have a time where their insurance stopped coverage of transportation to dialysis but once it was observed the facility began providing R1 with transportation to appointments. LPA interviewed 11 residents and 11 out of 11 residents denied the above allegation, stating that they have never been denied transportation and have not had issues with staff assisting with transportation at the facility. LPA interviewed R1 and R1 stated they had a short time where insurance did not cover their transportation, facility staff began providing the transportation once it was observed and staff also assisted with fixing the issue with the insurance. Based on statements and interviews conducted with staff/residents, and review of R1's files, 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, Mar 29, 2025 · control 28-AS-20250128121742

Allegation investigated: Staff yell at resident Staff do not maintain facility in good repair

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complaint visit in regard to the allegations listed above. LPA met with Business Office Manager Ruby Andrade and explained the purpose of the visit, Acting Administrator Narine Mertkhanyan arrived shortly. The investigation consisted of the following: During the initial visit conducted on 01/03/2025, LPA Gutierrez toured five bedrooms on the second floor and three bedrooms on the third floor. LPA obtained copies of the following documents: staff roster, resident roster, resident #1 (R1) LIC 601 Identification and emergency information, LIC 602 physicians report, and LIC 603 preplacement appraisal information. On todays visit LPA interviewed residents #2-#10, R1 refused to be interviewed, staff #1-#6 and delivered findings. See LIC 9099C. Unsubstantiated In regard to the allegation “Staff yell at resident”, it is alleged that staff have yelled at residents in care. During interviews with residents nine (9) out of ten (10) residents stated staff does not yell at them. R5 stated that staff makes them feel safe. During interviews with staff six (6) out of six (6) stated they never yell at residents and have never witnessed any staff yelling at them. S1 stated that if any yelling were to occur, they would speak to both resident and staff and document incident. In regard to the allegation “Staff do not maintain facility in good repair”, it is alleged that bedroom closet doors and sliding doors on second floor are in disrepair. During interviews with residents nine (9) out of ten (10) residents stated that nothing was broken in their bedrooms. R9 stated that if anything needs to be fixed, they come right away. During interviews with staff six (6) out of six (6) staff stated they repair anything right away if broken. R3 stated that if there are any work orders they are addressed the same day. LPA Gutierrez toured five (5) bedrooms on second floor and three (3) bedrooms on third floor and found no rooms in disrepair. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Narine Mertkhanyan.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 28-AS-20241227160505

Allegation investigated: Staff are unable to provide adequate care and supervision for the residents during a power outage

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 1/30/2025, to deliver findings. LPA Ramirez was greeted by back-up Administrator Narine Mertkhanyan and explained the purpose of the visit. Initial complaint investigation visit was conducted on 12/31/2024 and needs further investigation was documented. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Personnel Report (LIC 500), Resident Roster, Staff#1-9 interviews (S1-S9), Resident interviews#1- 11 (R1 – R11), Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC 610E) , Face Sheets for Residents 1-11 (R1-R11), Physician’s Orders for Residents 1-11 (R1-R11), and physical plant tour. SEE 9099-C for continued report. Substantiated The investigation revealed the following. Regarding Allegation: Staff are unable to provide adequate care and supervision for the residents during a power outage- It is alleged facility staff were unable to provide adequate care and supervision during a power outage on 12/24/2024. Resident interviews revealed on 12/24/24 the facility experienced a massive power outage from 1:30pm till 2am on 12/25/2024. According to the facility Emergency and Disaster Plan for residential care Facilities for the Elderly (610E), the facility emergency plan indicates “Back generator will automatically operate in case of an emergency power shut off. The generator is southwest of the building in the patio area. Facility is also equipped with flashlights. There will be a rotation and residents will be assigned with care members who will be constantly checking on residents and their needs.” Resident interviews revealed the facility automatic generator did not automatically turn on when the power went out. Resident interview revealed R2 lit a candle in their room as a source of lighting. Six (6) out of eleven (11) residents interviewed revealed staff did not check-in them constantly during the power outage. Nine (9) out of the nine (9) staff interviewed denied this allegation. Staff interviews revealed the facility automatic generator has been in disrepair and did not automatically turn on when the power went out. Staff revealed the facility did have two (2) portable generators on site but, staff was only able to get one (1) of the generators running. This portable generator powered hallway lights in the facility 2nd floor, 3rd floor, temporary string lighting in the dinning room and some oxygen machines if needed. Resident interviews revealed they were left in the dark while in their rooms, but the dinning room and front entrance of the facility was equipped with portable lighting. According to staff interviews, since the emergency pull cords were not functioning, residents that had cellphones had to call the front office cellphone for assistance. On 12/31/2024, LPA Ramirez conducted a physical plant tour and observed the facility generator located in the southwest of the facility to be in disrepair. As a result of the automatic generator being in disrepair, residents were left in the dark in their rooms with no heating, several staff were observed to be using their own cellphones to provide lighting while they worked, and emergency pull cords were not functioning, and residents that had cellphones had to call the facility front office cellphone for assistance. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. One (1) deficiency was cited during this investigation. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided via email. Staff allowed residents to be soiled while in care- It is alleged facility staff allowed Resident#3 (R3) to remain soiled during the power outage. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. R3 denied this allegation during interview. On 12/31/2024, LPA Ramirez conducted a physical plant tour and did not observe residents to be malodourous. LPA Ramirez toured resident rooms and observed resident beds to contain proper linen. Although the allegation 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. Staff did not meet a resident's hygiene need while in care- It is alleged staff did not meet residents’ hygiene needs. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. On 12/31/2024, LPA Ramirez conducted a physical plant tour and did not observe residents to be malodourous. LPA Ramirez observed sufficient hygiene supplies in the facility supply/stockroom. Although the allegation 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. Staff did not provide adequate food service- It is alleged staff did not provide adequate food service during the power outage on 12/24/2024. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Residents revealed the facility provided them with a hot meal during the power outage for dinner and snacks later on in the evening. Although the allegation 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. Staff left a resident unattended- It is alleged staff left R3 unattended during the power outage on 12/24/2024. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Interview with R3 revealed staff did not leave R3 unattended on 12/24/2024. R3 revealed staff did check in on R3, two or three times during the power outage. Although the allegation 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. SEE 9099-C for continued report. Staff did not provide laundry services for a resident while in care- It is alleged the facility washing machines were in disrepair during the power outage. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. Staff interviews revealed the laundry room was temporarily closed on 12/24/2024 from 2pm till 2am on 12/25/2024 due to the power outage, but the washing machines and dryers were not in disrepair. On 12/31/2024, LPA Ramirez conducted a physical plant tour and observed all washing machines and dryers to be operational. Although the allegation 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. Staff administered medication without proper consent- It is alleged staff administered R3 a medication without a physician’s order. One (1) out of eleven (11) residents interviewed corroborated this allegation. Nine (9) out of nine (9) staff interviewed denied this allegation. LPA Ramirez reviewed R3’s charting notes for December 2024, Medication Administration Record (MAR) for December of 2024 and physician’s orders. LPA Ramirez did not observe any discrepancies. Although the allegation 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. No deficiencies were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 28-AS-20241226093704

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 31, 2025

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. This requirement was not met as evidenced by Facility automatic generator was in disrepair during power outage and staff did not constantly check-in on residents per facility emergency disaster plan, which caused unsafe and uncomfortable acccommodations. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Back-up Administrator Mertkhanyan agreed to revise the facility Emergency Disaster Plan and will submit this plan by 2/6/2025. Administrator Mertkhanyan will certify a plan to submit revised Emergency Disaster Plan by 1/31/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 28, 2025

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 was not met as evidenced by: Staff were aware the facility automatic backup generator was in disrepair. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Administrator will develop plan that will address how the backup generator will be repaired, replaced or removed. Plan must be received by 9/28/25.

Allegation investigated: Staff do not treat resident with respect. Staff are not assisting resident in coordinating religious services at the facility.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial visit to investigate the above allegations. LPA met with Narine Mertkhanyan/S-1 and discussed the purpose of today’s visit. During this visit, LPA obtained a copy of the resident and staff rosters, interviewed Resident #2 (R-2) through Resident #7 (R-7), interviewed Staff #1 (S-1) through Staff #6 (S-6) and obtained a copy of the activity schedule. LPA attempted to interview Resident #1 (R-1) and was unsuccessful. Resident #8 (R-8) refused to be interviewed. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff do not treat resident with respect. It has been alleged that the front desk receptionist is disrespectful, speaks to residents in a rude manner and hangs up on calls and does not deliver messages. Staff interviews revealed that the staff at the front desk are not disrespectful nor speak to anyone (including residents) in a rude manner. Stafft interviews also revealed that front desk staff do not hang up on calls and that staff deliver messages to residents. Interviewed staff indicated they have not received any complaints regarding this matter. Interviewed residents revealed that the front desk staff are not disrespectful nor rude. Interviewed residents indicated that front desk staff do not hang up on calls and that staff deliver messages to residents. Interviewed residents indicated that they have not heard anyone complaining pertaining this matter. Interviews do not corroborate this allegation. Allegation: Staff are not assisting resident in coordinating religious services at the facility. It has been alleged that this facility is not allowing residents to have Catholic services at this facility. Staff interviews revealed that this facility was previously receiving visits from religious individuals to provide religious services for residents on a voluntary basis. However, staff indicated that the individuals providing this service have not recently provided this service. Interviewed staff indicated that they will continue to follow up to see if religious services can be provided at this facility for residents to attend on a voluntary basis. Staff interviews also indicated that on Sunday’s, a van from a local church provides transportation to residents that voluntarily would like to attend religions services. Interviews do not corroborate this 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 conducted, a copy of the Appeal Rights and this report was provided to Narine Mertkhanyan/S-1.the state’s words, verbatim · CDSS document, Jan 13, 2025 · control 28-AS-20250107124635

