Leisure Garden Senior Assisted Living Facility

Allegation investigated: Staff did not prevent resident from smoking near oxygen resulting in a fire. Resident sustained severe injuries due to staff neglect. Staff did not ensure the facility phone was answered. Staff are not providing adequate supervision for residents

On 8/08/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit was to deliver the findings of the complaint. On 04/14/2026 the Woodland Hills South Adult and Senior Regional Office received a complaint alleging the neglect and lack of care from the facility staff resulted in a resident sustaining injury due to a fire. On 4/14/2026, LPA Segovia conducted the initial twenty-four (24) hour complaint investigation visit. On 4/14/2026, the complaint was referred to the Community Care Licensing Investigation Branch and accepted as an investigation. (continue to LIC 9099-C Unsubstantiated The investigation determined the following: Regarding the allegation: Staff did not prevent resident from smoking near oxygen resulting in a fire. It was alleged that staff did not prevent Resident 1 (R1) from smoking near an oxygen tank which resulted in a fire. To investigate the allegation, between the dates of 4/27/2026 to 5/07/2026, the Department conducted interviews with one (1) resident (R1) and three (3) staff members (S1-S3). The Department’s interview with R1 revealed on 3/25/2026 they were smoking a cigarette in their room while wearing their oxygen mask when they accidentally burned their face. R1 confirmed they had been “reprimanded” multiple times due to their insubordination regarding this issue. R1 confirmed the day of the incident there was no, “boom” nor did they catch themselves on fire. Per R1, staff check on them frequently every, “20-30 minutes”. The Department’s interview with S1 revealed R1 had been given multiple warnings for being in violation of the house rules due to them smoking in their bedroom. Per S1, the day of the alleged incident (3/25/2026), R1 was taken to the hospital due to burn marks on their face. Per S1, they did not witness the incident but were informed by S2 who discovered R1 with what appeared to be red marks on their face, but no fire was present or observed. S1 stated when they questioned R1 as to what had occurred, R1 did not deny the fact that they were smoking in their room. Subsequently emergency services were called and R1 was transported to the hospital where they were treated for their burns on their face and discharged back to the facility. The Department’s interviews with S2 and S3 correlated with S1’s interview. S2’s interview revealed once they observed what had occurred, R1 was assisted with medical care/services. On 4/28/2026, the Department received confirmation from the facility pertaining to R1’s warnings/write-ups and 30-day notice of eviction due to their numerous incidents of smoking in their bedroom. Based on The Department’s interviews and the evidence collected, the Department’s findings of the complaint are UNSUBSTANTIATED at this time. (continue to LIC 9099-C) Regarding the allegation: Resident sustained severe injuries due to staff neglect. It was alleged that R1 sustained severe injuries due to staff neglect. To investigate the allegation, on 5/07/2026, the Department conducted an interview with one (1) resident (R1). The Department’s interview with R1 revealed, on 3/25/2026 they were smoking in their room with their oxygen tank when they burned their face. R1 confirmed they did not catch themselves on fire. Additionally, R1 revealed staff check on them often, “…every 20-30 minutes…” and once staff was made aware, they were immediately helped. On 4/23/2026, The Department subpoenaed R1’s medical record from Antelope Valley Medical Center. On 5/04/2026, the Department received R1’s medical records where the following was disclosed: “PT was smoking w/O2 tank has burs to nose an upper lip w/signed nose hairs. No other injuries were noted…The pain is moderate and characterized as a burning feeling. There is no inhalation of smoke or fumes, and no associated headache, dizziness, shortness of breath, chest pain or palpitations. There is no pain internally in…nose, mouth, or throat…There is no facial swelling…”. Based on The Department’s interviews and the evidence collected, the Department’s findings of the complaint are UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not providing adequate supervision for residents. It was alleged staff are not providing sufficient supervision. To investigate the allegation, on 7/22/2026, LPA conducted a record review of the facility’s Personnel Report, where it was documented, the facility had various staff for the following areas: Administrative, Kitchen, Housekeeping, Direct Care Partners (DCPs), Laundry, Medication Technicians (Med-Techs), Receptionist, and Activities. Additionally, LPA’s record review of the Department’s interview with R1 on 5/07/2026, R1 revealed staff check on them often, “…every 20-30 minutes…”. During LPA’s physical plant tour on 4/14/2026, LPA observed sufficient staff to be present and assisting residents. LPA observed various staff members to be present on both floors of the residents’ living quarters assisting residents and cleaning. Based on record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (continue to LIC 9099-C) Regarding the allegation: Staff did not ensure the facility phone was answered. To investigate the allegation, on 6/18/2026, LPA Segovia conducted a facility visit where they conducted an interview with one (1) staff member. LPA’s interview with S1 revealed the facility has been having issues with the phone lines and internet. S1 revealed the facility had been having issues since April of 2026. During LPA’s visit, LPA observed a technician working on the facility’s telephone lines and internet services due to technical issues. Additionally, LPA observed the facility’s continued scheduling of Spectrum for the month of June 2026, where various visitations had occurred. Based on interviews and observations, the facility’s telephone lines were observed to be having technical issues and the facility scheduled maintenance to fix the issue. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 8, 2026 · control 31-AS-20260414083041

Allegation investigated: Licensee does not ensure staff have the ability to adequately communicate with residents. Staff does not ensure resident is receiving their medications as prescribed. Staff do not allow resident to have private visits in their room.

On 2/11/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit. To investigate the allegation(s), at approximately 09:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:00 AM to 02:00 PM, LPA conducted interviews with one (1) resident (R1), one (1) staff member (S1) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Licensee does not ensure staff have the ability to adequately communicate with residents. It was alleged that staff cannot communicate with R1. To investigate the allegation, LPA conducted an interview with R1. LPA’s interview with R1 revealed that they can communicate with staff and that the staff are “great”. LPA’s interview with R1’s family member revealed they have never had any language barriers with the staff and have been able to communicate clearly in the English language. R1’s family member did disclose that another estranged member of the family could be unhappy or impatient when not given the information they inquired regarding R1 immediately upon their request. Based on interviews, R1 denied the allegation of any language barriers between them and staff, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff does not ensure resident is receiving their medications as prescribed. It was alleged R1 was not receiving their medication as prescribed. To investigate the allegation, LPA conducted interviews with one (1) resident and one (1) staff member. LPA’s interview with R1 revealed the staff give them their medication. LPA’s interview with S1 revealed R1 was discharged from Hospice who controlled their prescribed medication and is in the process of being reevaluated by their new medical team to determine what medications are needed. LPA conducted a record review of R1’s medication. LPA’s review of R1’s Centrally Stored Medication and Destruction Record (CSDMR) along with their Medication Administrator Record (MARs) confirmed R1 has been given their medication as prescribed. Additional record review of R1’s Hospice file confirmed R1 was discharged from their services on 1/26/2026. During LPA’s visit, LPA observed R1 to have been visited by their medical team along with their family member to evaluate their medical needs. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff do not allow resident to have private visits in their room. It was alleged that staff have not allowed R1 to receive visitors in their bedroom. To investigate the allegation, LPA conducted an interview with one (1) resident and one (1) staff member. LPA’s interview with R1 revealed that they are allowed visitors in their bedroom and have had no issues. LPA’s interview with S1 confirmed that they encourage visitors to use their visitation room if possible but never deny visitations from occurring. S1 also stated that if it is a shared room, their roommate would have to consent to having visitors in their bedroom. LPA’s supplementary record review of California Code of Regulation, Title 22, Division 6: 87468.1 Personal Rights of Residents in All Facilities revealed the following: “Residents in all residential care facilities for the elderly shall have all of the following personal rights:…To have their visitors…, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon”. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 31-AS-20260203142838

Allegation investigated: Facility staff withholds resident's personal funds. Facility staff hit resident with a trash can. Facility staff do not safeguard resident's personal items. Facility staff do not treat resident with respect.

On 2/11/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit. To investigate the allegation(s), at approximately 09:30 AM, LPA conducted a physical plant tour. By 10:00 AM, LPA requested relevant documentation. From 10:00 AM to 02:00 PM, LPA attempted interviews with thirteen (13) residents (R1-R13), two (2) staff member (S1-S2) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Facility staff withholds resident's personal funds. It was alleged that S2 are withholding R1’s money. To investigate the allegation, LPA attempted to interview one (1) resident and two (2) staff members. LPA’s interview with S1 revealed that R1 receives their income from the Social Security Administration which covers such aspects as rent and then what is left over is given to them to spend how they choose. LPA attempted to interview S2, but they were not present during LPA’s visit. LPA attempted to interview R1 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s record review of R1’s Record of Client’s/Resident’s Safeguard Cash Resources (SCR) confirmed R1, receives their Social Security Administration check where they then sign off monthly for their cash balances. LPA’s review of R1’s SCR did not reveal any discrepancy. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Facility staff hit resident with a trash can. It was alleged that staff hit R1 with a trashcan. To investigate the allegation, LPA conducted interviews with twelve (12) residents and one (1) staff member. LPA’s interview with all twelve (12) residents revealed that staff have never hit them with a trashcan nor have they witnessed other residents being struck by a trashcan. LPA’s interview with S1 revealed that R1 was the one who struck a staff member with a trashcan due to a behavioral episode and no injuries were notated. LPA’s record review of R1’s Physician’s Report revealed R1 to be diagnosed with various medical conditions. LPA’s web search of said conditions revealed symptoms related to diagnosis to cause a, “…detachment of reality through hallucinations”. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Facility staff do not safeguard resident's personal items. It was alleged that staff are not safeguarding R1’s personal belongings. To investigate the allegation, LPA interviewed one (1) staff member. LPA’s interview with S1 revealed R1 did not arrive to the facility with any valuable personal belongings. LPA’s record review of R1’s Safeguard of Personal Property/Valuables (SPV) confirmed R1 did not have any belongings to be listed. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Facility staff do not treat resident with respect. It was alleged staff are treating R1 disrespectfully. To investigate the allegation, LPA conducted interviews with twelve (12) residents. LPA’s interview with all residents confirmed that staff have not treated them disrespectfully nor have they witnessed it to have been done to others. During LPA’s visit, LPA observed various staff members interacting with residents including R1. LPA did not observe staff treating residents without respect. LPA did not observe residents to appear distressed. LPA observed R1 to be laughing with staff. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 31-AS-20260130085310

Allegation investigated: Staff do not ensure residents are provided with adequate food service. Staff do not prevent residents from disturbing other residents in care.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the administrator, Crystal Barrientos, and explained the reason for the visit. --- Staff do not ensure residents are provided with adequate food service. It was alleged that residents are served the same food for several days throughout the week. To investigate the allegation, on January 30, 2026, LPA requested documents and conducted a physical plant tour at around 12:45p.m. and interviewed twelve residents and four staff from around 1:30p.m. – 3:30p.m. A review of the facility menu shows facility offers a variety of well-balanced meals each day of the week. During the physical plant tour, LPA observed a variety of foods available. (CONT on LIC9099-C) Unsubstantiated During interviews with residents, two out of twelve residents stated facility does not offer a variety of foods. All other residents stated facility has a variety of foods and are not served the same food for several days. During interviews with staff, all staff stated they offer a variety of meals and snacks throughout the week. Based on interviews, observations and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ------ Staff do not prevent residents from disturbing other residents in care. It was alleged that Resident #1 (R1) is unable to sleep because residents are allowed to scream all night. To investigate the allegation, on January 30, 2026, LPA interviewed twelve residents and four staff from around 1:30p.m. – 3:30p.m. During interviews with residents, one out of twelve stated they hear loud noises at night that wake them up. All other residents stated they are unaware of such disturbances. During interviews with staff, all staff stated they are unaware of residents or staff screaming and waking residents. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 31-AS-20260129155426

Allegation investigated: Staff did not provide medical attention to resident in a timely manner.

On 12/29/2025 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Wellness Director, Rovelyn Thomas and stated the reason for their visit. To investigate the allegation(s), at approximately 09:45 AM, LPA conducted a physical plant tour. By 10:30 AM, LPA requested relevant documentation pertaining to the investigation. From 10:30 AM to 12:00 PM, LPA conducted interviews with one (1) resident (R1), two (2) staff members (S1-S2) and record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff did not provide medical attention to resident in a timely manner. It was alleged that staff failed to seek medical attention for R1 resulting in R1 being admitted to the hospital on 12/12/2025. To investigate the allegation, LPA conducted interviews with one (1) resident and two (2) staff members. LPA’s interview with S2 revealed on 12/11/2025, R1 was observed to have discoloration of their tongue and when they notified the Medication Technician (Med Tech), they were told that R1’s newly prescribed medication can cause such discoloration to occur. S2 then stated that on 12/12/2025, R1 was observed to have elevated concerns due to their diagnosis prompting staff to seek medical attention for R1. S2 stated that all of this was documented in the staff communication charts for review. LPA’s interview with S1 revealed that prior to R1’s medical incident of 12/12/2025, R1 had an unwitnessed falls on both 12/03/2025 and 12/04/2025. S1 stated when they tried sending R1 to the hospital due to them noticing they had increased weakness and refusal to eat, R1 denied medical attention. LPA’s interview with R1 revealed that they know when they need to go to the hospital or when they do not need to go. LPA observed R1’s interview to be contradicting for they would say that they didn’t remember the facility calling 911 but then would later state otherwise, “…I think maybe they did”. When questioned if they signed paperwork showcasing their refusal for medical assistance, R1 confirmed. LPA’s record review of the facilities’ communication chart (Connect Team) confirmed that facility staff did document the health-related issues pertaining to R1 in between the dates of (12/03/2025 to 12/12/2025), where it was notated R1 refused medical attention from emergency services on 12/03/2025, 12/04/2025 and 12/06/2025. Further record review of R1’s discharge paperwork from the hospital revealed that R1 was prescribed medication which when researched online confirmed said medication can cause discoloration of the tongue. Additional record review of the facility’s Unusual Incident/Injury Report (SIRs) confirmed the facility had self-reported to Community Care Licensing Division (CCLD), R1’s medical incidents where they refused treatment. LPA confirmed R1’s refusal of treatment per the facility’s, “Resident Acknowledgment of Refused Care” dated: 12/03/2025, 12/04/2025 and 12/06/2025. Further record review of R1’s Medication Administration Record (MARS) along with R1’s daily medical log confirmed, staff were conducting daily monitoring of R1’s medical levels specifically on 12/11/2025. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Wellness Director.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 31-AS-20251219113649

Type of visit: Required - 1 Year

On 12/16/2025 at approximately 9:30 AM, Licensing Program Analysts (LPAs), Angelica Segovia and Jose Tan conducted an unannounced annual visit to the facility. LPAs were greeted by the Administrator, Crystal Barrientos and stated the reason for their visit. LPAs asked for Census, Staff and Resident Rosters. LPAs conducted a physical plant tour at approximately 12:00 PM and the following was noted: Required postings were observed in the entry area. Currently there are nine (9) residents receiving Hospice care and sixty-three (63) residents on the Assisted Living Waiver (ALW). The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The smoke detectors were last serviced on 10/15/2025. The facility also has a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. Fire extinguishers were last inspected on 11/07/2025. Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. The appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food were in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separated from food preparation area. Bedrooms: The facility has two (2) floors. The first floor has fifty-two (52) shared bedrooms and the second floor has sixty-four (64) shared bedrooms. Random rooms were inspected and LPAs observed appropriate beddings and linens with sufficient lighting. (Continue to LIC 809-C) Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures including grab bars. Hot water temperature was measured at a range of 105.1°F to 116.0°F. Common Areas: These include the activity room, TV rooms, Beauty salon and dining area. The common areas were observed to be neat, clean and organized. Hallways/passageways are free of obstruction and lighted appropriately. The front door has a delayed egress. Per STD 850, fire clearance for delayed egress and secured locked perimeter was approved on 07/30/2020. Surrounding Grounds: Entry/exits and hallways on the first and second floor were free of obstruction. Toxins and cleaning supplies stored and inaccessible during inspection. There is patio furniture appropriate for outdoor use. The outdoor area was free of hazards. LPAs observed there to be no body of water. Laundry Room and Shower room: There are laundry rooms located on both the first and second floors. Laundry room is kept locked at all times. There is also a Common Shower room on each floor for residents who require assistance in showering. Shower rooms were observed to be clean and in proper order. Resident Files: The resident files are maintained in the Case Management Office. LPAs conducted a file review of random resident records to ensure compliance of licensing forms. Residents’ file were observed to be current and updated. Staff Files: The staff files are maintained in the Administrator's Office. LPAs also conducted a file review of staff records and observed them to be current and updated. Medications: The Medication Room is located near the Administrator's office. Medication room is locked at all times. Medication and Medication Records were reviewed for proper documentation. Office/Work Station: The Administrator's Office is located near the front entrance, near check-in. The Fire drill was last conducted on 11/10/2025. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Staff signed POLST for resident who cannot consent. Staff signed resident up/ signed paperwork for Hospice without consent of resident.

On 11/26/2025 at approximately 9:20 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit. To investigate the allegation(s), at approximately 09:30 AM, LPA conducted a physical plant tour. By 10:30 AM, LPA requested relevant documentation. From 10:30 AM to 1:30 PM, LPA conducted record review and interviewed one (1) staff member (S1). (continue LIC 9099-C) Unsubstantiated Regarding the allegation: Staff signed POLST for resident who cannot consent. It was alleged that the Administrator (S1) had signed resident’s (R1) Physician Orders for Life-Sustaining Treatment (POLST) without their consent. To investigate the allegation, LPA conducted interview with S1 where it was revealed that R1 upon admission to the facility did not have any next of kin or authorized legal representative. When questioned as to why they signed R1’s POLST, S1 denied signing the document. Per S1 the signatures did not match and proceeded to showcase paperwork from R1's file comparing their signature. LPA observed S1’s signature not to match the one shown on R1’s POSLT documentation. During LPA’s record review, LPA conducted a review of six (6) residents on Hospice where it was shown that S1 has not signed any of their consent forms or POSLT. Further record review showcased that S1 had not become the Administrator until 5/12/2025 which revealed discrepancy with R1’s POLST documentation where S1 was listed as the Administrator dated 12/23/2024. Based on Interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff signed resident up/ signed paperwork for Hospice without consent of resident. It was alleged that S1 had signed R1’s consent forms for Hospice without their knowledge or ability to consent. To investigate the allegation, LPA conducted an interview with one (1) staff member. LPA’s interview with S1 revealed that they did not sign R1’s Hospice documentation. Per S1, their signature had been done so fraudulently and without their knowledge nor consent. LPA’s review of S1’s signature compared to those documented on R1’s Hospice “Informed Consent” forms were observed to not match. Further record review of R1’s file showcased that the hospital had placed an order to have R1 admitted into Hospice on 12/23/2024. Further record review revealed that R1 was under an order of “Bio Ethics” by the hospital due to their medical diagnosis and lack of family/friend’s involvement; which resulted in the hospital becoming the designated decision maker of their medical treatments. Based on Interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 26, 2025 · control 31-AS-20251120102142

Allegation investigated: Facility staff does not allow resident to choose their own healthcare provider.

On 10/06/2025 at approximately 09:50 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by the Wellness Director, Rovelyn Thomas and stated the reason for their visit. The Administrator, Crystal Barrientos arrived shortly after to assist with today’s visit. To investigate the allegation(s) at 10:00 AM, LPA requested census, resident and staff roster. At approximately 10:15 AM, LPA requested pertinent documents pertaining to the investigation such as but not limited to: Home Health records, Pre-Appraisal and visitation log. At 10:30 AM LPA conducted a physical plant tour, to ensure the health and safety of the residents. Between 10:30 AM to 2:00 PM, LPA attempted interviews with seventeen (17) residents (R1-R17) and two (2) staff members (S1-S2). (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Facility staff does not allow resident to choose their own healthcare provider. It was alleged that staff did not allow a home health agency to provide services to Resident 1 (R1). To investigate the allegation, LPA conducted interviews with two (2) staff members and attempted interviews with seventeen (17) residents. Interviews with both staff members stated that they did not refuse services for R1 and only requested R1’s Plan of Care to better assist R1’s needs and services. S2 stated when they requested R1’s Plan of Care, the agency denied the request due to, “HIPPA Laws”. LPA’s interview with S1 revealed the same information was given to them from the home health agency. LPA’s interview with the Reporting Party (RP) confirmed the HIPPA information was relayed to the facility staff. LPA’s interview with R1 revealed that they are enrolled in Home Health and they can choose their own provider. When questioned if home health is providing services, R1 stated, “Yea”. LPA conducted additional interviews with nine (9) residents. All nine (9) residents stated they can choose their own care provider. LPA attempted to interview R11-R17 but due to either: their various medical diagnosis, refusal to be interviewed and/or not available, they could not be interviewed, therefore LPA terminated the interviews. During LPA’s record review, LPA reviewed the facility’s visitation log from September 2025 to Present. LPA’s record review revealed that R1’s home health agency conducted a visit on 9/24/2025. Further record review confirmed that R1’s Services Consent Forms for Admission to the home health agency were dated for the same date as the home health visit of 9/24/2025. Additional record review revealed that R1’s home health agency has conducted additional visits to the facility since. LPA's record review of the facility's Unusual Incident/Injury Report (SIR) revealed the facility self-reported the incident to Community Care Licensing Division (CCLD) dated 9/30/2025. Review of the SIR revealed the incident between the facility and home health agency were disclosed regarding R1's Plan of Care, but no denial of services for R1 were documented. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 6, 2025 · control 31-AS-20250929114618

Allegation investigated: Licensee does not ensure that facility elevator is maintained in good repair.

On 9/17/2025 at approximately 10:20 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced initial complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit was to investigate the above allegation(s). To investigate the allegation(s), at approximately 10:25 AM, LPA requested relevant documentation. By 11:00 AM, LPA conducted a physical plant tour. From 11:30 AM to 01:30 PM, LPA conducted record review and interviewed The Administrator. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Licensee does not ensure that facility elevator is maintained in good repair. It was alleged that the facility’s elevator has been broken. To investigate the allegation, LPA conducted an interview with the Administrator. Interview with the Administrator revealed that one (1) of the two (2) elevators is currently not working. The Administrator stated that the company working on the elevator have claimed it to be "Technical Issues”. They stated that they have been communicating with the company to see when they can return to fix elevator 1. When questioned by LPA how many residents on the second floor are non-ambulatory, The Administrator stated there are a total of seven (7) non-ambulatory residents. The Administrator stated, four (4) use wheelchairs but can walk and the other three (3) use walkers for assistance. LPA’s record review of Unusual Incident/Injury Report (SIR) revealed that the facility had self-reported the maintenance of elevator 1 along with the dates of services listed to Community Care Licensing Division (CCLD). LPA confirmed through record review the dates the elevator company was dispatched to the facility to work on elevator 1. During LPA’s physical plant tour, LPA observed elevator 1 to be off and not in working condition. However, LPA observed the second elevator (Elevator 2) to be working. LPA observed residents using elevator 2. Additionally, LPA used elevator 2 and observed the elevator to be working and in proper condition. Based on interviews, record review and observation, the facility has one of the two elevators working and have done their due diligence in requesting maintenance work on Elevator 1 to be fixed, therefore the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator. Let it be noted LPA Segovia had to email the report to the Administrator due to technical issues of LPA's printer. Regarding the allegation: Staff are not properly addressing pest infestation in the facility. It was alleged that the facility has not kept the facility free from pest. To investigate the allegation, LPA conducted an interview with the Administrator. Interview with the Administrator revealed that they have not had any concerns brought to their attention regarding bedbugs. They stated they have pest control services come out throughout the year to fumigate areas of the facility including residents’ rooms. Additionally, the Administrator revealed once a year, the entire facility is fumigated. LPA confirmed the facility’s fumigation services while conducting record review. However, during LPA’s physical plant tour, LPA toured a total of thirteen (13) random rooms located on both floors. During LPA’s tour, one (1) of the thirteen (13) rooms was observed to have what appeared to be a bedbug crawling on the mattress. LPA observed the Administrator to press down on the bug where red spillage (assumed to be blood) was then exposed from said bug. Based on LPA’s observation of the visible pest (bedbug) to be on the mattress, the allegation is Substantiated at this time. Citation issued, please refer to LIC 9099-D. Civil penalty assessed. No other immediate health and safety issues observed during the day of the visit. Exit interview conducted, appeal rights given and a copy of this report was provided to the Administrator. Let it be noted LPA Segovia had to email the report to the Administrator due to technical issues of LPA's printer.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 31-AS-20250911124329

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 3, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary... at all times. Maintenance shall include...for the safety and well-being of residents... This requirement is not met as evidenced by: LPA observed a bed bug on the mattress of one of the thirteen rooms toured which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2025

Plan of correction: The licensee agreed to have fumigation services provided to the room affected including the surrounding areas of the facility. Additionally, the licensee will order protective mattress covers and dispose of the affected mattress. Proof will be emailed to LPA Segovia by POC due date.

Allegation investigated: Residents are not able to leave the building due to staff locking the doors.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility, met with administrator, Crystal Barrientos, and explained the reason for the visit. ---Residents are not able to leave the building due to staff locking the doors. It was alleged that residents are locked in inappropriately. To investigate the allegation, on 07/18/2024 LPA Melissa Spaeth interviewed six (06) residents and four (04) staff. On 09/05/2025 LPA Duguma conducted a physical plant tour of the facility, interviewed one (01) additional staff and eight (08) additional residents. During interviews with residents, six (06) out of fourteen (14) stated they are able to leave the facility without having someone from the other side of the door open it for them. All other residents stated they and other residents, exit throught the locked doors marked "OFFICE" to enter and exit the facility. (CONT. LIC9099-C) Substantiated During the interviews with staff, all staff stated yes, the door is locked, however, there is someone in the office to let residents out twenty-four (24) hours a day, seven (07) days a week. Staff added there are alternate doors for residents to use in the event of an emergency. Upon arrival today, LPA Duguma observed two (02) residents in front of the building. As LPA was about to approach what appeared to be the main entrance to the facility, the two (02) residents gestured towards the office entrance and stated, "you have to go in and out through there". During the tour LPA observed the exit door all residents are using to enter and exit the building is equipped with a digital locking mechanism and marked OFFICE. LPA did note other exits in the facility that are delayed egress with alarms but not used as main entrances and exits which could pose a potential health, safety and personal rights risk to residents in care should they rely on muscle memory in the event of an emergency such as a smoke filled section of the building. After bring this to the Administrator's attention, facility immediately removed the digital locking mechanism from the OFFICE door and began using the double doors at the front of the building for residents to enter and exit the facility. Based on interviews and observations, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time. A plan of correction was not issued at this time as the facility took corrective measures in the presence of the LPA. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 31-AS-20240715094017

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 5, 2025

87468.1 (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by; Based on observations and interviews, the licensee is using the office as entrance and exit for residents and door has locking mechanism for residents trying to EXIT the building which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: A plan of correction was not issued at this time as the facility took corrective measures in the presence of LPA.

Allegation investigated: Staff mishandled a resident's personal belongings. Staff mishandled a resident's medications.

On 7/24/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit was to deliver the findings of the complaint. To investigate the allegation(s), on 7/16/2025 at approximately 11:00 AM, LPA requested relevant documentation. By 11:30 AM, LPA conducted a physical plant tour. From 12:00 PM to 2:00 PM, LPA conducted record review and interviewed one (1) resident (R1), two (2) staff members (S1-S2) and two (2) witnesses (W1-W2). (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff mishandled a resident's personal belongings. It was alleged that R1’s personal belongings were not cared for properly. To investigate the allegation, LPA interviewed one (1) resident, two (2) staff members and two (2) witnesses. Interview with both staff members and both witnesses revealed that R1’s belongings were infested with parasitic insects from the facility they were being relocated from. Interview with S1 revealed that they told R1 they could only bring their main necessities that were not infested, and all other belongings could not be transported at the time including R1’s television. Such items that were able to be transported to the facility included R1’s undergarments and medication. S1 did confirm that they had placed R1’s belongings outside but as a precautionary measure to ensure any parasitic insects were no longer viable and could not spread within the facility. Further interview with S1 revealed that the facility provided a television for R1’s bedroom. LPA’s interview with R1 confirmed that they were made aware that not all of their belongings could be transported due to the infestation. LPA’s record review of R1’s Personal Property and Valuables (SPV) showcased that R1’s belongings included such items as: undergarments and compact discs but no television. Further record review of the facility’s Unusual Incident Report (SIR) revealed that S1 attempted to contact R1’s previous residence to acquire about their television and other belongings; where they were told that R1’s television was not there nor their other belongings in question. During LPA’s physical plant tour, LPA observed R1’s room to be equipped with such items as: clothing, telephone charger and compact discs. Additionally, LPA observed a television that was provided by the facility. Based on interviews, record review and observation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff mishandled a resident's medications. It was alleged that staff failed to provide R1 with their medication. To investigate the allegation, LPA interviewed one (1) resident, two (2) staff members and one (1) witness. Interview with both staff members and witness revealed that the facility R1 was relocated from provided R1’s medical devices and medication. However, LPA’s interview with S1 revealed that not all of R1’s medications were provided. S1 stated that when R1 was relocated, R1’s Centrally Store Medication Record (CSDMR) was not provided, which limited the facility’s knowledge of what medications R1 had been prescribed. Due to this, S1 stated they are in the process of obtaining current and updated documentation pertaining to R1. When questioned about R1’s recent hospitalizations, S1 stated that R1 was sent to the hospital for medical reasons, one pertaining to R1 expressing their medical devices were not providing enough support. S1 stated R1 was then able to obtain additional prescriptions to help with their current medical needs. (Continue to LIC 9099-C) LPA’s record review confirmed that the facility did seek out medical treatment for R1 by sending them to the hospital and reported the incident to the appropriate reporting parties including Community Care Licensing Division (CCLD). LPA’s interview with R1 confirmed that the facility they were relocated from did not provide them with all of their medication including their respiratory aid and stated they had been without it, “…for quite some time”. Further record review confirmed that R1 was not provided with their respiratory aid when they were relocated. Additional record review confirmed that the facility had obtained an updated prescriptions order for R1 and their CSDMR showcased their medication had been given accordingly, including a new prescription for their respiratory aid. During LPA’s physical tour LPA observed R1’s bedroom to be equipped with their medical devices. LPA observed the devices to be in good condition. Based on interviews, record review and observation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 31-AS-20250715144637

Type of visit: Case Management - Other

On 7/16/2025 at approximately 10:15 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced Case Management visit to the facility to check on the residents who were relocated from a facility that is under a temporary suspension order. LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit. The facility accepted three (3) residents. At the time of the visit all three (3) residents were at their day program. A physical plant tour was conducted to ensure the health and safety of residents. The following was noted: LPA observed the bedrooms of all three (3) residents. LPA observed the bedrooms to be neat, clean and organized. LPA observed each room to be equipped with a bed, nightstand, chair, dresser and clean linens. LPA observed the residents’ rooms to have their personal belongings such as clothing in place. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 16, 2025

Allegation investigated: Facility has not properly disposed of hazardous items

On 6/18/2025 at approximately 10:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA was greeted by the Administrator, Crystal Barrientos and stated the reason for their visit was to gather information, conduct interviews and deliver findings for this complaint. To investigate the allegation(s) at 10:30 AM, LPA requested census, resident and staff roster. At approximately 11:00 AM, LPA conducted a physical plant tour, to ensure the health and safety of the residents. Between 10:30 AM – 12:00 PM, LPA conducted interviews with four (4) staff members (S1-S4). (continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Facility has not properly disposed of hazardous items. It was alleged that the facility is not properly disposing of hazardous material. To investigate the allegation, LPA interviewed four (4) staff members. Interview with all four (4) staff revealed that all hazardous materials are disposed of properly within sealed trash bags inside of the trash barrels located outside of the facility. Interview with S4 confirmed that the trash barrels have lids and must be maintained closed after trash is disposed. All four (4) staff confirmed that the trash along with any hazardous materials are picked up weekly. During LPA’s physical tour, LPA observed facility staff carts supplied with trash bags to dispose of materials. LPA observed the outside trash barrels to be closed with the appropriate lids. LPA observed there to be no hazardous materials such as but not limited to: mask, disposable leak pads, and/or diapers left unsecured within the facilities premises. All trash was observed to be within trash bags inside of the facilities trash barrels. LPA observed two (2) other facilities adjacent one on each side with their own trash bins. LPA observed one (1) out of the two (2) adjacent facilities to have their trash bin open without a lid. LPA’s record review of the past week’s weather forecast for the surrounding area showcased wind speeds ranging from 13 mph-21 mph. Furthermore, based on LPA’s interviews, observations and record review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 31-AS-20250617093103

Allegation investigated: Resident was sexually assaulted at facility.