Allegation investigated: Staff threatened resident.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Cynthia Flores, Assistant Administrator and discussed the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters, Staff In-service training logs for Resident's Personal Rights and Mandated Reporting/Zero Tolerance Policy, Resident #1 (R1) files such as: Information & Emergency Information (Face sheet), Admission Agreement, Physician's Report, Preplacement Appraisal, Personal Rights, Resident Assessment and Unusual Incident/Injury Report (dated 11/14/2024). LPA interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #1 (R1) - Resident #12 (R12). *****REPORT CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Staff threatened resident." It is alleged that R1 was called in the office and was threatened and intimidated by S1. (5) out of (5) staff interviewed denied the allegation and stated that they respect all residents. All staff interviewed indicated that they don't threaten the residents nor speak to the residents inappropriately. S1 stated that she spoke with R1 to investigate a complaint by S5 against R1, but did not threaten to kick out R1. S5 stated that R1 called him an idiot and stupid, but S5 did not react to avoid confrontation. R1 stated that she was not threatened by S1 but upset that S5 dis-respected her. R1 stated that she gets along well with the staff very well and no one has complained about her before. 11 out of 12 residents interviewed indicated they are happy with staff and they don't feel threatened or dis-respected by staff. Residents interviewed stated that they have not seen or heard of staff threatening other residents. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report was provided to the Assistant Administrator, Cynthia Flores.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 28-AS-20241118093134

Allegation investigated: Lack of supervision resulting in resident eloping from facility.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Assistant Administrator Cynthia Flores. *Note: Administrator on record is not current. The investigation consisted of: A physical plant tour of all common areas was conducted. Wellness Director/Staff (S1) is off today and was not interviewed. Staff (S2-S4), Skiled Nursing Facility (SNF) staff, hospital staff, and Downey Police officer were interviewed. LPA reviewed and obtained the following documents: Plan of Operation, SNF [Admission Record, Order Summary, Progress Notes, History and Physical, Transfer/Discharge Report, Discharge IDT Recapulation of Stay & Instructions, Resident's Clothing and Possessions, and LIC 602- Physician's Report dated 10/17/2024]. LIC 500 Personnel Report and resident rosters were obtained. *Narrative continues next page. Substantiated Allegation: Lack of supervision resulting in resident eloping from facility. It was reported that on 10/31/2024, resident (R1) was found wandering the streets in a very confused state and was transported to the hospital at 7:39 PM. According to information obtained, on 10/31/2024 two (2) Skilled Nursing Facility (SNF) escorted resident (R1) to the facility as pre-planned by facility staff and SNF care team, and the resident was received by Wellness Director/staff (S1) at 4:42 PM. Based on staff interviews, resident (R1) was transferred to the facility, and as Assistant Administrator was reviewing admission agreement the resident walked out the door. Wellness Director/staff (S1) attempted to redirect and followed him a short distance, but the resident refused to return to the facility. Staff (S1) is not on shift today and was not interviewed. Three (3) other staff were interviewed. Assistant Administrator/staff (S2) and another Wellness Director/staff (S3) stated that the facility did not consider resident (R1) a resident because the resident refused to sign admission documents. Per Health and Safety code §1569.2 (c) Definitions. “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered....The resident was received by staff (S1) at 4:42 PM. Per record review of SNF discharge documents provided to the facility, R1's Physician's Report states the R1 has Dementia and metabolic encephalopathy. The SNF Admission Record states R1 has difficulty walking and muscle weakness and "does NOT have the capacity to understand and make decisions". LPA interviewed SNF staff, hospital staff, and Downey Police Department personnel. The findings indicate, that facility staff did not call the police department after unsuccessful attempts to redirect the cognitively impaired resident. Downey Police Department received a phone call at 6:15 PM from a passerby stating a male was found wandering the streets off of Lakewood Blvd and Margaret St in a confused state. The passerby reporting party stood by until the Police Department arrived. Therefore, there is sufficient evidence to corroborate the allegation because facility staff neglected responsibility in ensuring the resident's safety. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D. An exit interview was conducted with Assistant Administrator Cynthia Flores. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 8, 2024 · control 28-AS-20241101154949

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Nov 13, 2024

§1569.2 (c) Definitions. “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.... This requirement was not met evidenced by: Based on record review, on 10/31/24 two (2) SNF CNAs escorted R1 to RCFE with belongings, discharge documents, and medications. R1 was received by staff at 4:42 pm. At 6:15 pm a passerby called police department to report they found a cognitively impaired male wandering the streets. This posed and immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 8, 2024

Plan of correction: Licensee shall submit by tomorrow a written plan of correction, that includes facility procedures when admitting a cognitively impaired resident. Submit proof by 11/13/24 that all staff were trained in Dementia wandering behavior, methods of redirection and care and supervision responsibilities.

Allegation investigated: Staff does not ensure resident has possession of her personal property

Licensing Program Analyst’s (LPA) Christian Gutierrez conducted an unannounced complaint investigation regarding the above allegations. LPA met Receptionist Rebecca Caballero at approximately 8:00 AM and explained reason for visit. Administrator Cynthia Flores arrived shortly. The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster (LIC 500), resident roster, R1’s identification and emergency information, admission agreement, residents’ personal property and valuables LIC 621, interview administrator, staff #1-2 interviews (S1-S2), and resident # 3-6 (S3-S6) interviews. Interview with Resident #1 (R1) was conducted telephonically on 10/24/2024. Resident #3 (R3) was unable to be interviewed due to hospitalization stay. SEE LIC 9099C Unsubstantiated The investigation revealed the following. Regarding allegation: Staff does not ensure resident has possession of her personal property. It is alleged that R1 did not receive his/her personal property after several request after leaving facility. According to information obtained resident received some items, but a cell phone charger, a clock radio, personal mail, a stay plate for dentures, and a notebook are missing. A total of four (4) residents were interviewed today and four (4) out of four (4) residents stated they have never had any belongs missing or heard that when residents leave that they are missing items. Administrator stated that S2 cleaned out room and took belongings to resident. S2 stated room was completely empty and all items were taken personally to new facility that was confirmed to be new residence of R1.S3 stated when rooms have items at time of cleaning there given to management. A copy of LIC 621 did not list items stated above. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. A copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 28-AS-20241021160054

Allegation investigated: Facility staff is mishandling residents money.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit regarding the above allegations. LPA Villalobos met with Administrator Cynthia Flores and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Staff#1-4 (S1-S4) and Residents #1-8 (R1-R8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of documents pertinent to the complaint investigation. The investigation revealed the following: In regards to the allegation "Facility staff is mishandling residents money." it is alleged that R1 is being defrauded financially by the facility as they should be receiving more money a month than they are getting after paying rent.... Conituned on LIC 9099-C Unsubstantiated (4) of (4) Staff interviewed denied the allegation. (7) of (8) Residents could not corroborate the allegation. Interviews with staff show that R1 moved into the facility on 12/20/23 after living in a skilled nursing facility (SNF). The SNF was R1's previous payee for their SSI/SSA benefits and it took time for the payee to be switched over to the current facility. This meant that R1 lived in the facility without paying rent from the day they moved in until June 2024 when the facility became the payee and received the SSI/SSA payments from the social security office. Following the 2024 SSI/SSP payment standards, the facility is only able to charge R1 the max amount of $1418.07, while leaving R1 a Personal and Incidental Needs Allowance (PNI) of $177. LPA reviewed R1s ledger on file and observed that $177 was the amount R1 received monthly after rent was paid. Additionally, the ledger showed an owed balance on file as the payments initially received from the social security office did not cover the total amount owed to the facility. There is a payment plan on file dated and signed 7/16/24 between the facility and R1 stating that R1 would pay $89 from their $177 PNI until it is paid off. This explains why R1 received less than $177 a month after July. R1 stated to not remember signing and if they did, they don't believe they were explained the truth. Additionally R1 claimed to be owed $900 a month but was not sure who or where the money should be coming from or why. As of this visit, R1's debt is paid off and it was stated by staff that going forward, R1's monthly PNI would be $177. Based on interviews, file review, and observations; 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. Due to printer issues, a copy of this report will be provided via emailed.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 28-AS-20241014121852

Allegation investigated: Staff did not prevent a resident from physically assaulting another resident in care. Facility did not maintain a comfortable temperature for a resident in care.