On 5/21/2025 at approximately 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit. LPA was greeted by the Administrator Crystal Barrientos and stated the reason for their visit was to deliver the findings for the above allegation(s). To investigate the allegation(s), on 5/21/2025 LPA conducted a physical plant tour at approximately 10:30 AM, requested pertinent documentation at around 11:20 AM and conducted interviews with eight (8) Residents (R2-R8) and seven (7) staff members (S1-S7) between 11:30 AM and 1:00 PM. On 4/02/2025 the Woodland Hills South Adult and Senior Regional office received a complaint alleging sexual assault. The complaint was referred to the Community Care Licensing Investigation Branch (IB) and accepted as an assignment. The complaint was assigned to Special Investigator Assistant (SIA) Amina Luckett. On 4/03/2025, LPA Melissa Spaeth conducted the initial twenty-four (24) hour complaint investigation visit. (Continue on 9099-C) Unsubstantiated The investigation determined the following: Regarding the allegation: Resident was sexually assaulted at the facility. It was alleged that Resident 1 (R1) was sexually assaulted by three (3) staff members. Interviews with R2-R8 stated that they have never heard nor witnessed any staff member sexually abuse residents. Interview with R6 revealed that they have heard R1, “…talking or screaming to the voices in their head”. Interviews with S1-S8 confirmed that they have not witnessed or heard of any residents having been sexually assaulted from staff members. Interview with the Administrator revealed that when R1 was discharged from the hospital they returned to the facility. When the facility became aware of the alleged incident, the Administrator stated they proceeded to conduct their own internal investigation as well as reporting the incident to the appropriate domains. LPA’s record review confirmed that a Report of Suspected Dependent Adult/Elder Abuse was submitted on 4/03/2025 to Adult Protective Services (APS). During a record review, LPA observed on 4/10/2025 SIA Luckett obtained the police report from the Special Victims Unit (SVU) where it stated that R1 was, “…scheduled to undergo a forensic sexual assault examination” but R1 later refused. Confirmation of refusal of the examination was confirmed on 4/29/2025 when SIA contacted the subpoena desk at Antelope Valley Medical Center regarding R1’s forensic exam where it was revealed R1 refused the exam. Additionally, on 4/10/2025 SIA subpoenaed R1’s medical records from Antelope Valley Medical Center. LPA’s record review revealed that R1 has various mental health disorders. Unusual Incident Reports (SIRs) were submitted to CCLD which show R1’s history of requesting to be sent to the hospital due to hearing voices and not feeling mentally well. LPA’s review of the police report noted that R1’s story regarding the allegation was, “…often changing and contradicting”. LPA’s review of medication revealed that R1’s care plan includes various medications which can cause side effects such as: agitation, suicidal tendencies, and/or vivid dreams such as nightmares. Furthermore, based on interviews, record reviews and SIA’s investigation there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 21, 2025 · control 31-AS-20250402085725

Allegation investigated: Staff did not provide resident with an appraisal Staff did not provide responsible party with an admissions agreement Staff do not communicate with responsible party regarding resident's care Staff did not assist resident with obtaining medical care

On 4/02/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to present the findings. The investigation consisted of the following: On 3/12/2025, Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial complaint investigation. LPA Spaeth reviewed the residents' files, interviewed eight (8) out of twenty-eight (28) staff members and interviewed twelve (12) out of one hundred seventeen (117) residents. LPA received copies of resident's records, resident roster, and the staff roster. Continued on 9099-C Unsubstantiated Regarding the allegation, staff did not provide resident with an appraisal: It is being alleged a resident did not receive a facility appraisal prior to their admission into the facility. On 3/12/2025, LPA reviewed the resident’s file (R1) and observed the Preplacement Appraisal Information (LIC 603) was completed prior to R1’s admission to the facility. Regarding the allegation, Staff did not provide responsible party with an admissions agreement: it is being alleged a resident’s responsible party was not aware R1 was admitted to the facility and the responsible party did not sign the admissions agreement. LPA reviewed R1’s documentation and did not observe a Power of Attorney (POA). R1 was interviewed on 3/12/2025 at 12:00 pm and stated there is no Power of Attorney. R1 stated they are able to make their own decisions. Regarding the allegation, Staff do not communicate with responsible party regarding resident's care: It is being alleged the Administrator has not communicated with the responsible party regarding the hospice care and facility care of R1. The Administrator was interviewed on 3/12/2025 at 10:00 am and stated since there is not a POA for R1, the care of the resident must be kept confidential. LPA Spaeth reviewed R1’s files and did not observe hospice paperwork. R1 and the Administrator both confirmed R1 was not receiving hospice care. Regarding the allegation, Staff did not assist resident with obtaining medical care: It is being alleged R1 missed a medical appointment because staff did not arrange R1’s transportation. R1 stated they did not want to go to the appointment and preferred the appointment to be arranged at another time. The Administrator confirmed R1 informed them to cancel the appointment. R2-R12 unanimously stated staff arrange transportation for all their medical appointments. Based upon LPA’s review of the resident’s records and the interviews conducted, the allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 31-AS-20250311111319

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

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA) Angela Panushkina to issue the findings of the above listed allegations. Upon arrival, LPA met with the Administrator and explained the reason for the visit. On 10/28/24, LPAs Panushkina and Segovia conducted an initial visit. During course of the investigation, interviews and record review were made. At 10:05am, LPAs requested resident and staff roster. At approximately 10:15am, LPAs conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:15am – 12:30pm, LPAs interviewed the Administrator, Assistant Administrator, Houskeeper, MedTech, three (3) staff, and six (6) out of twelve (12) residents, who were able to communicate. Continue on LIC9099-C Substantiated Allegation: Staff do not ensure that facility is free of pests It was alleged that facility has bed bugs and cockroaches. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that she was aware of the problem and the facility had already hired a pest control exterminator to take care of the issue. Additionally, six (6) out of twelve (12) residents interviewed informed LPAs that the facility used to have bed bugs and once it was addressed the facility hired pest control. Although the residents interviewed could not confirm any recent evidence of bed bugs, they all confirmed seeing cockroaches at the facility bathrooms and common areas. Moreover, during the physical plant tour, at approximately 11:40am, LPAs observed a cockroach on the wall, by the business office and visiting room. Therefore, based on interviews, record reviews and LPAs observation, this allegation is Substantiated. Deficiency cited during today's visit. Exit interview conducted, appeal rights explained and copy of this reports signed and delivered. This complaint investigation was conducted by Douglas Real, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews, conducted between 11/14/24 to 02/01/25 with the Administrator, Caregiver Supervisor, Weekend Supervisor, three (3) staff members and R1’s Power of Attorney (POA). Investigator also attempted to interview R1 on 02/01/2025. In addition, the Investigator subpoenaed R1’s Medical Records on 11/14/24 and received a copy on 12/03/24. Allegation: Staff neglect resulted in a resident sustaining a pressure injury The investigation finding revealed that R1 had been living at this facility since 07/16/19 and was diagnosed with Dementia. Interview with the Administrator revealed that R1 was eating and drinking less and was less engaged with caregivers. R1’s family was aware of R1’s changes in condition and on 10/12/24, R1 was sent to the hospital. Administrator also informed the Investigator that R1 had no prior skin breakdown issues, but the Weekend Supervisor (WS) informed the Administrator on 10/12/24 that R1 had a possible pressure injury on sacral area. However, after the Administrator received a picture (via text), she observed R1 may have bumped his/her bottom and or scratched him/herself leading to the small open wound. Interview with the WS corroborated the statement provided by the Administrator. Furthermore, interview with the Caregiver Supervisor (CS) revealed that two (2) days before R1 was sent to the hospital (on 10/10/2024) CS found a small open scratch on the R1’s bottom (sacral area). The following day (on 10/11/2024) CS checked on R1 and saw the skin around the open wound was discolored and appeared as a bruise. Due to the change of skin color around the open wound caregivers began turning R1 every two hours and noted when they rotated R1 on a reposition log. Investigator also conducted interviews with three (3) staff members who denied the above allegation and informed the Investigator that they did not observe any staff members neglect or harm any of the residents. All parties interviewed, also informed the investigation that the facility staff provide an appropriate level of care and supervision to the residents. Moreover, interview with R1’s POA revealed that the facility notified him/her of redness to R1’s bottom the day R1 was taken to the hospital. POA expressed no concerns regarding the above allegation. Lastly, review of R1’s hospital records revealed that R1 was seen in the hospital and admitted on 10/12/2024 due to weakness, decreased food/water intake, and decreased responsiveness. Upon admission R1 was identified as having a stage II pressure injury on sacral area. R1 was treated at the hospital and discharged to a Skilled Nursing Facility (SNF) on 10/16/2024. Based on interviews and information gathered during the investigation, there is insufficient evidence to prove the alleged violation occurred. Therefore, it deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Staff mishandled a resident's personal belongings It was alleged that R1’s glasses and dentures were missing. To investigate this allegation, LPAs conducted an interview with the Administrator (during the initial visit on 10/28/24) and were informed that she’d worked here since February 16, 2021, and doesn’t recall ever seeing R1 wear glasses nor dentures. LPAs were also informed that R1’s family frequently visited R1 and brought new clothes and took the old clothes without notifying the facility and or updating the Client/Resident Personal Property and Valuables (LIC622). Administrator also stated missing/found items are taken to the donation room by all staff. Moreover, three (3) staff members interviewed denied the above allegation and informed LPAs that they did not see R1 use glasses/dentures. LPAs also conducted interviews with six (6) out of twelve (12) residents, who were able to communicate, and all residents interviewed expressed no concerns regarding this allegation. Residents informed LPAs that they know to report missing/stolen items to the front desk or to any staff member and an investigation will be conducted. Most residents misplace items, and they are later found. Based on interviews and information gathered during the investigation, there is insufficient evidence to prove the alleged violation occurred. Therefore, it deemed Unsubstantiated, at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 1, 2025 · control 31-AS-20241024162441

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 8, 2025

Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed cockroachesin the hallway. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 1, 2025

Plan of correction: The Administrator will take all measures to maintain the facility free from cockroaches. Administrator will submit updated documentation of Pest Control service agreement to LPA by POC date.

Allegation investigated: Facility failed to conduct a proper pre-admission appraisal.

On 3/12/25 at approximately 9:30 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced initial visit to the facility. LPA signed in and was greeted by Administrator Jessica Pelaya. LPA stated the reason for the visit. An entrance interview was conducted with the administrator. Allegation: Facility failed to provide care for resident with restricted health condition. It was alleged the facility is not providing proper catheter care. To investigate the allegation LPA requested resident #1's (R1's) record, a resident roster and staff roster. From 9:50 a.m. to 10:50 a.m., LPA interviewed R1. At 11:17 a.m., LPA interviewed a placement consultant used by the facility via telephone. From 11:40 a.m. to 12:40 p.m., LPA reviewed R1's record and obtained copies which include Preplacement Appraisal Information (LIC603), Physician's Report (LIC602A), Appraisal/Needs and Services Plan (LIC625), Unusual Incident Reports, and R1's records from the Skilled Nursing Facility (SNF), R1 was in prior to admittance to this facility. At approximately 1:23 p.m., LPA conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. (Continue to LIC9099-C) Substantiated (continued from LIC9099) Allegation #1: Facility failed to conduct a proper pre-admission appraisal. It was alleged the facility admitted Resident #1 (R1) without knowledge of R1's restricted health condition. LPA's interview with R1 confirmed the use of a catheter. R1 informed LPA facility staff claims they first saw the catheter when R1 was brought into the facility on a gurney. R1 states they were not aware the facility did not know about the catheter as a representative from the facility had visited them in person prior to admittance. LPA's interview with the administrator revealed they did not know about the catheter and had received R1's skilled nursing record the same day the resident was admitted to the facility. According to the administrator they would not have accepted R1 had they known R1 had a catheter. Furthermore, according to the administrator the consultant used for placement assistance had not mentioned the presence of a catheter. According to the administrator they admitted R1 based on the information gathered from the consultant. Interview with the consultant corroborates they visited R1 on behalf of the facility and did not see the catheter bag. The consultant informed LPA they conducted an interview with R1. LPA's review of SNF paperwork confirms R1's use of catheter. LPA's review of the Preplacement Appraisal Information (LIC603) is dated the same date R1 was admitted to the facility. On the LIC603 Services Needed for Toileting, including assistance equipment, or assistance of another person is checked "Yes" with no explanation as to what kind of assistance R1 will need. LPA's review of hospital discharge paperwork after admittance to the facility confirmed resident has been released back to facility without Home Health services on different occasions. According to the administrator, the facility has created a plan to find a suitable facility for R1. Since R1 now qualifies for assistance, the facility is able to assess R1 and place an order for Home Health until a suitable facility is found. Based on record review and interviews, although the facility claims they did not know about the catheter, the consultant used represented the facility when they visited the resident in person. Either the consultant did not conduct a proper functional capabilities evaluation, or the facility did not interview R1 and failed to complete the preplacement appraisal prior to admission. Therefore, this allegation is deemed SUBSTANTIATED at this time. Exit interview conducted. Deficiency cited (refer to LIC9099-D). Copy of report provided. (Continued from LIC9099-A) LPA's interview with R1 confirmed the use of a catheter. R1 informed LPA facility staff claims they first saw the catheter when they were brought into the facility on a gurney. R1 states they were not aware the facility did not know about the catheter as a representative from the facility had visited them in person prior to admittance. LPA's interview with the administrator revealed they did not know about the catheter and had received R1's skilled nursing record the same day the resident was admitted to the facility. According to the administrator they would not have accepted R1 had they known R1 had a catheter. Furthermore, they contacted the Skilled Nursing Facility and attempted to return the resident but could not. According to the administrator the consultant used for placement assistance and the skilled nursing facility had not mentioned the presence of a catheter. According to R1 and the administrator the facility staff do not assist with the catheter because staff at the facility are not appropriately skilled professionals or have been trained by one to assist R1 with their catheter. According to R1 they would prefer to be transferred to a skilled nursing facility. According to the administrator they immediately call 911 to have R1 transported to the hospital when catheter needs arise. R1 confirmed that due to mitigating circumstances, they did not qualify for Home Health services upon release to the facility on one occasion, and the facility staff are not able to provide assistance with restricted health conditions. LPA's review of hospital discharge paperwork after admittance to the facility confirmed resident was released back to facility without Home Health services. According to the administrator, the facility has created a plan to find a suitable facility for R1. Since R1 now qualifies for assistance, the facility is able to assess R1 and place an order for Home Health. Based on record review and interviews although the facility failed to observe R1's use of a catheter prior to admitting them to the facility they have sought medical attention to address R1's catheter needs until a suitable facility is found. Therefore this allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 31-AS-20250305155629

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(1)(A) · Plan of correction due date: Apr 4, 2025

87457 Pre-Admission Appraisal (c)Prior to admission... (1)The appraisal shall document, at a minimum:(A) An evaluation of the prospective resident's functional capabilities,... as specified in Sections 87459, Functional Capabilities... This requirement is not met as evidenced by: Based on interviews and resident records review the licensee failed to conduct a proper preplacement evaluation with R1 to make sure the facility was suitable for R1 which is an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: The Administrator has agreed to the following: 1. Since R1 is still in the facility a Re appraisal and Appraisal needs and services will be conducted. 2. Staff responsible of placement/intake will take "Pre-admissions appraisal" in-service training and Submit training schedule, training material and sign in sheet to LPA by POC due date.

Allegation investigated: Facility staff did not assist resident with catheter care as per admission agreement Facility staff did not dispense medications to resident as prescribed

On 1/24/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya and LPA explained the purpose of this visit was to review resident’s records, conduct interviews, and present the findings. The investigation consisted of the following: On 01/06/2025, LPAs Spaeth and Segovia conducted an initial complaint investigation. As of today, LPA Spaeth reviewed residents' records at 9:30 am until 10:00 am and received copies of the documentation. LPA also received a copy of the resident roster and the staff work schedule. LPA Spaeth reviewed residents' medications and the medication records Continued on 9099-C Unsubstantiated at 10:00 am until 11:00 am. LPA received copies of the residents’ medication records. LPA Spaeth interviewed thirteen (13) out of one hundred twenty-two (122) residents at 11:00 am until 12:00 pm. LPA interviewed ten (10) out of fifty (50) staff members at 12:00 pm until 12:30 pm. Regarding the allegation, Facility staff did not assist resident with catheter care as per admission agreement: it is being alleged a resident had a clogged foley catheter and the catheter had not been flushed by staff. The resident (R1) who has a catheter stated when staff observed the clogged catheter, they immediately called 911 and R1 was transported to the hospital. R1 also stated staff explained R1 was being sent to the hospital so that a medical professional could flush out the catheter. Staff members (S1 – S6) confirmed this occurred. Regarding the allegation, Facility staff did not dispense medications to resident as prescribed: it is being alleged a resident had not received their medication. R1-R13 confirmed they receive their medication in a timely manner each day. S1-S10 confirmed residents receive their medication each day. Based upon LPA’s review of the resident’s records and the interviews conducted, the allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 24, 2025 · control 31-AS-20241231084604

Allegation investigated: Staff refused to release medical documents after receiving a medical consent form.

On 01/22/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya and LPA explained the purpose of this visit was to review resident’s records and present the findings. The investigation consisted of the following: On 01/06/2025, LPAs Spaeth and Segovia conducted an initial complaint investigation. As of today, LPA Spaeth reviewed residents' records at 10:00 am until 10:30 am and received copies of the documentation. LPA requested the resident roster and copies of the residents' records. LPA Spaeth interviewed the Administrator at 10:30 am until 11:00 am. Continued on 9099-C Unsubstantiated Regarding the allegation, Staff refused to release medical documents after receiving a medical consent form. It is being alleged the facility failed to send a resident’s records after the resident consented to their records being released to a specific party. LPA Spaeth reviewed all records and email correspondents that were sent and confirmed all records requested were sent to requester in a timely manner. Based upon LPA’s review of the resident’s records and the interview conducted the allegation is unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 31-AS-20241231131500

Allegation investigated: Staff did not provide adequate care or supervision resulting in resident being stuck in the toilet for an extended period of time

On 1/15/25 at approximately 11:00 AM, Licensing Program Analysts (LPAs) Angelica Segovia and Gary Tan conducted an unannounced initial visit to the facility. LPAs were greeted by Administrator Jessica Pelaya. LPAs stated the reason for their visit. It was alleged that Resident (R1) was found stuck inside of a toilet for four (4) hours resulting in R1 being admitted to the hospital for medical care. To investigate the allegation LPAs asked for census, staff, and resident Rosters. LPAs conducted a physical plant tour at approximately 12:30 PM. LPAs requested pertinent documents at approximately 1:00 PM. LPAs conducted interviews between 1:15 PM to 2:30 PM. LPAs interviewed one (1) resident and five (5) staff members. LPAs interview with Resident #2 (R2) confirmed that Resident #1 (R1) takes one (1) to one and half (1 ½) hours in the bathroom whenever R1 uses the bathroom and always locked the door. Interviews with staff members confirmed that five (5) out of five (5) stated that R1 independently uses the bathroom by themselves. Five (5) out of five (5) staff members also confirmed that R1 takes a long time using the restroom and always lock the door. Unsubstantiated LPAs Interview with Staff member one (S1) at 1:30 PM, revealed that when the incident occurred, they were conducting their morning Medication pass routine at around 8:00 AM and went to R1’s room but R1 was in the bathroom. S1 came back to check on R1 to give R1’s medication after twenty (20) minutes later and R1 was still in the bathroom. On the third attempt of S1 at around 8:50 AM, S1 found out that R1 was still and the bathroom but this time, S1 became worried and called Maintenance at around 9:00 AM to help gain access into the bathroom since R1 was not responding to them. After maintenance gained access inside the bathroom it became apparent R1 was stuck and was not able to get up by themselves. After several failed attempts to get R1 separated from the toilet, emergency services were called. At around 10:00 AM emergency services arrived and could not get R1 separated from the toilet. At around 11:30 AM R1 was transported with the toilet to the hospital where R1 was admitted and treated. Further interview with (R2) confirmed that R1 uses the bathroom by themselves and did not request any kind of assistance during the incident. Based on record review and interviews this allegation is UNSUBSTANTIATED at this time. No other health and safety issues observed. Exit interview conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 31-AS-20250108133702

Allegation investigated: Facility is in disrepair Staff do not provide a safe environment for the residents in care Staff do not adhere to the residents' dietary needs

At 10:50 a.m. on 12/17/24 Licensing Program Analysts (LPAs) Nicholas Reed and Angelica Segovia conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPAs toured the facility inside and out at 11:15 a.m. today, interviewed the administrator, staff, and 10% of residents [or thirteen (13) out of 123 residents] between 11:00 a.m. and 2:00 p.m., and conducted a record review of pertinent records, including but not limited to a medical assessment, dietary restriction documents, and staff and client rosters at 1:30 p.m. Regarding the allegation "Facility is in disrepair" it was alleged that facility elevators continuously break down, staff and residents get stuck inside. Facility tour revealed that both elevators were operational today. LPAs did not get stuck in either elevator. Interviews with twelve (12) out of thirteen (13) residents and four (04) out of four (04) staff interviewed today confirmed that they have not been trapped inside of facility elevators and they are operational. Interview with Resident #1 (R1) at 11:45 a.m. today revealed the Unsubstantiated back elevator is slow, but the front elevator works fine. Interview with Resident #2 (R2) at 12:45 p.m. today revealed they were not able to get out of the back elevator a few weeks ago, so they had to use the front elevator. Interview with the administrator at 11:00 a.m. today revealed that necessary maintenance was recently performed by an outside vendor on the back elevator. The administrator has not received any reports of people being trapped inside elevators. Record review of a work order revealed that an outside vendor completed mechanical and safety maintenance on 11/26/24. Based on observations, interviews, and record review, the facility elevators are in good repair today. The facility has performed maintenance in a timely manner as well. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff do not provide a safe environment for the residents in care” it was alleged that most resident bedroom windows do not have screens, and a stranger entered a resident bedroom causing the resident to feel unsafe. Interview with the administrator revealed they received no reports of residents feeling unsafe or strangers entering through resident windows. Facility tour revealed that all resident bedroom windows had screens attached and were in good repair. Interviews with thirteen (13) out of thirteen (13) residents and three (03) out of three (03) staff revealed they feel safe in the facility and no strangers have entered through their windows. Based on observations and interviews, the facility staff are providing a safe environment for residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff do not adhere to the residents' dietary needs " it was alleged that some residents are unable to eat facility food due to staff not providing a menu which suits their needs. During facility tour, LPAs observed special dietary restriction lists posted in the kitchen around 11:15 a.m. Postings included residents with allergies, pureed diets, chopped diets, low salt diets, and diabetic diets. Also posted were the main and alternate menus for today and the week. Interview with the administrator revealed that current and new resident dietary needs are reviewed, and the dietary restriction documents are updated accordingly. Interview with the kitchen director at 11:25 a.m. today revealed that staff accommodate residents’ dietary needs through preparing modified meals and alternate menus. If residents request different meals or second portions, kitchen staff willingly accommodate their requests. LPAs also saw adequate supplies of perishable and non-perishable foods stored in the refrigerators, freezers, and pantries. Interviews with three (03) out of three (03) residents with dietary restrictions between 12:20 p.m. and 12:35 p.m. today revealed they were served meals according to their modified diets. Interviews with ten (10) our of ten (10) other residents revealed they are able to eat the food served. Based on observations, interviews, and record review, the facility staff are adhering to residents’ dietary needs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 31-AS-20241209153418

Allegation investigated: Facility failed to keep passageways and stairways free of obstruction.

On 01/21/2026 Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to correct a citation. The determination remains Substantiated. Los Angeles County Fire Department, Fire Inspector, confirmed the door in question should not lock as there can be no obstructions to paths of emergency egress. LPA met with Crystal Barrientos and explained the reason for the visit. On 11/25/2024 at 9:45 a.m., Licensing Program Analysts (LPAs) Evelin Rios and Angelica Segovia conducted an unannounced complaint visit at this facility to investigate the above allegation. LPAs met with the Assistant Administrator Crystal Barruentos and explained the reason for the visit, entrance interview conducted. LPAs requested resident and staff roster. At approximately 10:00 a.m. LPAs conducted a physical plant inspection of the facility. LPA’s walked up the stairway closest to the entrance and encountered a locked door to the second floor. LPA’s waved to a staff on the other side of the door and staff opened door using a keypad. (Continue to LIC9099-C) Substantiated (Continued from LIC9099) On the other side of the door LPA Rios pushed at the door to attempt to open, door did not open, door is not delayed egress. From 10:05 a.m. – 12:00 p.m., LPAs interviewed the Assistant Administrator, three (3) staff, and seven (7) out of nine (9) residents, who were able to communicate. At approximately 1:30 p.m., LPAs requested copies of pertinent information which include, but not limited to LIC610E, STD850, evacuation diagram, unusual/injury incident report, and most recent fire inspection. Allegation: Facility failed to keep passageways and stairways free of obstruction. Regarding the allegation, it is alleged that on the second floor, resident windows are bolted shut and exit doors are locked. To investigate the allegation LPAs conducted a physical plant tour which revealed one (1) out of two (2) exit doors, as per facility evacuation sketch, was locked by keypad device. LPA’s interview with the assistant administrator revealed the door is delayed egress, but later after speaking to the administrator by telephone clarified the door is not delayed egress. Assistant administrator revealed that on 11/08/2024, the facility fire inspection did not find an issue with the door being locked as it opens during an emergency. Review of unusual/injury incident report submitted to the department revealed facility self reported a resident caused a “small” fire and was sent to a hospital, no injuries reported. Interviews with seven (7) residents who responded to questioning revealed a fire had taken place in the facility with residents reporting making various observation such as, hearing fire alarms, seeing smoke, people running, the fire department utilizing a fire hose and fire extinguishers. One (1) resident revealed they saw a resident with burn injuries on face and hand. Three (3) out of the seven (7) residents who responded to questions stated they were on the second floor during the fire and evacuated using the elevator or door at the other end of the facility. Seven (7) out of seven (7) residents reveled having knowledge the door closest to the entrance is locked. LPA’s interview with staff revealed hearing about the fire or witnessing the fire take place. LPA’s tour of five (5) resident rooms found windows are not bolted shut but may be difficult to open. Interviews with all but one (1) out of the seven (7) residents that responded revealed they felt staff appropriately handled emergency protocols. LPA's met with Administrator Jessica Palaya and conducted an interview at approximately 2:34 p.m. According to administrator resident mentioned on incident report did not have injuries and there were no injuries caused by the fire. Administrator requested fire inspection from Fire Marshall. A copy will be sent to LPA when facility receives inspection documents. Based on LPAs' observation, interview and records reviewed the facility has one (1) of two (2) designated exit doors on the second floor locked with a keypad device which obstructs the door from opening. Therefore, the allegation is deemed substantiated at this time. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal rights provided. Copy of the report provided.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 31-AS-20241120085825

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Nov 26, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on LPAs' observation and interviews, the facility keep one (1) of (2) two exit doors on the second floor locked, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: POC was cleared 11/27/2024. Administrator contacted LPA to inform them the door has been disengaged by the Door Dr. a company the facility uses.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Evelin Rios and Angelica Segovia conducted an unannounced case management - deficiencies visit in conjunction to Complaint #31-AS-20241120085825. LPA's met with the Administrator, Jessica Pelaya and Assistant Administrator Crystal Barruentos and explained the reason for the visit, entrance interview conducted. During the complaint investigation it was revealed the facility self reported to Community Care Licensing (CCL) on 10/25/2024, that a resident had started "small fire" in their room on 10/20/2024, five days after the fire had occurred. According to interviews with the assistant administrator and seven (7) residents, the fire, which occurred in the facility, required 911/ Fire Department response. The facility failed to report the fire to CCL the next working day. Deficiency cited, refer to LIC809-D. Appeal rights provided. Copy report provided.the state’s words, verbatim · CDSS document, Nov 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(3) · Plan of correction due date: Dec 30, 2024

(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (3) Fires... which occur in... the premises shall be reported no later than the next working day to the licensing agency. This requirement is not met as evidenced by: According to record reviews the facility failed to report a facility fire to CCL the next working day which poses an potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee will submit a statement of understanding on the allegation cited by POC due date 12/02/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an Annual Required visit and inspection of the facility. LPA met with the administrator Jessica Pelaya and explained the reason for the visit. At approximately 09:43 AM, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. Currently there are eighteen (18) residents receiving hospice care and sixty eight (68) residents on the Assisted Living Waiver (ALW). The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The smoke detectors were last serviced on 09/12/24. Facility also have a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. Fire extinguishers were last inspected on 11/30/23. The Fire Inspection was last held on 09/17/24. Kitchen: The kitchen has an industrial setting and observed to be clean and in proper order. Appliances and fixtures were observed to be functional. Sufficient amount of perishable and non-perishable food were in stock and properly stored. Kitchen is inaccessible to residents. Dishwashing liquids and other cleaning agents are separated from food preparation area. Bedrooms: The facility has two (2) floors. The first floor has fifty-two (52) shared bedrooms and the second floor has sixty-four (64) shared bedrooms. Random rooms were inspected and LPAs observed appropriate beddings and linens with sufficient lighting. Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures including grab bars. Hot water temperature was measured at a range of 105.4°F to 109.4°F. (continued on LIC 809-C) Common Areas: These includes the activity room, TV rooms, beauty shop and dining area. The common areas were properly furnished. The furniture were in good repair. Hallways and passageways are free of obstruction. The front door has a delayed egress. Per STD 850, fire clearance for delayed egress and secured locked perimeter was approved on 07/30/20. Surrounding Grounds: Entry/exits and hallways on the first and second floor were free of obstruction. Toxins and cleaning supplies stored and inaccessible during inspection. There is patio furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Room and Shower room: There is a laundry room located on both the first and second floors. Laundry room is kept locked at all times. There is also a Common Shower room on each floor for residents who needed assistance in showering. Shower rooms were observed to be clean and in proper order. Resident Files: Resident files are maintained in the administrator's office. LPA conducted a file review of random resident records to ensure compliance of licensing forms. Residents file were observed to be current and updated. Staff Files: Staff files are maintained at the business office. LPA also conducted a file review of staff records and observed to be current and updated. Medications: Medication Room is located near the administrator's office. Medication room is locked at all times. Medication and Medication Records were review for proper documentation. Office/Work Station: The administrator's office is located near the front entrance, near check-in, and the business office is located at the right corner, front side of the building. Staff records and two computers, for staff use were maintained in the business office. Fire drill was last conducted on 10/07/24. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.the state’s words, verbatim · CDSS document, Nov 2, 2024

Allegation investigated: Staff are withholding resident's funds Staff not keeping facility free from bed bugs. Staff does not keep facility clean.