On today’s visit, Licensing Program Analyst(LPA) Tyler Reyes met with Assistant Administrator Cynthia Flores and explained the reason for the visit and obtained a copy of the staff and resident roster. The investigation consisted of the following: During the visit LPA interviewed Resident #1 (R1) R1-R11 and Staff #1 (S1) S1-S7.LPA requested copies of the staff roster, resident roster, and face sheet, physician report, and work order report for air conditioning units. LPA's investigation revealed the following: regarding the allegation "Staff did not prevent a resident from physically assaulting another resident in care" it is alleged that that a physical altercation occurred between two residents regarding the room temperature. --Continued LIC 9099-C-- Unsubstantiated (7) of (7) staff members denied the allegation. Staff indicated that they have not witnessed any altercations between residents nor heard of any residents arguing in regard to room temperature. Staff indicated if they had reason to believe an altercation occurred, they would follow reporting protocol as required and take appropriate actions, including making necessary accommodations for residents. (9) of (11) residents had no knowledge allegation. Residents indicated that they have not experienced or witnessed any altercations between residents nor heard of any residents arguing in regard to room temperature. Resident’s states that the air conditioning unit is respectfully shared in their room with their roommate, and they have no complaints regarding its use. (2) of (11) residents R10 and R11 had altercation resulting in R10 hitting R11 in the face. Investigation revealed that staff had no knowledge of this incident or prior incidents occurring in the facility between R10 and R11. LPA observed residents using the air conditioning unit and there was no visible signs of conflict or discomfort related to its use during the visit. LPA's investigation revealed the following: regarding the allegation "Facility did not maintain a comfortable temperature for a resident in care." it is alleged that the roommate maintains an unbearable cold temperature in the room. (7) of (7) staff denied the allegation. Staff indicated that if a resident complained of room temperature, they would take appropriate actions, including making necessary accommodations for residents. (9) of (11) residents had no knowledge of the allegation. The temperature is kept at respectable temperature degree in their room. (2) of (11) stated they had prior issues regarding the temperature of the room but the ac is now kept at a respectable temperature degree in their room. LPA observed the ac unit and window in randomly selected resident's room to be in operable condition . The investigation revealed the following that staff had no knowledge of this incident or prior incidents occurring in the facility between R10 and R11. --Continued LIC 9099-C-- Based on the interviews conducted, files reviewed, and observations conducted 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 Interviewed conducted and a copy of this report was provided to Assistant Manager Cynthia Flores.the state’s words, verbatim · CDSS document, Oct 8, 2024 · control 28-AS-20241003094717

Allegation investigated: Lack of supervision resulted in resident sustaining a fracture while in care.

Licensing Program Analyst (LPA) Galarza & Mayra Cota conducted a subsequent complaint visit to deliver findings on the above allegation. The investigation was completed by DSS/CCLD Investigations Branch (IB) Investigator Laarni Santiago. The purpose of the visit was explained to Assistant Administrator Cynthia Flores. The investigation consisted of: On 1/12/2024, LPA Nicol Wesley conducted a health and safety check and reviewed and obtained relevant documents pertaining to resident (R1), as well as a resident roster and staff roster. No health and safety concerns were observed during that visit. Investigator Santiago obtained medical records and interviewed 7 staff, Primary Care Physician, R1's family member, and hospital staff. On 2/28/2024, an interview was attempted with resident (R1) at a higher level facility.Per, R1's family former resident (R1) died at a higher level facility mid-March 2024. ***Narrative summary continues next page. Unsubstantiated Allegation: Lack of supervision resulted in resident sustaining a fracture while in care. It is alleged that resident (R1) had multiple in December 2023 that resulted in a fractured pelvic area. An additional fall occurred on January 7, 2024 after the resident returned from dialysis clinic. DSS Investigator Laarni Santiago conducted interviews with facility staff, resident's family members, and outside sources. Facility and medical records were reviewed and obtained. Medical records verified that R1 fell in December 2023 at the facility and was then admitted to a skilled nursing facility. Upon discharge back to the facility on January 7, 2024 the resident had another unwitnessed fall. Resident (R1) was found by facility housekeeper, whom immediately responded to the resident, and R1 was later transported to the hospital. Interviews with staff and family members verified that resident (R1) was independent with all Activities of Daily Living (ADL's); alert and oriented; able to communicate their needs; and able to navigate around their room and facility independently utilizing a walker/wheelchair. Records corroborated that resident (R1) was self-sufficient. Physician's Report stated that the resident was a fall risk due to weakness from dialysis, pain, with amputated fingers and toes. However, Primary Care Physician indicate that the resident could still manage on their own with minimal supervision. Although, R1 was known to be a fall risk due to their medical condition, the resident was compliant with maintaining the use of their assistive device and staff checked on the resident every two hours and close supervision was received while the resident was in the common area. The facility has a call light system for all residents and R1 always called staff for assistance when needed. Investigator attempted to interview R1 on 2/28/24. Resident (R1) died at a higher level facility mid-March 2024. Based on interviews and record reviews, there is insufficient evidence to prove the alleged violation occurred. 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 conducted with Assistant Administrator Cynthia Flores. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 28-AS-20240111153633

Allegation investigated: Facility staff is mishandling residents money. Facility staff not allowing resident to receive phone calls. Facility staff not allowing resident to receive mail. Facility staff not allowing resident to leave the facility.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Assistant Administrator, Cynthia Flores and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Assistant Administrator,Staff 1-Staff 2 (S1-S2) and Residents 2-Residfent 13 (R2-R13). R1 was not interviewed as resident is currently in the hospital. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of documents pertinent to the complaint investigation. Continued on LIC 9099-C Unsubstantiated The investigation revealed the following. Regarding Allegation: Facility staff is mishandling residents money. It was reported that R1 does not have enough money in their account and owes the facility over $1000.00. Record review confirm that R1 was admitted to the facility on 12/20/23. R1 transferred to the facility from SNF. Interviewed Assistant administrator stated that if the resident transferred from SNF, income verification is done prior to transfer and if there is an overpayment on SSI record, they discuss the payment options with resident. Facility records indicated that R1 doesn't have conservator and the facility is the payee for R1. LPA observed that Admission agreement was signed by R1 with the monthly rate $1344.82 for basic services on 12/20/23. On January 2024 R1's rent was increased to $1418.07 and notice of increase was provided to R1 (copy was provided to LPA). However, R1 doesn't paid the rent until 06/03/24 when funds become available for R1. Total amount for the rent since R1 was admitted to the facility was $11,865.13. As of today, facility received the total amount of $9,086.31 and record review reveals that R1 owes $2,258.25 to the facility. Assistant Administrator stated that the facility has developed a payment plan for R1, due to the fact that R1 has an outstanding balance and is not current on their rent. R1 was agreed to pay amount that they own the facility. R1 will pay $89.00 every month until the balance is paid in full. Regarding Allegations: Facility staff not allowing resident to receive phone calls and Facility staff not allowing resident to receive mail. It was alleged that facility declining calls for R1 and R1 not receiving mails. Interviewed Assistant Administrator and staff denied the allegations. They stated staff are ensuring that residents are receiving phone calls. Staff stated when residents are receiving a phone calls, staff is locating the residents and they can speak on the phone to the caller. At times, staff take a message for a call back per resident request, caller request or if a resident is out of the building and give the message upon return. They stated that they didn't decline any phone calls for R1 or other residents. Per Assistant administrator and staff, clients are given their mails when they are sent to them. Staff interviews revealed that when mail comes to residents, the mail is sorted according to the room number and is promptly delivered to the resident. Staff denied that they have failed to ensure that R1, or any resident, received their mail. Resident interviews revealed that residents are receiving phone calls and also receiving their mail on time and had no issues with postal mail correspondence at the facility. Continue 9099C Regarding Allegations: Facility staff not allowing resident to leave the facility. It was alleged that R1 cannot leave the facility and someone else leave and do her shopping and have someone else doing her errands. Interviewed Assistant administrator and staff denied the allegation. Interviews revealed that residents are allowed to leave the facility either with assistance or without assistance based on physician's orders. If assistance is required for transportation staff will help assisting book via Access, Dial a Ride, Taxi for medical appointments, or facility transportation, companionship to outing will be arranged also with staff. Record review shows that R1 able to leave the facility with assistance. Staff stated if R1 needs to go for shopping staff will assist him/her. So far R1 hasn't said he/she needs someone to help him/her for shopping or doing his/her errands. Interviewed residents confirmed that they can leave the facility if they want. They stated that they let the staff know and sign out and sign in upon return. Based on interviews, file review; although the allegation(s) 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 was conducted with Assistant Administrator. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 15, 2024 · control 28-AS-20240807142151

Allegation investigated: Staff neglect let to resident sustaining wounds Staff did not notify authorized representative of residents wound which resulted in hospitalization Staff did not provide timely medical care for resident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit at the facility to deliver findings for the above allegations. LPA met with Cynthia Flores and explained the reason for the visit. The investigation consisted of the following: On 8/17/23 LPA Flores and Margaryan conducted a Health and Safety check and tour the facility no deficiencies were observed. LPAs requested copies of staff/resident roster and resident #1(R1)’s Physician's Report, Admission Agreement, Face Sheet, resident appraisal, Appraisal/Needs and Service plan. On 8/16/23 Investigation Bureau assigned the investigation to investigator Olivia Spindola. On 8/17/23 Wound notes were emailed to LPA Flores. On 3/21/24 LPA Flores subpoena medical records. On 5/21/24 LPA Flores conducted a subsequent complaint investigation visit at the facility and conducted interviews with staff and residents. On 7/22/24 LPA conducted a complaint investigation visit and deliver findings. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegations: Staff neglect let to resident sustaining wounds, Staff did not notify authorized representative of resident’s wound which resulted in hospitalization, and Staff did not provide timely medical care for resident. It is alleged R1’s representative noticed a wound on R1’s foot, staff facility was notified by R1’s representative of wound who agreed to have in-house physician follow up, wounds have been present for several months, and R1’s representative did not receive any update regarding foot wound. On 6/13/23, R1’s family member visited R1 at the facility. Family member assisted R1 with a shower and noticed R1 had a wound. On 6/13/23, R1’s representative was notified by family member of wounds and representative then notified staff #2 (S2) via email of the wound on R1’s left heel. S2 replied that they will assist R1 with medical attention. On 6/19/23, R1 was send out to the hospital due to complaints of pain. On 6/22/23, R1 was discharge from the hospital to a skill nursing facility (SNF) for care. On 7/12/23, R1 was discharge from SNF and returned to the facility. On 7/14/23, R1 initiated home health care. On 7/20/23, wound care agency evaluated R1 and noted R1’s wound still open which measured 3.5cm by 3.5cm. On 7/22/23, R1 was transferred from the facility to a SNF for care. Interviews conducted with facility staff revealed, that facility staff were aware that R1 had developed left foot wound, and three staff stated the wound in R1’s left heel was present for several weeks. Per Incident report dated: 6/19/23 staff contacted wound specialist regarding R1’s left heel wound, who recommended triple antibiotic ointment and recommended to send R1 to the hospital. Medical records reviewed, revealed R1 was seen at the hospital on 6/19/23 for a wound on the left heel. The wound was described as a “left heel wound with black color”. Hospital also noted on the history that paramedics stated resident was brought to the hospital for “evaluation of a wound on the left foot which has progressively worsen and the wound has been present for about a week, increasingly red and swollen.” On 7/26/23, Wound Care services noted a wound on “Left, Lateral Heel is a Wagner Grade 1 Diabetic Ulcer and has received a status of Not Healed.” The wound’s measurements were 3.5cm length x 3.5cm width x 0.1cm depth. Based on the interviews conducted and documents reviewed facility staff were aware of the wounds before the hospitalization on 6/19/23, R1’s representative notified S2 on 6/13/23 of the wound, there is documentation that a wound specialist recommended R1 to go out to the hospital, R1 went out to the hospital on 6/19/23, six days after the wound was reported to staff, and family representatives were not communicated regarding the wounds either prior to 6/19/23 or after. (CONTINUED ON LIC 9099C) Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) 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, due to Resident #1 sustaining a wound to the left heel, worsening due to health conditions, and facility staff not seeking medical attention in a timely manner while in care. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Cynthia Flores and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 22, 2024 · control 28-AS-20230815130109

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 23, 2024

Additional Personal Rights of Residents in Privately Operated Facilities (a)...: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on interviews conducted and documents reviewed licensee failed to ensure R1 did not develop a wound which poses an immediate risk to the health, safety, or personal rights to the persons in care. *Immediate Civil Penalty for $500 is being issue*the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Administrator will certify in writing that staff including administrator will follow up on any medical need upon observation, communication, or discovery of such, and will provide training to staff on the above and submit trainig logs to the department by POC due date of 7/23/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 23, 2024

Additional Personal Rights of Residents in Privately... (a)... :(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews conducted and documents review licensee did not ensure R1 received medical attention in a timely manner which poses an immediate risk to the health, safety, or personal rights to the persons in care. *Immediate Civil Penalty for $500 is being issue*the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Administrator will provide training to staff regarding reporting, seeking medical attention, and assisting residents in a timely manner and will submit logs to the department by POC due date 7/23/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jul 29, 2024

Personal Rights of Residents in All Facilities:(a) Residents...shall have...:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement is not met as evidence by: Based on interviews and document review licensee did not ensure that R1's family were informed of the wound development which poses a potential risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Administrator will maintain communication with resident's representatives in writing, and will provide a training to staff to ensure that communication is properly log in the charting notes by POC due date 7/29/24.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit to note additional deficiencies that were found during the complaint investigation. LPA met with Narine Mertkhanyan and explained the reason for the visit. On 8/25/23 LPA Flores initiated a complaint investigation. During the course of the investigation, it was found that Resident #1(R1) had a restricted health condition. R1’s physician’s report dated: 11/16/20 does not note R1 had dementia. However, on 6/19/23 upon R1’s hospitalization, the hospital noted R1 with dementia. Due to R1’s cognitive skills, R1 was not able to measure blood sugar and/or provide self with injections per regulations for restricted health conditions. During the same hospital visit of 6/19/23, it was found that blood test was highly elevated and “flagged as critical results.” Appraisal/Needs and Services plan dated 7/13/23 does not note any care for R1’s restricted health condition. R1 began receiving home health services on 7/14/23 and there are no records to indicate she was receiving them prior to that date. On 8/25/23 and 5/21/24 LPA conducted complaint investigation visits at the facility and did not find documents related to restricted health condition or provided documents upon request. Therefore, there are no records to indicate that R1 was receiving medication for restricted health condition or a plan to provide care for restricted health condition. Deficiencies are noted on LIC 809D on per Title 22 Regulations. Exit interviews was conducted with Cynthia Flores and a copy of this report LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Jul 23, 2024

Diabetes: (a) The licensee shall be permitted to accept or retain a resident... if the resident is able to perform his/her own glucose testing... and is able to administer his/her own medication... or has it administered by an appropriately skilled professional. This requirement is not met as evidence by: Based on interviews and documents reviewed the licensee did not ensure R1 was able to perform own glucose testing or was checked by a skilled profesional which poses an immediate health, safety, or personal rights risk to the persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Administrator will certify in writing that will ensure that each resident with a restricted health condition is able to care for self or is under care from a skilled professional to the department by POC due date 7/23/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87611(b) · Plan of correction due date: Jul 29, 2024

General Requirements for Allowable Health Condition: (b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure facility maintain a plan of care for R1 who had a restricted health condition which poses a potential risk to health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jul 22, 2024

Plan of correction: Administrator will create a plan of care for each resident with an allowable health condition and maintain medication records and submit a copy to the department by POC due date 7/29/24.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA's) Tyler Reyes and Valeria Maldonado conducted an unannounced Required-1 year visiting using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Narine Mertkhanyan and assisted LPAs with the visit. There are currently 125 elderly residents, 60 years and older residing in the facility. The first floor has a parking garage, lobby, administrative offices, employee lounge, beauty salon, supply room, outdoor patio, dining room, and kitchen. The 2nd floor includes 40 resident rooms, laundry room, medication room and activity room. 3rd floor has 40 resident rooms, laundry room, maintenance/storage room, and activity room. There are (2) operable elevators. The following 12 (CARE) tools domains were utilized during the inspection. Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents medications. Staff are cleaning and disinfecting throughout the day. Operational Requirement: The facility is licensed for (160) residents with age range 60 and over. 160 non-ambulatory, of which (5) may bedridden in rooms 24, 25, 26, 27, and 28. Hospice waiver for 30. Facility has the appropriate liability insurance. Physical Plant and Environmental Safety: There are a total of 80 rooms in the facility which each has there own restroom. LPAs toured the common areas, kitchen, dinning area, public restrooms, and outside areas. Resident bedrooms had the required furniture for comfort and safety and had sufficient lighting. All indoor and outdoor passages were free from obstruction. Private resident bathrooms were inspected. Restrooms were clean, toilets and water faucets worked properly and properly supplied. During the tour of the physical plant, LPA's observed the laundry rooms on the 2nd and 3rd floor open with cleaning supplies accessible to residents in care. LPA's informed staff of the open doors and the doors were closed. However, after passing by the laundry room again, the door was again opened with cleaning supplies still accessible. Continued on LIC 809-C Water temperature was measured throughout the residents bedrooms and temperatures ranged from 110 -119 degrees F which is within required range of 105-120 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately available. Last Emergency Disaster Drill was conducted on 5/17/24. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguishers were observed to be fully charged. Staffing: The facility has sufficient staffing in the facility. The facility has at least one person to have updated First Aid and CPR training certificate. Personnel Records-Training Information: Staff has criminal record clearance. Staff have current CPR/first aid training. Resident's right/Information: The facility has Personal Rights Poster stationed in the main hallway. Facility provided internet and telephone access for the residents in care. Facility provides internet and telephone access to the residents. Planned Activities: There is a designated activity poster for the month of June observed in the dinning room. Food Service: The kitchen was observed for the ability to prepare and serve food. LPAs observed an appropriate food supply of two (2) days of perishables and one week (7) days of non-perishables. Incidental Medical and Dental: Medications for resident are stored in the facility Medication room. All medication observed during visit were properly labeled in their original containers. Staff designated to administer medication has the proper annual training on file. Resident's Records-Incident Reports: A total of (5) residents files were reviewed. Required documents were observed. Continued on LIC 809-C Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation. LPA conducted 4 staff interviews and 5 resident interviews during today's visit. Resident with Special Health Needs: Facility has hospice waiver for 30 persons there are currently no persons with hospice residing at the facility. There is proper fire clearance and signs posted residents using oxygen. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC809-D page. Exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 13, 2024

Allegation investigated: Communications of resident's authorized representative are not being answered promptly by facility staff