On 10/11/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to interview residents and deliver the findings. LPA Spaeth interviewed fifteen (R1 – R15) out of 133 residents at 10:00 am until 11:30 am. The investigation consisted of the following: On 10/10/2024, LPA Melissa Spaeth and Angelica Segovia conducted an initial visit. LPAs toured the facility at 9:35 am until 10:10 am. LPAs requested and reviewed the following records at 10:10 am until 10:25 am; (1) resident roster (2) residents’ documents; (3) staff roster; (4) exterminator schedule; and (5) facility personal and incidental funds. LPA received copies of the documentation. LPAs viewed ten out of sixty rooms with the maintenance staff member (S1) at 10:25 am until 11:15 am. LPAs interviewed the back-up Administrator at 11:00 am until 11:20 am. Continued on 9099-C Unsubstantiated Regarding the allegation: staff are withholding a resident’s funds. It’s alleged a resident has not received their monthly funds for the past two months. R1 to R15 unanimously confirmed they receive their monthly personal and incidental funds. LPA interviewed the back-up administrator who stated they give the funds to the residents each month and have never missed. Regarding the allegation: Staff are not keeping the facility free from bed bugs. It’s alleged the facility has had bed bug issues for some time. LPAs checked ten rooms. There were no bed bugs in the two beds within each room and there were no bugs in the corners of the room or on the floor. The maintenance staff member (S1) confirmed the entire facility was professionally sprayed during the month of May 2024. S1 stated if a resident suspects there is a bed bug in their room, the professional exterminator will spray the specific room. LPAs' reviewed the bed bug service reports which confirms the professional exterminator has sprayed various rooms. The exterminator will spray the room, submit a bed bug service report with the date the room was sprayed, and the exterminator will initial the report. The professional exterminator has been spraying various rooms from May, 2024 until September, 2024. LPAs received copies of the reports which is proof the facility has been professionally sprayed for bugs. R1 to R15 unanimously confirmed they have not seen any bed bugs within the facility. Regarding the allegation: Staff does not keep the facility clean. It’s alleged that the facility is dirty and smells like urine. During the tour of the facility, LPAs observed three staff members cleaning residents' rooms, the common areas, and the hallways. LPAs did not smell any urine but did smell the cleaning solutions that were used during the cleaning process. R1 to R15 unanimously confirmed their rooms are cleaned each day and they do not smell urine in the facility. Based on interviews and record review, the allegations are unsubstantiated. An exit interview was conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 31-AS-20241003151416

Allegation investigated: Staff did not ensure resident was taken to his medical appointments

On 9/25/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya and LPA explained the purpose of this visit was to deliver the findings. The investigation consisted of the following: On 09/04/2024, LPA conducted an initial complaint investigation. LPA Spaeth reviewed residents' records at 12:45 pm until 1:15 pm. LPA requested the resident roster and copies of the residents' records. LPA Spaeth received the documents requested. At 1:30 pm until 2:30 pm, LPA Spaeth interviewed ten (10) residents, twelve (12) staff members and the Administrator. Continued on 9099-C Substantiated Regarding the allegation, Staff did not ensure resident was taken to his medical appointments: it is being alleged that facility staff have been neglecting the client’s mental health treatment by not ensuring R1 attends the appointments. LPA’s interview of the Administrator revealed R1 missed the June, 2024 appointment because the facility driver was not available. The Administrator stated the facility driver is the only person who can drive residents to their appointments. R1 confirmed they missed the appointment. Based upon interviews conducted, the allegation is substantiated. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 31-AS-20240829144644

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(6) · Plan of correction due date: Sep 25, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (6) Arrangements to meet health needs, including arranging transportation as specified in Section 87465… This requirement is evidenced by: The facility staff did not provide R1 transportation to their doctor's appointment which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: LPA Spaeth discussed with the Administrator the facility program states the facility will provide transportation services per the program design.

Allegation investigated: Staff did not ensure a safe environment for resident.

On 08/27/2024 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit to the facility to continue the investigation on the above allegation. LPA met with Administrator Jessica Pelaya and explained the purpose of the visit. An entrance interview conducted. Allegation: Staff did not ensure a safe environment for resident. Regarding the allegation, it has been reported that staff are failing to protect Resident #1 (R1) from harm, potentially due to R1’s need for a higher level of care. To investigate the allegation LPA Rios conducted an initial complaint visit on 05/29/24. During the initial visit LPA interviewed the administrator and obtained copies of R1's file. LPA reviewed the following: Identification and emergency information, Physician's Report, Preplacement Appraisal, Appraisal/Needs and Services Plan, various discharge paperwork, and R1’s Assisted Living Waiver Program (ALW) Individual Service Plan. On 05/29/24 at approximately 11:15 a.m. while conducting the physical plant tour, LPA interviewed thirteen (13) residents and two (2) staff. LPA also reviewed unusual incident reports submitted by the facility about R1. (Continued on LIC9099-C) Substantiated On 05/29/24, LPA Rios interviewed a Registered Nurse (RN) who is part of the Assisted Living Waiver Program (ALW) team, familiar with R1's placement. On 08/27/24 LPA interviewed R1's assigned Public Guardian (PG) at the time. A review of R1's record shows R1 was admitted to this facility on 09/24/21. According to the interview with R1’s PG they confirmed R1 has had periods where they have been admitted to skilled nursing facilities, hospitals and rehabilitation centers due to R1’s behavior at this facility. PG’s interview revealed the facility has always held a bed for R1 while waiting for R1’s discharge during those periods. On 06/12/24, the facility provided to the Community Care Licensing Department (CCLD) information regarding their efforts to transfer R1 to another facility. According to the information provided on January 2024 the administrator notified ALW nurse of R1’s change in behavior and requested assistance with finding another placement that could provide the required level of care. On 03/18/24 the administrator contacted R1’s PG notifying that the resident required a higher level of care and needed to be transferred. The interview with PG on 08/27/24, confirms they received a request on 03/18/24 for a transfer and they completed and returned the requested document. On 05/16/24 facility administrator coordinated an assessment with another facility, but the assessment resulted in a failed admission. Interviews with two (2) staff and the administrator on 05/29/24, revealed R1 will wander into other resident’s bedrooms and have heard other residents complain about R1’s behavior entering rooms without permission. Staff have also heard residents complain about R1’s yelling in the hallways repeating the same statements. Interview with nine (9) out of thirteen (13) residents who were interviewed for this allegation also corroborate witnessing R1 wander into their rooms or other rooms and yelling in the hallways. Interview with administrator revealed R1 has been known to display these behaviors when they need a medication adjustment. LPA attempted to interview R1, but R1 did not respond to questioning. One (1) staff revealed they witnessed a resident #2 (R2) push R1 causing R1 to fall down to the floor. Staff explained that R1 was grabbing R2’s plate. Another staff witnessed the same resident R2 grab R1 and return R1 to R1’s room. Staff and residents interviewed also reported seeing R1 with a bruise on their face recently prior to LPA's visit. LPA's observation of R1's face on 05/29/24 did not reveal a bruise. Staff and administrator interviewed report not witnessing how R1 got a bruise but that it could have been an un-witnessed fall. (Page 2 of 3) Review of ALW Individual Service Plan dated 12/03/22 to 06/03/23 revealed R1 has a risk of falls and is at risk of injury due to diagnosis. Physician's Report with exam date 12/16/24 notes client is non ambulatory and list motor impairment as muscle weakness. Six (6) out of the thirteen (13) residents interviewed on 05/29/24 corroborate witnessing resident’s yell, push or hit R1 when R1 is exhibiting a behavior. Resident's did not provide specific dates. LPA could not determine how long R1 has been exhibiting behaviors, however interviews with staff and residents indicate R1's behaviors where increasing and not stabilizing and other residents had already displayed increasing aggressive behavior towards R1. LPA's review of unusual incident reports revealed R1 had been sent out of the facility for different reason such as, confusion, not feeling well and dementia behavior. LPA could not find written documentation on actions or plans taken when R1 returned to the facility. According to interviews with the administrator and two (2) staff they were directed to keep a close eye on R1 and to follow R1 whenever possible. Staff also kept R1 in the medication room with them by offering R1 cookies and whenever possible the administrator would keep R1 in the administrator’s office. Interview with administrator on 08/27/24, revealed a written plan to address R1’s changed behaviors was not created after they notified ALW nurse on January 2024 that R1 had a change in behavior. According to the administrator the facility had a one on one for R1, but nothing documented on paper for this change. Information provided by the facility and the ALW nurse confirms they believed R1 required a higher level of care that the facility could not provide. Review of R1’s updated (no date recorded) Appraisal/Needs and Services Plan reveled facility did not document R1’s behavior of R1 wandering into other residents’ bedrooms, R1 yelling in the hallways, or R1’s tendency to grab other residents’ meal trays. On on 05/29/24 LPA could not find documentation the facility had developed a plan to assist R1 while they waited for R1’s possible transfer and that staff actions did not adequately provide R1 with a safe environment. Therefore, based on record review and interviews the allegation is deemed Substantiate at this time. Deficiencies cited (refer to LIC9099-D). Exit interview conducted. Appeals rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 31-AS-20240524135605

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 6, 2024

87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... This requirement is not met as evidenced by: Based on interviews conducted, the facility did not take appropriate action to mitigate R1 from sustaining an unexplained injury although facility was aware of R1's change in condition which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: R1 is no longer in the facility. Administrator agrees to conduct in-service training with all staff regarding regulation cited and develop a plan to ensure resident changes in condition are addressed accordingly and included in the needs/services plan. Provide as proof sign in sheet of staff attendance by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 6, 2024

87468.1 (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of: Based on interviews conducted with residents and staff, the facility did not take appropriate action to mitigate treatment of R1 by other residents' increasing aggressive behavior towards R1, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: R1 is no longer in the facility. Administrator agrees to conduct in-service training with all staff regarding regulation cited. Provide sign in sheet of staff attendance as proof of correction to CCLD by POC due date.

Allegation investigated: Staff are not releasing resident’s medical records despite receiving a medical release form

On 8/14/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to deliver the findings for this complaint. The investigation consisted of the following: On 08/01/2024 Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM), Troy Agard initiated a complaint investigation. LPA Spaeth and LPM Agard toured the facility at 10:00 am until 10:30 am. LPA reviewed resident records and obtained copies of documentation. LPA and LPM also interviewed a resident (R1) at 11:00 am until 11:30 am. Conintued on 9099-C Unsubstantiated The investigation revealed the following: Regarding the allegation: Staff are not releasing resident’s medical records despite receiving a medical release form. It’s being alleged that a resident (R1) had stated to the reporting party they granted permission for a friend to receive copies of their records. It is also alleged that R1 signed a Release of Client/Resident Medical Information Form (LIC 605A) on 12/03/2023 in which they authorized a friend to receive all their medical records from the facility. On 06/11/2024, a similar allegation was investigated in complaint number 31-AS-20240301092942 in which it was alleged the facility refused to provide medical information despite having signed consent. On 07/23/2024 the regional office received additional information from a new complaint. On 8/01/2024, LPA Spaeth and LPM Agard interviewed R1 at 11:00 am until 11:30 am who stated all their medical records could be released and confirmed who the medical records could be released to. During an interview with the facility administrator, they were aware of the consent but when confirmed with R1, R1 did not provide the same response and was unable to get confirmation from the resident. The department shared with the facility R1’s current request to have their records released as of the day of the interview. The facility administrator was made aware of this confirmation on the day of the interview. Based on interviews conducted and records reviewed the allegation(s) is unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 31-AS-20240723153041

Type of visit: Case Management - Deficiencies

LPA Spaeth conducted an unannounced visit regarding Complaint #31-AS-20230929144615 and was greeted by the case manager. The case manager stated the Administrator, Jessica Pelaya was out of the office and the co-administrator, Jon Dipaling was notified. LPA Spaeth toured the facility with a staff member at 10:30 am until 11:00 am. During LPA's tour, LPA observed one of the two elevators was not working. LPA Spaeth spoke to the co-administrator by phone at 10:55 am who stated the elevator needed to be repaired. Based upon LPA's observations, and pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).the state’s words, verbatim · CDSS document, Jul 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 18, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...This was evidenced by: LPA observed one of the two elevators was not working which poses an immediate health, safety or personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: During LPA's visit, the elevator repair company was contacted and the elevator was repaired during LPA's visit.

Allegation investigated: Resident was raped by another resident in care. Staff fail to meet resident's hygiene needs. Staff failed to provide basic laundry services. Staff cut resident's hair against their will. Facility is infested with insects/pest. Facility is in disrepair. Staff fail to provide residents clean eating utensils.

On 7/11/2024 Licensing Program Analyst (LPA), Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to conduct interviews and present findings. LPA conducted a physical tour at 9:30 am until 10:30 am. LPA interviewed twelve (12) residents at 10:30 am until 11:30 am and interviewed four (4) staff members at 11:30 am until 11:45 am The investigation consisted of the following: On 10/03/2023 LPA Spaeth initiated a complaint investigation. LPA reviewed the resident files. LPA received copies of the documentation. On 7/08/2024, LPA Spaeth conducted a second visit, interviewed eight staff members at 3:00 pm until 4:00 pm, and received additional resident documentation. continued - 9099-C Unsubstantiated Regarding the allegation: Resident was raped by another resident in care. It’s being alleged that a resident was raped by another resident. LPA Spaeth interviewed eight caregivers/staff members (S1 to S8) and the Administrator who stated they have not witnessed this happen and a resident did not report to them this occurred. LPA Spaeth interviewed twelve residents (R1 – R12) who stated this did not occur to them, they did not witness this occurrence and also stated another resident did not inform them this happened. The resident mentioned in the complaint is no longer living at the facility and contact information was not provided to the facility staff when the resident moved out of the facility. Therefore, this allegation is unsubstantiated. Regarding the allegation, Staff fail to meet resident's hygiene needs. It’s being alleged that the residents have not received showers, staff use the same loofah when assisting residents in the shower, and the loofah is never sanitized after each use. S1 – S8 unanimously stated when assisting residents with showering, a loofah is not used. A clean wash cloth and clean towel are used for reach resident. S1 – S8 also stated a shower schedule is followed each day. S1 – S8 are assigned specific residents with showering so that no one is overlooked. S1 – S8 also stated if a resident requests a shower each day, the staff are happy to accommodate their request. The Administrator stated the shower schedule was created to ensure all residents receive a shower twice a week. LPA Spaeth received a copy of the shower schedule. During the facility tour at 10:15 am, LPA observed the shower room and there was no loofah in the room. Eight (8) out of the twelve (12) residents interviewed stated they receive assistance with showering and also unanimously stated a loofah is not used but a clean wash cloth and a clean towel are used. The eight (8) residents who receive assistance with showering stated they are assisted two times a week. The eight residents also stated staff never miss assisting them each week and stated if they ask for an additional shower day, the staff always accommodates their request. Therefore, the allegation is unsubstantiated. Regarding the allegation, Staff failed to provide basic laundry services. Its being alleged that residents’ clothes and bed sheets have not been washed. It is also alleged that residents wear the same clothing for five days in a row. S1 – S8 stated the residents are encouraged to change their clothes each day and they have never witnessed a resident wearing the same clothes for five days in a row. S1 – S8 confirmed there is one caregiver who washes the residents’ clothing and bedding. S1 – S8 also confirmed the residents have not stated their bedding or clothing have not been washed. LPA interviewed the caregiver (S7) who confirmed they wash the residents’ clothing and bedding. S7 stated there are many times that a resident’s sheets might be washed more than one time a week due to accidents that occur in a residents' bed. Continued 809-C LPA interviewed twelve residents (R1 – R12) who unanimously confirmed their clothing and bedding is washed every week. R1 – R12 also stated they do not walk around in the same clothing for five days. Therefore, the allegation is unsubstantiated. Regarding the allegation, Staff cut resident's hair against their will. It’s being alleged that a staff member told a resident they must shave their head due to a medical condition. One (1) out of the twelve (12) residents interviewed stated they had a medical condition and the resident decided to have their head shaved in order to alleviate the medical condition. The resident discussed the possibilities with a staff member and the resident made the choice to have their head shaved. The staff member did not force the resident to shave their head. The other twelve residents stated they were never forced to shave their heads. S1 – S8 stated they never forced a resident to shave their head. Therefore, the allegation is unsubstantiated. Regarding the allegation, Facility is infested with insects/pest. It’s being alleged there are bed bugs, roaches and spiders in the facility. Also it is alleged that a pest control company has not treated the facility. During LPA’s facility tour, LPA was escorted by the maintenance staff member. Both parties checked ten rooms at 10:00 am until 10:30 am. LPA did not observe any bed bugs, roaches or spiders. R1 – R12 stated the facility had a professional company spray the rooms. LPA Spaeth received a copy of the bed bug service documentation which proves each room was professionally fumigated on May 4, 2024. R1 – R12 unanimously stated there are no bugs in their rooms. Therefore the allegation is unsubstantiated. Regarding the allegation, facility is in disrepair. It’s being alleged that there are holes and mildew on the walls. During today’s facility tour, LPA did not observe holes or mildew. Therefore the allegation is unsubstantiated. Regarding the allegation, Staff fail to provide residents clean eating utensils. It’s being alleged staff do not dispose of plastic utensils after each meal. Also it is alleged staff are reusing plastic utensils without properly cleaning them. LPA Spaeth interviewed the three dining hall staff (R9 – R11) who unanimously stated the eating utensils are thrown away by residents after each meal. R9 – R11 stated they never reuse the used plastic utensils. All three unanimously stated there are fifty plastic forks in sealed bags. When the residents are served their meals, the sealed bags are opened and each resident receives clean utensils. The residents then dispose of the utensils. R1 – R12 all stated they dispose of the plastic utensils after every meal. Therefore the allegation is unsubstantiated. Exit interview conducted and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 31-AS-20230929144615