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Executive Director Narine Mertkhanyan and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Executive Director Narine Mertkhanyan, Staff 1-3 (S1-3) and Residents 1-8 (R1-8). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of documents pertinent to the complaint investigation. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Communications of resident's authorized representative are not being answered promptly by facility staff, it is alleged that R1 wants to move out of the facility for unknown reasons and numerous attempts to get in contact with facility management regarding this request have gone unanswered and phone calls have not been returned since approximately 02/29/24. Allegedly the facility receptionist has taken contact information down but R1's family member (R1 FM) has not received a call back and due to this lack in communication R1's FM is concerned regarding R1's safety and care. Interviews conducted with Executive Director Narine Mertkhanyan and S1-3 revealed that facility staff have not received messages from R1 FM. Executive Director Narine Mertkhanyan and S1 stated that R1 is self-responsible and has not spoken to staff about moving out of the facility. They stated that R1 has spoken to staff about moving rooms but not about moving out of the facility. S2 stated that R1 has mentioned that they might move somewhere else to be closer to family but R1 has not talked to Executive Director or S1 as they are the staff that would assist R1 with moving out. Staff stated that when they receive messages for any resident, staff ensure that the messages are delivered to them in a timely manner. They stated that most residents have their own personal phones and might use their phones to return calls. They stated that the facility phone is always available for resident use. Staff stated that resident safety is a top priority and they have not received any concerns from anyone regarding concerns with resident safety or care. Staff stated that all residents receive adequate care and that there is enough staffing throughout the day to ensure that residents are receiving appropriate care and supervision. S2 stated that when they take a message down it is forwarded to the appropriate staff for follow up. Interview conducted with R1 revealed that they are self-responsible and have thought about moving to another facility to be closer to family but they have not decided where so they have not spoken to management about that yet. R1 stated that they did speak to staff about moving rooms and staff assisted them with that request. R1 stated that they do not have concerns regarding communications, safety or care. Interviews with 8 out of 8 residents revealed that they are satisfied with the services that they receive at the facility and do not have any concerns regarding communication, safety or care. They stated that staff give them their messages whenever they have any. LPA review of R1 file revealed that R1 is self-responsible. LPA reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and provide care for the residents in placement. Based on interviews conducted with facility staff, facility residents, and LPA review of documents 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. A copy of the report was provided to Executive Director Narine Mertkhanyan.the state’s words, verbatim · CDSS document, May 13, 2024 · control 28-AS-20240509125328

Allegation investigated: Staff do not practice safe food handling techniques

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Assistant Administrator, Cynthia Flores. The purpose of the visit was discussed. During the visit today, LPA obtained copies of the staff roster and resident roster. Interviews with Assistant Administrator and Staff S1 and S2 were conducted from 9:40 AM to 10:05 AM. Interviews were conducted with Residents R1-R8 from 10:10 AM to 11:00 AM. Tour of the kitchen and dining room area which included observation of dining room and observation of the kitchen which includes the food supply. In regards to the allegation Staff do not practice safe food handling techniques, based on tour conducted, interviews conducted and information gathered, LPA observed in the dining room that the servers were wearing gloves. Observation in the kitchen was that staff wore gloves. There was no food left on any of the counters in the kitchen and in the freezer there were no perishables left unopened. There were 5 boxes of gloves observed in the kitchen area. Unsubstantiated Interviews were conducted with Resident's R1-R8 and 7 of the 8 stated that staff do wear gloves when serving food. 1 of the 8 stated she doesn't pay attention if they wear it or not. 8 of 8 resident's stated that they have never had any food served that is uncooked or raw and that it is always served well. 6 of 8 resident's stated that the food was good and that it has gotten better. 2 of the 8 resident's stated they prefer getting their own food for their meals. Interviews were conducted with staff who all stated that the there is not chicken left on the counter. All stated that it is served fresh after cooking in the oven. Also stated that food from oven is put in steamer 10 minutes before being served and food is never cooked on the steamer. LPA observed steamer with no food being cooked in it. Staff also stated that gloves are worn in the kitchen and when serving food. 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 was conducted with Assistant Administrator, Cynthia Flores.the state’s words, verbatim · CDSS document, May 2, 2024 · control 28-AS-20240425122625

Allegation investigated: Questionable death. Staff did not ensure resident received adequate care. Staff allowed resident to be left in soiled clothing for extended periods of time. Staff did not ensure resident was provided with bathing services.

Licensing Program Analysts (LPAs) Galarza & Tyler Reyes conducted an initial 10-day complaint investigation visit in regards to the allegation listed above. LPA discussed the purpose of the visit with Cynthia Flores. Administrator arrived shortly after. The investigation consisted of: A physical plant tour of the interior of the facility, record review, and interviews of staff (S1- S6) and residents (R2-R13) were conducted. Resident (R1) passed away and was not interviewed. Resident (R1's) file documents were reviewed. The following documents were obtained: Face Sheet, Preplacement Appraisal Information, Physician's Reports, Home Health Notes, incident reports, Appraisal Needs/Services Plan, LIC 500 Personnel Report, and resident roster. ***See narrative summary on next page.*** Unsubstantiated Allegation: Questionable Death. It is alleged that on December 20, 2023 resident (R1) was found unresponsive and not breathing in their room. According to information obtained the resident died Pneumonia due to COVID-19, and R1's family was not aware that the resident was ill. Based on interviews conducted, the findings indicate that the facility had a COVID-19 outbreak in December 2023, and the facility conducted mass testing of COVID-19 on December 20, 2023, the same day that R1 died. The COVID-19 mass testing results were obtained the following day. Resident (R1) tested positive for COVID-19. A total of six (6) staff were interviewed. Staff stated that the resident tested positive for COVID-19 and died at the facility. Per staff, the resident used oxygen daily and had respiratory pre-existing conditions. Only (1) staff stated that they observed a change in condition approximately 3-4 days prior to R1's death. According to staff, R1 began to speak less, but because the resident required oxygen at all times breathing issues were not noted as a change in condition. LPA obtained the LA County Death Certificate that lists the cause of death as Pneumonia, COVID-19, and Acute Respiratory Failure. Therefore, there is insufficient evidence to corroborate the allegation. Allegation: Staff did not ensure resident received adequate care. It was reported that sometimes facility staff responded to R1 rudely, mean, and sarcastically when the resident requested assistance. A total of 12 residents were interviewed, of which none reported issues with care services. A total of six (6) staff were interviewed, of which all denied the allegation. According to interviews conducted, resident (R1) frequently pulled the call system string and staff responded in a timely manner to the resident. Resident (R1) was able to transfer to the bed on their own, but was full assist on ADL's. Staff stated that the resident's care needs were not neglected and the resident was treated well. There is insufficient evidence to support the allegation. Allegation: Staff allowed resident to be left in soiled clothing for extended periods of time. It is alleged that facility staff did not change R1's incontinence diaper as needed, because the resident required a diaper change more frequently than every 2 hours. It was reported that on several occasions R1 was heavily soiled with urine when family visited the resident. All staff interviewed denied the allegation and stated that the resident was changed at least every 2 hours, but often was changed hourly because the resident drank a lot of water and needed more frequent diaper changes. Staff stated that they never received complaints from the resident or responsible parties about incontinence care. A total of 12 residents were interviewed, one (1) resident reported that staff sometimes ignore the call request, and there have been times they wait more than 20 minutes to receive incontinence care. Based on interviews conducted, there is insufficient evidence to corroborate the allegation. Allegation: Staff did not ensure resident was provided with bathing services. It is alleged that resident (R1) was not being bathe as necessary after incontinence incidents. Based on staff interviews, the findings indicate that residents receive baths twice weekly and/or as needed. In R1's case, the resident was often bathe 3 times a week due to bowel incontinence. All staff denied the allegation. A total of 12 residents were interviewed, none reported issues with bathing schedule. Per record review, resident (R1) received regular bathing assistance. Therefore, there is insufficient evidence to corroborate the 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 was conducted with Administrator Narine Mertkhanyan. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240319095008

Allegation investigated: Facility failed to provide medical attention in a timely manner.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to deliver findings for the allegation above. LPA arrived and met with Assistant Administrator, Cynthia Flores, to explain the reason for the visit. The investigation consisted of the following: On 9/21/22, LPA Chan conducted the initial visit to gather rosters and documents pertaining to Resident #1 (R1). Interviews were conducted with the Assistant Administrator, 4 Staff, and 5 Residents. On 2/2/23, LPA interviewed the administrator, 2 staff and 6 residents. The investigation revealed the following: Allegation – Facility failed to provide medical attention in a timely manner. It was alleged that Resident #1 (R1) requested medical attention but was delayed 48 hours which resulted in resident losing 3-6 liters of blood. Unsubstantiated LPA interviewed a total of 8 facility personnels, 11 residents, and reviewed documents to determine the findings for this allegation. According to staff interviews, R1 has a history of menstrual bleeding. Some staff stated they assisted R1 with changing the pad when R1 requested help. Staff did not observe substantial bleeding from R1 that appeared alarming when they showered or changed R1. They also stated R1 mainly requested help with bathing and changing and did not share the medical history with staff. However, when R1 requested the facility’s help in arranging medical appointment, staff did so. For this incident, staff recalled checking on R1 during their shifts and did not see any signs of distress on R1 days prior to hospitalization. When R1 reported feeling weak, the staff asked if 911 should be called. Per R1, resident did not want them to contact 911, but rather, to arrange for a telehealth visit. Staff assisted with the request and R1 spoke with the doctor. Per the physician’s recommendation, R1 should be evaluated at the hospital and staff tried to assist in arranging non-emergency transportation. Staff informed R1 there were no bariatric transportation on that day and will continue to find one. In the meanwhile, R1 did not disclose to staff about the menstrual bleeding nor symptoms that required immediate medical attention until the next day. Staff immediately called 911 when R1 requested it. Based on information gathered, R1 appeared to be self-independent with medical needs and did not fully share the medical history with the facility. Staff could not have known the significant amount of blood loss. LPA interviewed a total of 11 residents. 7 out of the 11 residents, who need some assistance from staff, indicated that staff assisted right away when they asked for help. Some residents, who had requested medical attention, stated that staff provided medical attention in a timely manner. 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. An exit interview was conducted with Cynthia Flores. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20220912163936

Allegation investigated: Staff refused to accept resident in to the facility

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Assistant Administrator, Cynthia Flores. The purpose of the visit was discussed. During the visit today, LPA obtained copies of the staff roster and resident roster. Interviews with Assistant Administrator and Staff S1 and S2 were conducted from 10:00AM to 11:15 AM. Interview was conducted with Resident R 1 telephonically on 03/04/2024. In regards to the allegation Staff refused to accept resident in to the facility, based on interviews conducted and information gathered it was revealed in interviews with staff that R 1 was never admitted to the facility because he refused to pay the 1st month's rent and was very upset and yelling. Staff stated that R 1 was given the wrong information from the Social Worker from Skilled Nursing. LPA observed an e-mail exchange between the Social Worker from Skilled Nursing and the representative from the Assisted Living Waiver Program. The Social Worker stated that it was her understanding that the first month's rent was paid and was not aware that R 1 has to wait 6 months before the funding is in Unsubstantiated process. Interview with Staff Marketer who stated that they had done everything correctly, but R 1 was upset over the money. Stated that R 1 left the office without signing the Admissions Agreement. Also stated that it was explained the facility has to follow the diet through the ALW Program. Stated they did attempt to send R 1 back to his skilled nursing, but they would not accept him back. Interview was conducted with R 1 who stated that the staff member tried taking R 1 back to the skilled nursing, but they refused to take him back. Also stated that he was unaware of a $49 prorated charge and that facility was seeking $1000 before move in, but he decided to wait. 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.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 28-AS-20240301161357

Allegation investigated: Resident eloped from the facility because staff did not provide adequate supervision.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a visit to investigate the above allegation. LPA met with Cynthia Flores/S-1 and discussed the purpose of today’s visit. During this investigation, LPA obtained a copy of the resident and staff rosters, reviewed R-1’s file and obtained relevant information, interviewed Staff #1 (S-1) through Staff #4 (S-4) and interviewed Resident #2 (R-2) through Resident #5 (R-5). LPA was unable to interview R-1 as R-1 has been missing from this facility since 01/28/2024 and R-1’s whereabouts are unknown. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Resident eloped from the facility because staff did not provide adequate supervision. It is alleged that R-1 eloped from this facility due to staff not providing adequate supervision. (3) out of (4) staff interviews revealed that R-1 was in the facility on 01/27/2024 and was reported missing on 01/28/2024. Staff interviews revealed that a missing person’s report for R-1 was filed with the local police department and an incident report was submitted to community care licensing. (3) out of (4) staff interviews revealed that staff continue to have communication with the local police department and local hospitals in attempts to locate R-1. (3) out of (4) staff interviews also revealed that in October of 2023, R-1 was out in the community for an extended amount of time prior to this latest incident. A missing person’s reports was filed with the local police department and reports were also submitted to community care licensing. Per information obtained, R-1 was located and taken to a hospital for treatment of a medical condition not related to a cognitive impairment. Staff interviews revealed that R-1 is self-responsible and goes out to the community daily throughout the day independently. R-1’s Physician Report indicates that R-1 does not have a cognitive impairment and R-1 is able to leave the facility unassisted. R-1 only had their initial appraisal/needs and services plan upon admission (dated 12/27/2021) and per S-1, R-1 does not have an updated plan as R-1 has not had a change in condition. Per R-1’s appraisal/needs and services plan, R-1 is self-responsible and is able to perform activities of daily living independently. Interviewed staff indicated that R-1 has not had a change of condition. LPA obtained a chronology for both incidents reflecting the dates the facility called local hospitals and/or local jails in attempts to locate R-1. (1) out of (4) interviewed residents indicated that R-1 appeared to be their normal self, went in and out of this facility independently and did not appear to have a cognitive impairment. (3) out of (4) interviewed residents indicated they do not know R-1 and that residents keep to themselves. Interviewed staff also indicated that R-1 kept to R-1’s self. Interviews conducted and documentation reviewed do not corroborate this 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 conducted, a copy of the Appeal Rights and this report was provided to Cynthia Flores.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 28-AS-20240213084149

Allegation investigated: Resident sustained a fracture while in care Staff did not seek timely medical attention for a resident Staff did not ensure a resident was properly fed while in care Resident's call light is in disrepair

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit in regards to the original complaint dated 06/28/2022. The initial visit was conducted 06/30/22 and included the following: Licensing Program Analyst (LPA) Glenn Trueman conducted a Health and Safety Check visit in response to the above mentioned allegations. LPA met with Administrator Lisa Pham and Assistant Administrator Cynthia Flores and explained the reason for the visit. Investigation consisted of the following: LPA requested copies of Client & Staff Rosters and conducted a tour of facility at 12:50 PM along with Administrator Lisa Pham and Assistant Administrator Cynthia Flores which also included the common areas. LPA also reviewed and received copies from Resident #1's (R1) file. LPA observed the clients to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns during today's visit. LPA observed a sufficient supply of perishable and non-perishable foods for the clients in care. Unsubstantiated Investigation was conducted by the Investigations Branch (IB) and completed 10/10/2022 for allegations Resident sustained a fracture while in care and Staff did not seek timely medical attention for a resident. Investigation consisted of interviews with facility staff, nurse practitioner and review of medical documentation. At today's visit at 10:30 AM LPA toured the facility with Assistant Administrator Cynthia Flores and inspected the call lites in Rooms 2, 6, 22, 45, 48, and 63. Interviews were conducted at 11:00 AM with Resident's R 2- R7. In regards to the allegation Resident sustained a fracture while in care, based on interviews conducted by the Investigations Branch( IB) and medical documentation reviewed it was revealed in interviews with staff that R 1 had told staff about unwitnessed falls. R 1 was assessed and staff did not observe any injuries, swelling or redness. Staff still contacted R 1's doctor and R 1's Nurse Practitioner. The following morning at 0915 hours R 1 complained of minor pain and staff promptly contacted the Nurse Practitioner who stated in interviews conducted that there were no bruises/ swelling or redness. R 1 was observed walking and did not complain of any pain. Nurse Practitioner confirmed that staff acted accordingly and reported R 1's condition in a timely manner. Nurse Practitioner also stated that she denied having any complaints or witnessing any Neglect/ Lack of supervision by facility staff. 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 above allegations are UNSUBSTANTIATED. In regards to the allegation, Staff did not seek timely medical attention for a resident, , based on interviews conducted by the Investigations Branch( IB) and medical documentation reviewed it was revealed in interviews with staff that R 1 had told staff about unwitnessed falls. R 1 was assessed and staff did not observe any injuries, swelling or redness. Even though R 1 was not complaining of any pain, and no bruises or swelling, staff immediately contacted Care More Health and requested a medical evaluation. Per Nurse Practitioner the staff immediately notified her of R 1's reporting and condition. Subsequently the Nurse Practitioner evaluated R1 and medically cleared R 1. 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 above allegations are UNSUBSTANTIATED. In regards to the allegation Staff did not ensure a resident was properly fed while in care, based on interviews conducted with staff, and residents R 2- R 7 and information gathered all 6 of 6 resident's interviewed stated they are always fed and get all 3 meals and a snack and stated if a resident does not come to the dining room they will bring food to their room. Interview with Assistant Administrator Cynthia Flores who stated that R 1 did get all her meals and if residents not feeling well they will bring to their rooms. Also stated that R 1 is verbal and had a cell phone to communicate with staff if needed. Staff S 1 stated that they will check in rooms if they are eating and also check in the dining room. They make a list downstairs and check who has received their meals. 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 above allegations are UNSUBSTANTIATED. In regards to the allegation, Resident's call light is in disrepair, based on resident and staff interviews conducted and tour of Rooms 2, 6, 22, 45, 48, and 63, it was revealed that all call lites were operable when tested by the LPA. Staff responded to the call lite for assistance in a timely manner. Interviews with staff who stated that the panel in the office lites up and the staff has a walkie talkie to communicate which room needs assistance. There is also a panel that lites up on each floor that will show which room needs assistance. 6 of 6 resident's interviewed stated that the call button works and the staff respond quickly. Also stated it is easy to use and staff does a good job. 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 above allegations are UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 28-AS-20220628152050