Allegation investigated: Staff did not refill resident's medication in a timely manner. Staff did not dispense medication to resident as prescribed. Staff do not prevent residents from smoking in non-smoking areas.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegations. LPA met with administrator, Jessica Pelaya, and explained the reason for the visit. --- Staff did not refill resident's medication in a timely manner. It was alleged that facility was out of insulin for Resident #1 (R1). To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. On 07/03/2024, LPA Duguma requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. A review of R1’s Medication Administration Records indicates R1’s insulin was self-administered during the month in question. During interviews with staff, all staff stated residents are issued medications timely and as prescribed. (CONT on LIC 9099-C) Unsubstantiated Staff #2 (S2) stated insulin is not refilled every month by corresponding with the primary care physician or the pharmacy, rather it is on a cycle and routinely refilled without anyone having to request for a refill and at no time did the resident not have access to or receive insulin. S2 stated resident was admitted to the facility on 06/02/2023 and received the first dose at the facility on 06/03/2023. S2 added that the insulin R1 was admitted to the facility with was a two (02) month supply and lasted until the first refill on 08/02/2023. During interviews with residents, all residents stated their medications are refilled in a timely manner. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not dispense medication to resident as prescribed. It was alleged that Resident #1 (R1) is to take insulin three (03) times a day but it was not dispensed as prescribed. To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. On 07/03/2024, LPA Duguma requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. A review of R1’s prescription documents indicate a change in dosage from three (03) times a day to once a day before bedtime. A review of the Medication Administration Record indicates that R1 self administered the insulin at 9:00 PM. During interviews with staff, all staff stated residents are dispensed medications as prescribed. During interviews with residents, all residents stated their medications are dispensed as prescribed. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not prevent residents from smoking in non-smoking areas. It was alleged that the facility’s hallways smell like marijuana and R1’s roommate smokes cigarettes in the room. To investigate the allegation, on 08/07/2023, LPA Antonia Alvizar-Ettima interviewed three (03) staff from 11:50 AM to 2:30 PM. (CONT on LIC 9099-C) On 07/03/2024, LPA Duguma conducted a physical plant tour and requested documents at 10:30 AM, interviewed two (02) staff from 11:30 AM – 12:30 PM and interviewed thirteen (13) residents from 12:30 PM – 2:30 PM. During the physical plant tour, LPA did not experience any marijuana or cigarette odor throughout the facility. During interviews with staff, all staff stated residents do not smoke marijuana or cigarettes in the facility and are not aware of R1’s roommate smoking cigarettes in their room. During interviews with residents, all residents stated they are not aware of marijuana or cigarettes being smoked anywhere in the facility. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 3, 2024 · control 31-AS-20230803121542

Allegation investigated: Facility did not notify responsible party of resident's death. Facility refused to provide resident's personal belongings to responsible party.

On 06/19/2024 at 09:30 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with Administrator Jessica Pelaya and explained the reason for the visit. At 10:00 am pending interview was made. At 10:30 AM LPA Casillas conducted a physical plant tour. LPA collected Resident #1's (R1's) death certificate. On 6/17/2024 LPA had previously requested resident roster, Liability Insurance, Bond, LIC 500 and copies of pertinent information relevant to the investigation including but not limited to resident records, police reports, and any other information pertaining to the investigation, therefore these items were not collected on this visit. Continued on LIC9099-C Unsubstantiated On 11/08/2021 LPA Spaeth conducted an investigation for complaint # 31-AS-20211108150903. Two allegations are the same as the allegations in this complaint. LPA Casillas compared notes and conducted interviews to verify the information obtained in the previous complaint. This visit is a follow up to make sure that nothing was missed from the first investigation. Allegation #1 Facility did not notify responsible party of resident's death. It is alleged that facility did not notify responsible party of resident’s death. Regarding this allegation it is reported that Resident #1’s (R1) family was not notified of R1’s death when it happened on 07/06/2021, but instead was notified a week later. LPA interviewed the Administrator, and it was confirmed that the previous Administrator and the Los Angeles Sheriff's Department had tried to reach the family member in a timely manner, however the family member returned calls several days after the death of R1. Furthermore, in an interview conducted by LPA Spaeth it was discovered that R1’s grandson, admitted to getting the days confused and thought that a message left was on 07/12/2021 and not 07/06/2021. Based on interviews and record reviews this allegation is deemed unsubstantiated at this time. Allegation #2 Facility refused to provide resident's personal belongings to responsible party. It is alleged that facility refused to provide residents’ personal belongings to responsible party. Regarding this allegation it is reported that the facility is failing to return R1’s belongings after their death. LPA confirmed with Administrator that residents' possessions were securely stored in the donation room for over (2) two years from R1's death. R1’s family members were made aware that items were available for pick up however, LPA was advised that R1's family members failed to arrange for delivery or pick up of R1’s possessions after facility staff attempted to get in contact with family numerous times. Furthermore, Administrator states that they had a conversation with R1's relative and they were supposed to rent a U-Haul and pick up R1's property but never showed up. Based on record reviews and interviews this allegation is deemed unsubstantiated at this time. No citations issued. Exit interview was conducted. A copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 31-AS-20220804154108

Allegation investigated: Staff did not seek medical care for resident Licesee refused to release medical documents after receiving a medical consent form.

On 6.11.2024 Licensing Program Analyst (LPAs) Leslie Ngo-Castaneda and Lorena Casillas arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPA met with Administrator Jessica Pelaya and was explained the purpose of the visit. An entrance interview was conducted. To investigate the allegations, LPAs Leslie Ngo-Castaneda and LPA Angela Panushkina conducted an initial complaint visit on 3.8.2024. On this day LPA conducted a physical plant tour of the facility at time. LPAs interviewed thirteen (13) out of one hundred thirty (130) residents and interviewed the Administrator. LPAs reviewed and obtained the resident's admission agreement, physician's reports, appraisal needs and services plan, identification and emergency information, and consent forms. Continued to LIC 9099-C Unsubstantiated On 3.11.2024, 3.18.2024, and 4.5.2024 LPA Leslie Ngo-Castaneda requested medical record. Medical records were reviewed on 3.18.2024, 3.25.2024, 4.2.2024, 4.5.2024, 4.8.2024, 4.12.2024, and 5.9.2024. On date an interview was conducted R1s Nurse Practitioner. Allegation: Staff did not seek medical care for resident. It is alleged that R1 needed surgery for a diagnosis that effects the brain and staff did not seek medical attention. The interview with R1 revealed that the facility staff assists with making and arranging for medical attention including appointments and any follow up medical recommendations. In interviewing the Administrator there may be times when R1 does not want to go for their scheduled appointments and will decline to go and a new appointment will be scheduled, again R1 will decline. R1 acknowledged and indicated that scheduled appointments have been cancelled by them. The facility continues to assist the resident and will follow up with the doctor for in person visits. R1 has no issues with the facility a believes the facility is assisting with their medical needs. LPA reviewed R1 medical records and interviews with R1s (Nurse practitioner). Based on the medical records reviewed, it appears that the resident has had all appropriate test completed to address their medical condition that effects the brain. Interview with the nurse practitioner reveals that the facility has done what they can and that the resident condition is within normal pressure and medical specialist follow-up appointments and recommendations are followed. Since R1 was diagnosed, R1 has been continuing receiving care for treatment from a medical specialist. Interview with other residents revealed they are satisfied with the assistance being provided; no complaints expressed. Based on information obtained through interviews and record review this allegation is deemed unsubstantiated at this time. Continue to LIC 9099-C Allegation: Licensee refused to release medical documents after receiving a medical consent form. It was alleged that the licensee refused to release medical documents after receiving a medical consent form. Per staff interviews and records review, all staff are trained on releasing confidential information/Health Insurance Portability and Accountability Act (HIPAA). LPA conducted records review for R1, LPA observed the original Release of Client/ Resident Medical Information- LIC605A in R1’s file unsigned. During the course of the investigation, a copy of LIC 605A was presented to the LPA, signed, and dated 12.3.2023. LPA interviewed R1 on 3.8.2024. The interview revealed that R1 did not give consent to any individual for medical information to be released and stated they only speak for themselves. LPA showed the LIC 605A to R1 who verified the signature on the form was not theirs. R1 indicated that the form was signed by someone else who was not given consent to obtain confidential information or medical documentation. Because of this, facility staff did not release any medical documents or other confidential information. The interviews and documentation review do not corroborate this allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted. Copy of report delivered to Administrator.the state’s words, verbatim · CDSS document, Jun 11, 2024 · control 31-AS-20240301092942

Type of visit: Case Management - Deficiencies

On 05/29/2024 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit in conjunction with complaint control #31-AS-20240524135605. LPA met with Administrator Jessica Pelaya and explained the purpose of the visit. At approximately 10:35 a.m. LPA requested copies of documents in resident #1s (R1's) file. LPA reviewed the following: Identification and emergency information, Physician's Report, Preplacement Appraisal, Appraisal/Needs and Services Plan, various discharge paperwork, and Individual Service Plan. According to R1's records and interview with administrator R1's cognitive ability has declined. Furthermore, interview with Assisted Living Waiver Registered Nurse (RN) responsible for placement assistance corroborates R1 has had a change in condition which would require R1 to have a higher level of care. Review of physician's report revealed it was conducted in 2021. R1's Appraisal/Needs and Services Plan indicated it is an updated appraisal but does not have a date and does not include information relevant to residents current health condition and behavior R1 engages in. Deficiency cited (refer to 809D). Exit interview conducted, appeal rights provided, and a copy of the report was given.the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jun 10, 2024

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5)Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually... This requirement was not met by evidence of: Based on interviews conducted with staff and residents and record review conducted by LPA, the licensee failed to have R1 receive an annual medical assessment which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Administrator will provide a copy of R1's medical assessment/physician's report and updated appraisal needs and services when completed to LPA by POC due date 06/10/2024.

Allegation investigated: Facility staff mismanaged residents’ money. Facility staff did not refill resident's medication in a timely manner. Facility staff did not provide resident medication as prescribed. Facility staff do not prevent residents from smoking in non-smoking areas. The facility elevator is in disrepair. Facility staff does not ensure facility is clean and sanitized. Facility staff are not maintaining a comfortable room temperature for resident.

On 05/07/2024 at 09:10 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with Administrator Jessica Pelaya and explained the reason for the visit. At 10:00 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were made from 11:00 am to 4:00 pm. LPA requested resident roster, Liability Insurance, Bond and LIC 500. LPA requested copies of pertinent information relevant to the investigation including but not limited to resident records, medication logs, elevator inspection certificates, maintenance logs and resident fund logs. Continued on 9099-C Unsubstantiated Allegation #1 Facility staff mismanaged residents’ money. It is alleged that staff mismanaged residents’ money. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. LPA reviewed resident records and along with Assistant Administrator (AA) went over random resident money and logs. Upon review LPA discovered that there are no discrepancies regarding resident money, all receipts, funds and signatures are accounted for. Furthermore, interviews with residents revealed that they have no concerns regarding any funds missing or being withheld from them by the facility staff. Based on interviews, record reviews, and LPA's observation this allegation is deemed Unsubstantiated at this time. Allegation #2 Facility staff did not refill resident's medication in a timely manner. It is alleged that facility staff did not refill resident's medication in a timely manner. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. LPA reviewed resident medicine records and along with Staff #1 (S1) who is the Medicine Technician Supervisor, went over resident medication refill receipts. Upon review LPA discovered that there are no discrepancies regarding resident medication refills, all medication logs reviewed were accurate. LPA was informed by S1 that medications are delivered every night at around 7:00 pm Monday through Friday from Maggie’s pharmacy, which is the only pharmacy used for regular medicine refills. LPA was also informed by S1 that if residents need medication other than their regular medication that the local Rite Aid Pharmacy is used. Based on interviews, record reviews, and LPA's observation this allegation is deemed Unsubstantiated at this time. Allegation #3 Facility staff did not provide resident medication as prescribed. It is alleged that facility staff did not refill resident's medication in a timely manner. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. LPA reviewed resident records and along with Staff #1 (S1) went over resident medication logs. Upon review LPA discovered that there are no discrepancies regarding resident medication distribution, all medication logs reviewed were accurate and all medication matched to medication logs. Based on interviews, record reviews, and LPA's observation this allegation is deemed Unsubstantiated at this time. Continued on LIC9099-C Allegation #4 Facility staff do not prevent residents from smoking in non-smoking areas. It is alleged that facility staff do not prevent residents from smoking in non-smoking areas. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe there to be two (2) designated areas where residents are allowed to smoke outside in the patio. LPA did not observe any residents smoking inside the facility, nor were there any residents smoking in the rooms that LPA inspected. Furthermore, interviews with staff and residents confirmed that some residents do not follow the rules regarding smoking, however staff are diligent in instructing residents to designated areas and asking them to immediately stop smoking by putting cigarettes out. Based on interviews and LPA's observation this allegation is deemed Unsubstantiated at this time. Allegation #5 The facility elevator is in disrepair. It is alleged that the facility elevator is in disrepair. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe that there are two (2) elevators in the facility. LPA was able to use both elevators and observed that they were last serviced on 12/06/2023 by Inspector # AH916, inspection expiration date is 12/06/2024. During LPA’s use of the elevators, they were both functioning properly, and alarms were audible. The elevators were clean and were functioning properly. LPA was informed by Staff #3 and Staff #4 that there is one resident that continuously spits as part of their behavior, therefore they have assigned two (2) shifts to specifically clean the hallways and the elevators. Elevators are cleaned at around 7:00 am, 12:00 pm, 2:00 pm and 9:00 pm. LPA was informed that in between those cleaning hours if elevators are visibly soiled, housekeeping will be called, and they are immediately cleaned. Based on interviews, record review, and LPA's observation this allegation is deemed Unsubstantiated at this time. Continued on LIC9099-C Allegation #6 Facility staff does not ensure facility is clean and sanitized. It is alleged that facility staff does not ensure facility is clean and sanitized. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe that there were multiple staff members with portable cleaning carts throughout the facility performing their cleaning duties. LPA also observed that the facility was free and clear of clutter. LPA observed that the common areas, dining facilities, kitchen area, storage areas, and resident rooms that were inspected, were clean. Interviews with staff revealed that cleaning crew is split in two (2) shifts, 7:00 am to 2:00 pm and 2:00 pm and 9:00 pm, there is no cleaning staff from 9:00 pm to 7:00 am. Furthermore, interviews with residents revealed that their rooms are cleaned every day, multiple times a day if needed. Based on interviews, record review, and LPA's observation this allegation is deemed Unsubstantiated at this time. Allegation #7 Facility staff are not maintaining a comfortable room temperature for residents. It is alleged that facility staff are not maintaining a comfortable room temperature for resident. On 05/07/2024 LPA conducted interviews with the Administrator, five (5) staff, and thirteen (13) out of one hundred twenty nine (129) residents. During facility tour LPA was able to observe that there were six (6) thermostats throughout the facility. The readings at 10:15 am were 67, 73, 74, 73, 73 and 74 degrees Fahrenheit. The facility upon entry was at a comfortable 73 degrees Fahrenheit and throughout the day it remained at 73 degrees Fahrenheit. LPA toured the facility again at 12:30 pm and the readings were 67, 73, 73, 74, 73 and 73 degrees Fahrenheit. LPA toured the facility one last time at 3:00 pm and the readings for temperature remained the same. The readings throughout the day stayed within regulation. Interview with Staff #2 (S2) revealed that every time there is a maintenance order, it is sent through an application on their phone where they can address the concern. S2 explained that once the concern is sent to their application the staff will begin to repair what is needed. S2 stated that they have not received a concern regarding the temperature being too hot. Based on interviews, records review, and LPA's observation this allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 8, 2024 · control 31-AS-20240503155205