Allegation investigated: Resident developed injuries (wounds) while in care. Resident was sent to the hospital without any medical records. Resident was incorrectly charged for rent.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to investigate the above-mentioned allegations. LPA met with Cynthia Flores, Assistant Administrator and explained the purpose of the visit. During the initial visit on 01/11/2022, LPA Bonnie Tao toured the facility, reviewed the records of Resident #1 (R1) and obtained a copy of resident roster, staff roster, R1's records such as Identification and Emergency Information, Physician report, Admission Agreement, Appraisal, and Personal rights. LPA Tao also requested a copy of R1's needs and services plan, incident report, dated 1/6/22, and wound care notes. During today’s visit, LPA Pena obtained the following records/files: Staff & Resident Rosters, Incident report (dated 01/06/22), R1’s records such as Admission Agreement, Face Sheet/ Identification & Emergency Info Sheet, Physician's Report, Resident Appraisal, Needs and services plan, Medical Records, Personal Rights, Wound care notes, Rent increase notification letter and Rent Invoice/Receipt dated 12/16/2021. LPA also interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #2 (R2) - Resident #11 (R11). LPA attempted to interview former Resident #1 (R1) 3x, however, R1's contact information is no longer valid. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Resident developed injuries (wounds) while in care.” It is alleged that a resident was sent to the hospital after developing wounds on his buttocks. No other details provided. Staff interviewed stated that they do rounds regularly to check on residents. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. Staff also stated that they reposition resident to prevent rashes, sores or wounds. Staff also stated that when caregivers notice rashes or wounds, they report it immediately to the Med Tech for assessment and doctors are notified for treatment and to authorize care from a Home Health nurse or wound care specialist, if needed. LPA interviewed 10 residents of which 2 are incontinence. None of the residents interviewed stated that they have any injuries, wounds nor pain in the buttock area. Some residents interviewed also stated that they never develop wounds under facility's care. LPA reviewed the incident report submitted to CCL dated 01/06/2022 stating that R1 was being treated for the wound and under the care of a wound specialist. Report indicated that the wound specialist ordered R1 to be sent to the hospital because R1 was non compliant with the wound care plan. Based on documentation reviewed, R1 moved into the facility on 12/16/2021 and Preplacement appraisal information indicated that R1 has a history of skin breakdown and was diagnosed with moderate protein calorie malnutrition. Therefore there was insufficient evidence to corroborate with the allegation. In regards to the allegation: “Resident was sent to the hospital without any medical records.” It is alleged that a resident was sent without any medical records to the hospital. No other details provided. Interviewed staff denied the allegation. Staff stated that mainly, it is the front desk receptionist who prepare the medical records prior to sending a resident to the hospital. Staff also stated that the emergency packet for the residents is located in the front desk and if receptionist is not available Med Tech on duty is responsible for providing emergency packet to paramedics. Interviewed residents denied the allegation and some residents stated that the office staff send them to the hospital with their medical records every time. Some residents also stated that if the facility did not provide it, they will hear it from the hospital personnel, but they never had that issue. Documents reviewed indicated that R1 was sent to the Hospital on 01/06/2022 and a staff provided EMT with R1's report, face sheet and medication list at 6:06pm. Therefore there was insufficient evidence to corroborate with the allegation. In regards to the allegation: “Resident was incorrectly charged for rent.” It is alleged that the rent was for $1200+, which is more than what the resident was told it would and more than the resident's SS check of $1080. Interviewed staff denied the allegation. S1 stated that the rental fee for most SSI recipients increase annually and they notify all residents in advance by writing. S1 indicated that R1 was admitted to the facility on 12/16/2021 and paid a pro rated amount for 12/16/2021-12/31/2021. S1 stated that R1 was notified of the rate increase via letter upon his admission. Interviewed residents stated that they were never charged incorrectly for rent. Residents interviewed stated that the facility notify them of the annual rate increase in advance by letter or memo. Documents reviewed indicated that a notification letter regarding the rent increase was provided to R1 on 12/16/2021 by the Administrator. Additionally, the staff provided R1 an invoice for a pro rated rent between 12/16/2021-12/31/2021. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of the report was provided to Cynthia Flores, Assistant Administrator.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 28-AS-20220107103208

Allegation investigated: Staff mismanaged resident's medication. Staff failed to safeguard resident's personal belongings. Staff failed to treat resident with dignity and respect. Staff confiscated resident's wheelchair.

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Cynthia Flores and explained the reason for the visit. The investigation consisted of the following: During the initial visit conducted on 9/7/2022 LPA Glen Trueman conducted interview with Assistant Administrator and obtained copies of the following documents: staff and residents roster, copies of relevant documents from R#1 file were provided. Due to insufficient information available at the time the above allegations needed further investigation. (Continued on 9099-C) Unsubstantiated During subsequent visit conducted on 10/26/23 LPA Tena Herrera obtained copies of staff and resident rosters and copies the following documents for R1: Face Sheet, Physcian’s Report, Replacement Appraisal, order from doctor indicating resident needs higher level of care, Acknowledgment of Discharged signed by responsible party, Inventory of Personal Items (upon discharge) and Signed Theft and Loss Policy. Conducted 7 staff interviews and 11 resident interviews. LPA attempted to interview R1 but they are no longer a resident at the facility as of 11/1/2022, LPA left voicemail for a returned call in the am and tried again twice in the afternoon with no success in reaching R1. Investigation Revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that staff are mismanaging R1’s medication as sometimes staff fail to administer medications to R1. Interview with S7 revealed that at times R1 would return from being out in the community intoxicated and because of this sometimes medication will not be administered as R1’s doctor would instruct MedTech’s to not provide dosage since medication cannot be taken while intoxicated or with alcohol. Interviews with MedTech staff and those who held a previous position as MedTech each stated that medications are never intentionally refused to residents. Interviews with residents 10 out of 11 residents denied the above allegation and stated that they are given their medication on time, have never been denied their medication, and feel the staff are doing a good job with their medication management. During visit LPA toured medication room, reviewed MAR and 5 residents medications, no issues were observed. Allegation: Staff failed to safeguard resident's personal belongings. It is alleged that S7 entered R1’s room and went through their personal belongings and after this the personal belongings went missing. LPA interviewed S7 and it was revealed that on one occasion while R1 was at a nursing home R1’s responsible party came to collect clothing for R1 and refused to sign the Inventory for Personal Belongings log, upon return to the facility R1 claimed that they were missing clothes but couldn’t provide specifics as to what was missing just stated that they knew they had more clothing. On another occasion R1 claimed a cologne was missing, after searching for the missing item, it was found have fallen behind R1’s dresser. Based on interviews with staff 7 out of 7 staff stated they do not handle residents belongings unless the resident asks for assistance, the only staff that does handle residents belongings is the Laundry Staff. (Continued on 9099-C) Based on interview with laundry staff S4 stated they only do washing for 2 residents at a time to avoid confusion and mix up of items, there is a list they go by when doing the laundry to ensure accuracy. Based on interviews with residents, 9 out of 10 residents stated that they have never had any of their personal belongings go missing. Allegation: Staff failed to treat resident with dignity and respect. It is alleged that staff does not treat R1 with dignity and respect as R1 feels that staff have forcefully attempted to send them to Skilled Nursing Facility (SNF) in efforts to “get rid” of them. Based on interviews with staff 7 out of 7 staff stated that they have never forcefully sent residents to SNF’s. Interviews with S1 and S7 revealed that residents are not sent to SNF’s directly from facility, if they have a medical condition in which they are hospitalized the doctor at the hospital will refer them to a SNF for rehabilitation before them returning to the facility. Based on interviews with residents 10 out of 11 residents indicated that they have never forcefully been sent to the hospital or SNF. R2 indicated that they were once sent to a SNF and didn’t want to go, however, this was done through the hospital doctor after R2 suffered injuries from a fall and does not feel they were forced, understood that it was best for their recovery. Allegation: Staff confiscated resident's wheelchair. It is alleged that R1 used to have an electric chair and one day it went missing and staff put it in a room called the “beauty shop”. Based on interviews with staff 7 out of 7 staff stated that they have never taken a residents wheelchair nor have they seen/heard of another staff doing so. In interview with S7 they stated that on occasion R1 would borrow other residents electrical wheelchairs and staff would have to remind residents to not lend or borrow each others belongings to avoid any issues. Based on review of records, upon discharge from the facility R1 was given all his belongings with wheelchair included. Interviews with residents 9 out of 11 residents interviewed denied the above allegation and stated that staff has never taken their wheelchair, walker or cane from them. Based on statements and interviews conducted with staff and residents, review of R1 files and medication review, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 28-AS-20220902145555

Allegation investigated: Staff are not meeting residents needs

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced initial 10-Day complaint investigation regarding the above allegation. LPA met with Cynthia Flores who assisted with this visit. Purpose of today's visit was explained. The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters, Facility Policy of Personal Care and Admission Agreements, interviewed Assistant Administrator, Staff 1 to Staff 4 (S1 to S4), Resident 1 to Resident 7 (R1 to R7) Continue 9099C Unsubstantiated Investigation revealed the following: Regarding allegation: Staff are not meeting resident’s needs. It was alleged that facility have taken away residents’ haircuts and residents were told this week would be no more haircuts. RP stated that their concerned about residents in wheelchairs not being able to leave the facility to go get haircuts. Interviewed Assistant Administrator and staff denied the allegation. During the interview with Assistant Administrator, LPA advised that facility provided haircut services to all residents’ long time ago, before pandemic. There was a hairdresser who came to the facility for all residents’ haircuts or other cosmetology services and residents or responsible parties paid for those services. Haircut or other cosmetology services not included in the basic services plan and on the admission agreements considered as a 3rd party services. Assistant administrator and interviewed staff indicated that facility residents including residents on the wheelchair very independent and they able to leave the facility without assistance. But if they need any assistance for outside services including a haircut, staff will assist them to make an appointment, walk with them or give a ride to get to hair salon and back. Interviewed staff also indicated that sometimes family members taking residents to hair salon to get the haircut. All interviewed residents denied the allegation. they stated that facility staff always assist them with hair cut services and never heard that staff said no more haircuts this week or any other days. Interviewed residents stated that staff always make an appointment for them for haircut or other services if they need it. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held. A copy of the report was provided to Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 28-AS-20231006111645

Allegation investigated: Facility neglected resident and they sustained a fracture while in care

Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit and met with Assistant Administrator Cynthia Flores and Administrator Lisa Pham arrived a short time later and assisted with the visit. The investigation consisted of interviews with seven staff members (S#1-S#7) and ten residents (R#1-R#10, reviewing and obtaining staff and resident rosters from 2022 and current, R1 LIC602A dated 03/25/2021, 02/08/2022, 02/09/2022, R1 face sheet, Appraisal/Needs and services plan for R1 dated 02/08/2022, Preplacement Appraisal Information, Hospital discharge orders dated 02/07/2022, Physicians orders for R1 dated 02/7/2022. SIR dated 02/04/2022, and Admission Agreement. The investigation revealed the following: (continued on 9099C) Unsubstantiated Allegation: Facility neglected resident and they sustained a fracture while in care Based on interviews conducted and reports reviewed, it was discovered that R1 sustained fracture at or around 7:00AM on 02/03/2022 due to unwitnessed unforeseen fall. R1 was not considered a fall hazard at the time of the fall. According to staff interviews, R1 was complaining of shoulder pain and R1 noticed a bruise on R1 upper arm near the shoulder. Med-Tech and caregiver were notified, and the facility provided observation, and medical attention by in house medical staff to assess R1. The facility immediately contacted R1 Physician and Physician ordered for R1 to be transported to Hospital. R1 was transported to Norwalk Community Hospital on 02/03/2022 at 1:25PM. Facility notified the family. R1 returned to facility on 02/07/2022 with order for half bed rails to prevent slipping from bed. R1 agreed with the order. LPA interviewed 7 staff and all 7 of 7 staff denied the allegations. All staff stated that they are required by facility policy to check on residents every 2 hours but that checks are done more frequent if needed. LPA interviewed 10 residents (R#1-R#10) and all 10 of 10 residents stated they get good attention at facility and could not collaborate the allegation. 9 of 10 residents stated staff check on them during the day and evening and ask if resident needs anything. R1 stated R1 slipped out of bed, R1 stated R1 did not fall. R1 stated R1 was sleeping when R1 slipped out of bed and that staff were not neglectful or at fault. R1 stated facility acted right away and sent R1 to the hospital. R1 stated R1 is very happy at facility and is satisfied with the care R1 receives. R1 stated staff check on R1 frequently and R1 has not slipped out of bed since incident on 02/03/2022. W1 who is family member stated W1 is very happy with the care provided to R1 and was aware of R1 incident on 02/03/2022 as facility did contact W1. Facility updated R1 LIC602A on 02/08/2022 and 02/09/2022 and Appraisal Needs and services plan on 02/08/2022.. There is no evidence that facility neglected R1 at this time. Based on interviews, observations, and records reviewed, it is determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the assistant Administrator Cynthia Flores and Administrator Lisa Pham and copy of report was provided along with appeal rights. . .the state’s words, verbatim · CDSS document, Oct 12, 2023 · control 28-AS-20220204143051

Allegation investigated: Staff did not communicate with resident promptly and appropriately. Financial abuse. Facility staff failed to keep resident's rooms clean. Facility staff failed to keep facility free from insects.

** This report supersedes the original complaint investigation report dated 9/14/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.** Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit and deliver findings to the superseded reports for the allegations listed above. LPA met with Assistant Administrator Cynthia Flores and explained the purpose of today's visit. The initial investigation complaint visits were on 11/03/21 and 12/10/21. LPA Nicole Spencer took a tour of the physical plant and interviewed the Residents, Staff and reviewed residents and facility's records. During the subsequent visit on 9/14/2022, LPA Pena took a partial tour of the facility and exercised strict mitigation measures due to the most recent Coronavirus Disease 2019 (COVID-19) outbreak this facility had. LPA re-interviewed the Assistant Administrator, interviewed two (2) more residents and collected a copy of the staff roster, resident roster, housekeeping/maintenance schedule and housekeeping deep cleaning schedule (Aug-Oct. 2021). LPA also obtained copies of the pest control service invoices, surety bond, and for three (3) specified residents: account balance ledger and resident fund management authorization form. During today’s visit, LPA Pena obtained copies of the resident & staff rosters, housekeeping/maintenance schedule (Aug-Sep 2023), pest control service invoices (Aug–Sep 2023), PNI record for R1 (Feb 2021-Oct 2021) as well as random residents (Aug-Sep 2023). LPA interviewed additional residents and staff, Resident #13 (R13) – Resident #17 (R17) and Staff #4 (S4) - Staff #5 (S5). LPA also conducted a tour of the facility’s common areas and (6) random resident rooms in the 2nd and 3rd floors (Room #s 5, 17, 28, 33, 63 and 64). *****CONTINUED ON LIC9099-C***** Unsubstantiated *****This report supersedes the original complaint investigation report dated 9/14/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** Regarding allegation: Staff did not communicate with resident promptly and appropriately. It was alleged that staff will not communicate with the resident despite several attempts regarding the Social Security paperwork. An interview with the A1 revealed that she is not aware of this allegation. A1 stated that the residents’ concerns are promptly dealt with. The facility has suggestion and work order boxes that residents can use if they have concerns. Interview with A2 who denied the allegation indicated that if residents need assistance with SSI, she will do a 3-way call with the resident and SS office. A2 denied not addressing a resident promptly or appropriately and has not heard of any residents with this complaint. Interviews with staff revealed that they respond to residents’ concerns right away and have not had any complaints about the staff not responding promptly or appropriately. Staff members also stated that they deal with residents’ concerns promptly. (12) out of (17) Residents interviewed stated that staff communicate with them professionally. Other residents stated that the staff are nice, and they have no issues or concerns. LPA observed staff/ resident interactions during the visits conducted on 9/14/22 and 10/09/2023 and did not observe staff communicating inappropriately to any resident. LPA observed the interactions to be respectful. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. Regarding allegation: "Financial abuse." It is alleged that R1 has not received his PNI allowance in about 7 months. It is also alleged that R1 never received his stimulus check money, and his roommate has also had this issue. Interview with A1 revealed that A2 deals with all the residents’ finances and is not aware of any financial abuse. A2 is working with R1 and assisting with his money. A2 stated that R2 manages his own SSI money/finances. A2 also stated that she is not aware of any residents who are having this issue. A2 stated that the payees are given their allowance at the beginning of the month. S3 stated that she is not aware of this allegation, has not heard anyone complain about SSI and does not deal with SSI. (15) out of (17) residents interviewed stated that they don’t have any concerns, issues, or knowledge of financial abuse in the facility. Other residents indicated that they handle their own money, or that their SSI money is handled by a family member. (4) out of (17) residents stated that their SSI money gets deposited to their personal checking account and they have no concerns. Some residents also stated that the facility gives them their monthly allowance to spend. LPA reviewed R1's SSI PNI records (Feb 2021-Oct 2021) plus (5) random SS1 PNI records (Aug 2021-Oct 2021) and LPA did not observe any discrepancies. LPA observed that R1 received his stimulus check on 4/07/2021. All the residents SSI PNI records reviewed by LPA showed the SSI funds with corresponding debit and credit entries. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. *****CONTINUED ON LIC9099-C***** *****This report supersedes the original complaint investigation report dated 9/14/2022 to include additional information. Investigation findings on this report remain the same, UNSUBSTANTIATED.***** Regarding allegation: “Facility staff failed to keep resident's rooms clean.” It is alleged that staff used to clean R1’s room but lately in the last couple of months has only been taking out the trash and changing the sheets and that's all. Interviews with staff members revealed that housekeeping is done daily, and room checks (taking out trash, replacing paper products) are completed daily with the deep cleaning done once a week. A1 stated that if a resident has an issue with the cleaning, A1 will have housekeeping do it again. A2 stated that housekeepers clean the resident’s rooms at various times throughout the day. Staff members have not heard any residents complaining about this issue recently. Interviews with staff indicated that housekeeping staff provide housekeeping services (cleaning and room checks) daily. Deep cleaning services are done on a weekly basis. (15) out of (17) residents stated that housekeeping cleans often and does a very good job. Housekeepers check the rooms every day and do a thorough job. LPA reviewed the facility's housekeeping/maintenance schedule as well as housekeeping deep clean schedules and duties for (Aug 2021-Oct 2021) and (Aug 2023-Sep 2023). The documents revealed that they have staff assigned to clean the residents’ rooms daily and deep clean on a weekly basis. Therefore, there was not enough supportive evidence to concur with the reported allegation. Regarding allegation: “Facility staff failed to keep facility free from insects.” It is alleged that R1 has had an issue with gnats in his room for quite a while, especially in the bathroom. Interviews with staff revealed that they have not seen any bugs or heard of residents complaining about bugs. A1 stated that R1 has a plant in the room that attracts gnats. But housekeeping does maintenance sprays in the area once a week and pest control technicians come in monthly to service the facility. A2 stated that they do not have any insect problems and they take preventive measures. Interviews with staff members indicated that they have not seen any bugs in the facility and heard of anyone complaining about this issue. (13) out of (17) residents stated that they have not seen any bugs or gnats or heard anyone else about this issue. Some residents indicated that they eat in their rooms that may have attracted bugs and insects. LPAs toured the facility on 11/03/2021, 12/13/2021, 9/14/2022 and 10/09/2023. On 11/03/2021 and 12/13/2021, previous LPA observed gnats in the common areas and in (1) out of (5) rooms. However, LPA Pena did not observe bugs or gnats in the common areas and total of (11) random residents’ rooms or bathrooms during the visits on 9/14/2022 and 10/09/2023. LPA reviewed the facility's pest control invoices for (Aug-Oct 2021) and (Aug-Sep 2023) and observed that the facility continues to have regular pest control services. Therefore, there was not enough supportive evidence to concur with the reported allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview and a copy of this report was provided to Lisa Pham, Administrator and Cynthia Flores, Assistant Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 28-AS-20211027151500