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Jessica Pelaya and explained the reason for the visit. At approximately 09:30am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. Currently there are ten (10) residents receiving hospice care and seventy (70) residents on the Assisted Living Waiver (ALW). The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The smoke detectors were last serviced 09/23/23. Facility also have a functional sprinkler system. There are fire extinguishers located throughout the facility hallways. The charge date for the fire extinguishers was 11/30/23. The Fire Inspection was last held on 07/25/23. Kitchen: The kitchen is industrial. Appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly stored. Knives were stored and locked. Bedrooms: The facility has two floors. The first floor has fifty-two (52) shared bedrooms and the second floor has sixty-four (64) shared bedrooms. Random rooms were inspected and LPAs observed appropriate beddings and linens with sufficient lighting. Bathrooms: Each resident unit on both floors have their own bathrooms. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was between 105-107 degrees Fahrenheit. No cleaning supplies observed stored in resident bathrooms. Common Areas: These includes the activity room, tv room, beauty shop and dining area. The common areas were properly furnished. The furniture were in good repair. Hallways and passageways are free of obstruction. The front door has a delayed egress. Per STD 850, fire-clearance for delayed egress and secured locked perimeter was approved on 07/30/20. Surrounding Grounds: Entry/exits and hallways on the first and second floor were free of obstruction. Toxins and cleaning supplies stored and inaccessible during inspection. There is patio furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Room: There is a laundry room located on both the first and second floors. Laundry room is kept locked at all times. Resident Files: Resident files are maintained in the administrator's office. LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: Staff files are maintained at the business office. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication Room is located near the administrator's office. Medication room is locked at all times. Medication and Medication Records were review for proper documentation. Office/Work Station: The administrator's office is located near the front entrance, near check-in, and the business office is located at the right corner, front side of the building. Staff records and two computers, for staff use, were maintained in the business office. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, May 4, 2024

Allegation investigated: Staff do not ensure the facility is free from bed bugs.

On May 3, 2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to investigate the complaint and report the findings for this complaint. Regarding the allegation… Staff do not ensure the facility is free from bed bugs. it is being alleged a resident’s room (R1) had bed bugs. The room was sprayed but the bed bugs are still located in R1’s room. LPA and a staff member toured the facility at 1:00 pm until 1:20 pm . The staff member and the LPA checked five rooms. LPA Spaeth checked an additional five rooms with other staff members at 1:25 pm until 1:40 pm. Five (5) out of the ten rooms (10) had bed bugs in the residents’ rooms and in residents’ beds. LPA Spaeth interviewed the maintenance staff member (S1) at 2:00 pm until 2:20 pm. S1 stated a professional service sprayed each room during the month of January, 2024 and February, 2024. continued 9099-C Substantiated that time, S1 has been spraying residents’ rooms when there is a report of bed bugs within the rooms. S1 stated uses a product purchased at Home Depot. S1 confirmed only the rooms that have reported bed bugs are the rooms that have been sprayed during the month of March, 2024 and April, 2024. S1 also stated staff and residents will report to S1 when there are bed bugs and S1 will spray that particular room. Based upon LPA’s observation of bed bugs in five residents’ rooms, the allegation is substantiated. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, May 3, 2024 · control 31-AS-20240503093510

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87303(a) · Plan of correction due date: May 10, 2024

87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary at all times. Maintenance shall include...mainte- nance services & procedures for the safety and well-being of residents, ....This is evidenced by: Based on LPAs observations and staff interview, the licensee did not comply with the section cited above by not ensuring the facility is free of bed bugs. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Administrator agreed to request the professional service spray the entire facility.

Allegation investigated: Resident eloped from the facility

On May 3, 2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by the Administrator, Jessica Pelaya. LPA explained the purpose of this visit was to deliver findings for this complaint. The investigation consisted of the following: On 12/14/2022, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested documents. LPA Spaeth requested the following documents: 1) resident roster, 2) incident reports dated 12/06/2022, and 3) R1’s physician’s report. All documents were received at the time of visit. LPA Spaeth conducted interviews with two staff members, and the Administrator. LPA Spaeth attempted to interview R1 on 08/04/2023; however, R1 declined. Continued 9099-C Substantiated Regarding the allegation… Resident eloped from the facility. It is being alleged the resident eloped from the facility on 12/06/2022 without staff members’ knowledge. The reporting party called the facility on Tuesday, 12/06/2022 and asked to speak to R1. The reporting party was told by staff R1 was sleeping. The reporting party called again on Thursday 12/08/2022 and staff told the reporting party R1 left the facility without staff member’s knowledge. During interviews with the two staff members (S1 and S2), S1 and S2 confirmed they worked the morning of 12/06/2022. S1 and S2 confirmed Room 103 was unlocked. S1 and S2 confirmed Room 103 was used for storage. Upon entering the room, S1 and S2 observed the door leading to the outside of the facility was open. S1 and S2 confirmed the Administrator has stated to all staff Room 103 must remain locked at all times since an exit door leading to the outside is located within that room. When S1 observed the side door was open, S1 sent a snapshot of the open door to Administrator. The Administrator confirmed the resident had eloped the morning of 12/06/2022. The Sheriff’s Department was called and the Department filed a missing person’s report. LPA Spaeth observed the report was dated 12/06/2022. LPA Spaeth reviewed the 12/06/2022 incident report that was sent to CCL regarding the elopement of R1. The report revealed S1 and S2 observed the side exit door was open. The report also stated S1 and S2 conducted a head count and discovered R1 was not at the facility. The Administrator confirmed the staff called the Administrator on 12/06/2022 confirming R1 was not in the facility. LPA Spaeth reviewed R1’s Physician’s Report (LIC 802) dated 08/28/2020 which revealed R1 would need to be accompanied with staff if R1 left the facility. Based upon LPA’s interviews and review of R1’s LIC 802 dated 8/28/2020, the allegation is substantiated. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, May 3, 2024 · control 31-AS-20221213113305

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 6, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and ….furnishings and equipment. This requirement is not met as evidenced by: Based on LPAs interviews, the licensee did not comply with the section cited above by not ensuring the storage room door was locked. The door was unlocked and R1 left the facility unassisted by staff. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Administrator agreed to providing a sign in sheet for all staff stating all exit doors will be checked at the beginning of each shift.

Allegation investigated: Staff did not respond to communications from resident's representative in a timely manner.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with administrator Jessica Pelaya and explained the reason for the visit. During the course of the investigation, interviews and record review were made. At 12:10 PM, LPA requested resident and staff roster. At 12:20 PM, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 12:40 PM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 12:45 PM – 1:45 pm, LPA interviewed the Administrator, two (2) staff and thirteen (13) residents out of 130. Allegation: Staff did not respond to communications from resident's representative in a timely manner. It was alleged that R1's representative had made multiple attempts to communicate with facility staff regarding changing primary payee from R1's representative to the facility. LPA interviewed Administrator regarding the allegation. (Continue on 9099C) Unsubstantiated Administrator wasn't aware of the issue since this matter is related to bustiness Administration. Administrator confirmed that R1's representative had never brought communications concerns to them. Interview with S2 and S3 revealed that R1's representative called twice and both times all concerns were solved. S3 stated that the first time R1 representative called was about the possibility of making the facility as primary payee and the second time R1's representative requested to know the procedure for the change of the payee. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted a copy of this report delivered.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 31-AS-20240417143123

Allegation investigated: Staff inappropriately touched resident in care.

At 10:45 a.m. Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent unannounced complaint visit to continue investigation on the allegation above. LPA met with, Administrator Jessica Pelaya and explained the reason for today's visit. An entrance interview was conducted with the administrator Jessica at 10:45 a.m. and a review of previously obtained records from LPA's visit on 02/22/2023 were discussed. On todays visit LPA reviewed and obtained copies of the facility's current resident roster, shower schedule, and three (3) staff LIC501s (job applications). At 11:35 a.m., LPA along with Jessica, conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. While conducting physical plant tour LPA interviewed four (4) of the seven (7) residents previously interviewed on 02/22/2023 that are still in the facility and later interviewed five (5) more residents currently requiring assistance with showers. (Continued to LIC9099-C) Unsubstantiated (LIC9099-C) Allegation: Staff inappropriately touched resident in care. To investigate the allegation LPAs Evelin Rios and Melissa Spaeth conducted an initial visit on 02/22/2023. On initial visit LPAs obtained copies of facility's resident roster, employee roster, shower schedule, employee schedules, resident #1's (R1's) facility record, police report Information involving R1, unusual incident/injury report related to police report, and hospital discharge paper work for R1. On 02/22/2023 LPAs interviewed the administrator Jessica, interviewed seven (7) residents, and interviewed two (2) staff that assist resident's with showers. LPA review of records and interview with the administrator on 04/15/2024 revealed no staff fitting a description of the alleged perpetrator assisted residents with showers then and now. Interview with seven (7) residents on the initial visit on 02/22/2023 and interviews with residents today do not corroborate the allegation revealing, never being inappropriately touched by staff or witnessing or hearing about staff inappropriately touching a resident. Interviews with staff on 02/22/2023 do not corroborate the allegation. Interview with the administrator on 02/22/2023 and today deny the allegation. Interview with administrator on 04/15/2024 revealed R1 only required "stand by assistance" when showering due to their fall risk status. Interview with administrator and staff revealed R1 would shower in their own bathroom or shower in the larger facility bathroom where in either scenario, staff would stand by the shower with the curtain closed reassuring R1 someone was their to assist if R1 had a fall. LPA search of male staff names that assist residents with showers revealed there is no previous allegation similar to this complaint. LPA interview with R1's conservator revealed R1 may make false accusations if they feel they are not getting their way. Based on interviews, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 31-AS-20230213132242

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA Spaeth stated the purpose of the visit was regarding an incident report and death report received by Community Care Licensing. Community Care Licensing received an incident report dated 4/09/2024 stating a resident passed way on 4/09/2024 at 6:20 am. LPA Spaeth reviewed resident's file (R2) from 1:50 pm until 2:15 pm. LPA received copies of the documents. LPA interviewed a resident and one staff member at 2:10 pm until 2:30 pm. LPA Spaeth will be conducting additional staff interviews and will return to the facility at a later time. Exit interview conducted and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Apr 12, 2024

Type of visit: Case Management - Deficiencies

At 10;15am Licensing Program Analysts (LPAs) Angela Panushkina and Leslie Ngo-Castaneda, conducted a Case Management Visit in conjunction with the complaint #31-AS-20240301092942. LPAs met with the Administrator explained the reason for the visit. At 11:40am, LPAs conducted visits to random resident rooms in an Assisted Living (2nd floor) and conducted an interview with ten (10) out of thirteen (13) residents. Upon entry to three (3) out of five (5) rooms LPAs noticed the following: Toilet was not properly working in room #210 Bathroom flooring around the door frame in room #210 and #209 was damaged/chipped. Room #209 had a broken dresser Closet doors in room #210 and #218 were off the tack and damaged. Window screen in room #225 was ripped. Evacuation chairs on a second floor were missing Deficiencies cited on LIC9099-D, based on LPAs observation of the physical plant. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 15, 2024

Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPAs observation licensee did not comply with the section cited above, by not ensuring that three (3) out of five (5) resident rooms are in good repair. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Administrator agreed to submit proof of picture or an invoice with by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(f)(1) · Plan of correction due date: Mar 15, 2024

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by: Based on LPAs observation, the licensee did not comply with the section cited above by not having the evacuation chair in their stairwell, which poses/posed a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: The licensee agreed to purchase the evacuation for each stairwell at the facility and will submit the proof of purchase to CCL on or before the POC date.

Allegation investigated: Facility staff did not safeguard resident's belongings.

On 03/01/2024 at 11:27 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Melissa Spaeth conducted an unannounced complaint visit to the facility to investigate the above allegation. LPAs met with Assistant Administrator Crystal Barrientos and explained the purpose of the visit. Entrance interview conducted. A physical plant tour was conducted at approximately 11:42 a.m. by LPAs along with the Assistant Administrator to ensure the health and safety of the residents in care. LPAs observed water damage running along a wall on north side of the first floor. According to Crystal the facility recently experienced a water leak due to the recent rain in the area. The leak has been addressed and the cosmetic repair is expected to be completed by Wednesday, March 6, 2024. Allegation: Facility staff did not safeguard resident's belongings. It is alleged clothing is not being returned to residents after laundry is completed. To investigate the allegation LPAs conducted a tour of both laundry rooms in the facility and obtained records relevant to the investigation. ( Continued on LIC9099-C) Substantiated From approximately 12:00 p.m. to 1:25 p.m. LPAs interviewed three (3) staff that have provided laundry service for residents and fourteen (14) out of one hundred one (131) randomly selected residents. From approximately 1:30 p.m. LPA reviewed the facility's laundry schedule for residents found to need the assistance, LIC 500, and facility program mentioning laundry services. Interview with the assistant administrator revealed the facility has added new large capacity washers, explained the facilities laundry process and revealed the designated person for laundry no longer works for the facility and currently the Direct Care Provider (DSP) Supervisor is overseeing laundry services. DCPs have been instructed to assist with laundry and follow a schedule for residents needing the assistance but will assist any resident who requests laundry service. The assistant administrator also discussed the facility's process for documenting residents personal belongings when they first arrive to the facility. According to the assistant administrator many of the residents and their families have refused documenting or inventorying item brought in by residents or items provided to them by family when they are already at the facility. Interviews with seven (7) out of fourteen residents (14) corroborate either personally having various clothing gone missing after it was collected for laundry or arriving to the facility with items that they have later never seen again. Interview with two (2) out of three (3) staff corroborate they have heard residents and their families' complain about clothing going missing after laundry service. According to interviews with staff the facility is working on the issue and has implemented procedures to return clothes to the right resident. Although residents' interviewed could not recall exactly which items have gone missing or if they had completed an inventory of items during the admission process, interviews with both residents and staff revealed they had brought up their issues with laundry service to staff and management. Based on interviews conducted, the above allegation is found to be SUBSTANTIATED at this time. Deficiencies cited (refer to 9099-D). Exit interview was conducted with administrator. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 31-AS-20240222134011

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Mar 15, 2024

87217(b)Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff... This requirement was not met by evidence of: Based on interviews conducted with staff and residents the licensee failed to take appropriate measures to return residents' personal property after laundry service which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: The Licensee will create a laundry service procedure that will ensure residents' clothing is returned to them and review procedure with staff. Once completed Licensee will send a copy of laundry procedure and a staff signed in sheet indicating the laundry procedure has been reviewed by them. Submit documentation to LPA by POC due date.

Allegation investigated: Staff did not seek timely medical attention for a resident in care

Licensing Program Analysts (LPA) Melissa Spaeth and Evelin Rios conducted an unannounced complaint visit to the facility. LPAs met with the Administrator Assistant and explained the purpose of the visit is to deliver the findings regarding the allegations listed above. An entrance interview was conducted. On 10/21/2022, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch (IB) on 10/21/2022 for a full investigation and was accepted on 10/21/2022. On 10/26/2022, LPA Melissa Spaeth conducted an initial complaint visit. During the visit at 10:26 am, LPA conducted a review of resident records, reviewed Medication Administration Record Sheets (MARS) and at 11:30 am interviewed the Medication Technician Supervisor, a caregiver and the Administrator Jessica Pelaya. ontinued on 9099-C Substantiated The hospital records were subpoenaed and reviewed by IB investigator Heidy Bendana. On 11/30/22, IB Investigator Bendana conducted a complaint investigation visit to the facility at which time the investigator reviewed facility files and interviewed five (5) staff and three (3) residents. Regarding the allegation: Staff did not seek timely medical attention for a resident in care. It’s being alleged that Resident 1 (R1) had experienced weakness, problems breathing and urinary discomfort for an unspecified period of time. Staff had knowledge of R1’s condition and did not seek medical attention. During the IB investigation, information was gathered through facility files, including resident records, and medical records. Interviews were conducted with potential witnesses and staff. During interviews, it was discovered that R1 had complained of stomach and abdominal pain for an unspecified time. R1’s urine output was very little. R1 was vomiting and was running a fever. Four (4) out of the thirty-three (33) staff members confirmed R1 was vomiting and had low output. One (1) staff member stated R1 was declining for about a week. Two (2) staff members stated R1 reported they were not feeling well and were in pain. The Administrator confirmed they were aware of the medical conditions and health history of R1. The Administrator also admitted that a staff member reported about R1 experiencing stomach pain and having minimal urine output. The Administrator stated they did not know the length of time R1 had been in pain. The Administrator then called home health who advised to send R1 to the hospital. One (1) of the witnesses interviewed by IB indicated that based on R1’s health conditions and on low or little urine output, the issue should have been immediately addressed by a skilled professional or staff. If not addressed, the issue could lead to a urinary tract infection which can cause sepsis or a fever and also could cause low blood pressure. The facility documents notated the resident complained of pain and discomfort. Based on interviews and record review, there is a sufficient information and/or evidence to support the allegation. Therefore, the allegation is substantiated. Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiency was observed and cited during the visit. See LIC 9099-D.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 31-AS-20221021140132

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 12, 2024

87465 Incidental Medical & Dental Care (g) The licensee shall immediately telephone 911 if an injury,... has resulted in an imminent threat to a resident’s health including,.. an apparent life-threatening medical crisis...This requirement was not met as evidenced by: Based upon staff interviews, staff failed to call 911 when staff observed the resident had experienced pain and discomfort which poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: The Administrator will develop and implement staff training regarding proper documentation of resident's decline in health and procedures in reporting the residents decline in health. Administrator will provide a staff sign in sheet when staff has completed the training.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 12, 2024

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in... physical,..functioning &...assistance is provided... When changes...are observed, the licensee shall ensure that changes are brought to attention of resident's physician... This requirement was not met as evidenced by: Staff interviews revealed the changes in R1's health were not brought to the physician's attention in a timely manner, which poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 1, 2024

Plan of correction: The Administrator will develop and implement staff training regarding proper documentation of resident's decline in health and procedures in reporting the residents' decline in health. Administrator will provide a staff sign in sheet when staff has completed the training.

Allegation investigated: Resident sustained multiple pressure injuries due to staff's negligence

Licensing Program Analyst Melissa Spaeth (LPA) conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA was greeted by the Administrator. On 1/04/2023, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch as an assignment to investigate the complaint on 01/05/2023. The investigation consisted of the following: On 01/06/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested resident’s documentation, the resident roster, and the staff roster. During LPA’s visit, LPA received the requested documentation. Continued 9099-C Substantiated A complete investigation was conducted by IB Investigator, Jose Santana. During the course of the investigation, Investigator Santana interviewed the administrator, resident(s), and staff members. Investigator Santana also interviewed a hospital staff member and received hospital medical records. Regarding the allegation: Resident sustained multiple pressure injuries due to staff's negligence - It’s being alleged that a resident has multiple pressure injuries. Some of the pressure wounds were severe with dead skin tissue and were labeled as necrotic. It was reported that staff were not rotating the resident or helping the resident out of bed after the resident became bed bound. Medical records revealed the resident had multiple wounds including unstageable pressure injuries to the left medial thigh, right hip, and left hip. Hospice and a wound specialist records stated the resident received care when the resident’s pressure injuries developed. The facility and hospice records indicate the resident developed a deep tissue pressure injury to the left medial thigh around 12/17/2022 and another DTPI on the resident’s right lateral hip on 12/20/2022. Between 12/20/2022 and 12/29/2022, the wounds became unstageable. Facility records indicated on 12/30/2022, the resident developed a new unstageable pressure injury on the resident’s left hip. Facility caregivers stated they repositioned the resident every two hours. However, the hospice nurse and wound specialist believe the resident’s comorbidities may have contributed to the development and progression of the pressure injuries due to staff not repositioning the resident every two hours. The resident stated facility staff members were only repositioning the resident two times per day. IB Investigator interviewed the physical therapist on 2/28/2023 who stated that physical therapy was discontinued July, 2022 but stated the resident needed to continue physical therapy. The resident stated to the resident’s nurse practitioner that the resident was bed bound and wanted physical therapy. Facility staff denied being aware of the resident’s request. However, the facility did not ensure the resident’s physical needs were met. Due to the resident’s worsening leg contractures and increasing leg pain, the resident was unable to reposition themselves in bed. The resident experienced severe pain when caregivers attempted to reposition the resident which resulted in the resident’s refusal to be repositioned. Per Title 22 Regulations, a facility may provide care to residents who have contractures, provided that “the contractures do not severely affect functional ability and care and/or supervision is provided by an appropriately skilled professional.” A facility is also required to keep a written record of care, including documentation from a physician of the contracture’s stability, and method of intervention. The facility retained the resident despite the resident’s leg contractures that kept them from walking, failed to ensure the resident received adequate intervention while on home health services, and did not keep a written record of the limited intervention they did receive. The investigation revealed the facility contributed to the resident’s pressure injuries by not adequately addressing their contractures. The allegation that facility Neglect/Lack of Supervision contributed to the development of the resident’s pressure injuries is therefore substantiated. An immediate Civil Penalty of $500.00 is being issued today, due to the staff’s negligence. Refer to LIC 421M. At this time an Enhanced Civil Penalty (ECP) determination is pending and may be assessed at a later date. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 31-AS-20230104135833

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Feb 19, 2024

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, ... those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 pressure injuries. This requirement is not met as evidenced by: Facility staff failed to adequately address the resident’s pressure injuries which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Administrator will provide staff training regarding proper documentation for repositioning residents in care. Administrator will provide staff sign in sheet for the training provided. During todays visit LPA issued a Civil Penalty of $500.

Allegation investigated: Staff did not ensure a safe environment for resident in care.

On 01/10/2024 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegation. LPA arrived at 10:00 a.m. and met with Administrator, Jessica Pelaya. LPA explained to Jessica the reason for the visit. An entrance interview was conducted. At 10:26 a.m. LPA interviewed the weekend administrator designee Edgar Cruz present during the incident in question. At approximately 10:35 a.m. LPA conducted a physical plant tour of the facility and interviewed resident #3 (R3) and resident #4 (R4) who may have information pertaining to residents in question (resident #1 (R1) and resident #2 (R2)). At approximately 11:20 a.m. LPA Rios obtained and reviewed copies of residents' record, resident roster and staff roster. At approximately 11:30 a.m. LPA conducted interviews with seven (7) other residents. At approximately 1:00 p.m. LPA interviewed R1's relative and staff #1 (S1). Allegation: Staff did not ensure a safe environment for resident in care. It is alleged resident #1 (R1) was hit on the head repeatedly by resident #2 (R2). (Continued on LIC9099-C) Unsubstantiated Interview conducted with the weekend administrator Edgar Cruz revealed R1 had reported to staff, R2 had hit R1 on the head with a stick 11 times. According to Edgar, R1 reported the incident and R1 had a wound on his right hand so the facility sent R1 to the emergency room to receive medical attention. Edgar reported R1 was not observed to have injuries on their head or bleeding from their head. Edgar reported he interviewed R2 and R2 denied hitting R1. According to Edgar the police arrived to the facility and after they were done questioning the residents, they requested the facility separate the residents. According to Edgar their where not witnesses to the incident. LPA contacted R1, R1 states they were hit by their roommate. R1's relative informed LPA, R1 had mentioned in November that their roommate was already causing trouble. LPA attempted to interview R2, but R2 had moved out of the facility on 01/09/2024 and did not leave contact information. Interview with R1's current roommate R3, revealed they have been hit on the back by R1 without provocation and could not recall if they had reported it to staff. Interview with R2's last roommate, R4, revealed they did not have any physical or verbal altercations with R2 prior to R2's departure. R4 revealed R2 would come to the room "drunk'' and would sleep most of the time. Interview with administrator corroborates R2 would return from the community inebriated. Interview with the administrator Jessica revealed they were not present during the incident in question and had heard about it afterwards. Administrator did not want to infer if R2 did or did not hit R2 on the head but denied the allegation the facility did not ensure a safe environment for resident in care. According to the administrator R1 was temporarily removed from the room as a precaution and eventually R2 agreed to move to a different room. According to administrator their has been no incidents involving R1 and R2 prior to the one mentioned on this complaint. LPA's interview with other residents did not corroborate the allegation. LPA Rios review of the discharge paperwork dated 12/09/2023, did not report any head injuries on R1. Based on the information obtained, LPA could not find a corroborating witness to the incident. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview conducted. No deficiencies were cited. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 10, 2024 · control 31-AS-20240103123503

Type of visit: Case Management - Deficiencies

On 01/10/2024 at 2:14 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced case management - deficiencies visit in conjunction to complaint control number #31-AS-20240103123503. During complaint investigation, the following was discovered: During interviews with staff it was revealed resident was sent to the hospital with an injury to his right hand and resident #1 (R1) had reported the injury was caused by an altercation with another resident. Staff report the administrator was notified but a special incident report was not submitted to the department. LPA could not find a report made by the facility in the regional office database. Administrator confirmed they did not submit a special incident report. Deficiencies issued (refer to LIC809D). Civil Penalty assessed and issued (refer to LIC 421FC). Exit interview conducted. Appeal Rights provided. A copy of report was provided.the state’s words, verbatim · CDSS document, Jan 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 17, 2024

87211(a) Each licensee shall furnish to the licensing agency... the following:(1)A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the section cited above as evidence by a special incident report for R1 was not submitted to CCL which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Administrator will submit an incident report for the incident described on this report and a written statement that all incident reports will be reported in a timely manner by poc due.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and met with the Administrator. LPA stated the purpose of the visit is to obtain a copy of a resident's (R1) documentation. LPA Spaeth received a copy of R1's Admissions Agreement. The Administrator stated the specific documentation requested would be sent to LPA Spaeth via email by Friday, 1/05/2023. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Jan 3, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA Spaeth stated the purpose of the visit was to confirm the facility has completed the Fire Inspector, Jay Marietta’s request for the following procedures be completed by December 18, 2023. - Maintain records of periodic testing and maintenance of the fire alarms. LPA received a copy of the Inspection, Testing and Maintenance Cover Sheet from the contractor, Fletcher’s Fire Protection dated July 25, 2023 which is documentation confirming the fire alarm had been tested. - At 3:45 pm LPA observed the mid hallway doors that were installed on the second floor were removed. - AT 3:50 pm, LPA observed the inspection/license sign was displayed. There are no deficiencies to report at this time. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Dec 20, 2023

Allegation investigated: Staff does not allow resident to have visitors. Staff are listening in on resident's private phone conversations.

On 11/21/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit for the above allegations. LPA arrived at 1:30 p.m. and was greeted by Administrator, Jessica Pelaya. LPA explained to Jessica the reason for the visit. An entrance interview was conducted. At 1:50 p.m. LPA conducted a physical plant tour of the facility with Jessica. LPA requested copies of the facility resident roster and staff roster. At approximately 2:00 p.m. LPA interviewed resident #1 (R1), the resident mentioned in this complaint and randomly selected six (6) other residents to interview. LPA also interviewed staff #1 (S1) at reception responsible for answering calls and dialing phone numbers for residents on the community telephones. At 2:26 p.m. LPA observed a family member in the lobby requesting to visit with a resident at this facility. LPA observed S1 at reception take the family member into the facility for a visit. Receptionist returned to the lobby a little while later. LPA confirmed with receptionist they walked the family member to where the resident was. (Cont. to LIC9099-C) Unsubstantiated (Cont. from LIC9099) Allegation #1: Staff does not allow resident to have visitors. It is alleged the facility has allowed R1's family member, to determine who visits or gets information about R1. To investigate the allegation LPA interviewed R1. Interview with R1 revealed they are allowed visitors. When LPA asked if the facility had ever denied them a visitor, R1 responded, they didn't know anything about that. LPA's interview with Jessica revealed R1 is not conserved and due to resident's rights family members would not be able to request the facility to keep visitors from meeting with resident unless the resident makes such request. LPA reviewed R1's admission agreement, visitor's policy section. According to Jessica due to HIPPA laws facility is not allowed to share personal information about a resident to individuals in the public requesting personal information about the resident unless the resident gives facility permission to do so. Interviews with residents revealed they are allowed visitors and the facility has not denied them visitors. Based on interviews and LPA's observation this allegation is deemed Unsubstantiated at this time. Allegation #2: Staff are listening in on resident's private phone conversations. It is alleged staff listen in on R1's phone calls. To investigate the allegation LPA interviewed R1. Interview with R1 revealed they take personal calls on the community telephone. According to R1 they can take and make calls to whoever they want. When LPA asked if R1 has ever not answered a personal call or has hung up a telephone call R1 requested LPA to stop prying into their personal business. R1 went on to confirm they are comfortable taking calls here. When LPA asked R1, if they ever felt facility staff eavesdropped on their telephone conversations, R1 responded no. LPA interviews with various residents revealed if they use the community telephone they feel like they have privacy and they don't think staff are eavesdropping on their telephone conversations. Based on interviews this allegation is deemed Unsubstantiated at this time. Exit interview conducted. No deficiencies were cited. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 31-AS-20231115140007

Allegation investigated: Residents not provided with written notice of room changes Use unsanitary laundry practices Flooring in disrepair

On 11/03/2023 Licensing Program Analyst (LPA) Mariana Agban arrived at the facility to conduct an unannounced subsequent complaint investigation. Upon arrival, LPA was greeted by the administrator, and the purpose of the visit was explained. Allegation: Residents not provided with written notice of room changes It was alleged that residents have not been notified in writing regarding their move to other floors of the facility. Interview with the Administrator confirmed that residents have been notified only verbally regarding their move. LPA advised Administrator to provide written notices to all residents who will be moving to different areas in the facility. Based on observation and interviews the allegation is deemed Substantiated at this time Allegation: Flooring in disrepair During the physical plant tour on 10/23/23, LPA observed that floor in despair. LPA observed gaps in between the tile floor and cracks on the floor. (Continue on (9099C) Substantiated Interview with the Administrator revealed that during the remodeling of the floor, the previous workers had done "a poor job" of attaching the new tile on top of the old tile. Administrator stated that they have already been in contact with a contractor to fix the issue. Based on observation the allegation is deemed Substantiated at this time. Allegation: Use unsanitary laundry practices It was alleged that clean linen carts were tied with trash bags. Interview with Administrator confirmed the allegation. Administrator stated that they have talked to staff about cross-contamination to prevent the bug transmission from one room to another. LPM Gillyard observed towels on the floor during the physical plant tour on 10/23/23. Administrator stated that they will implement a new protocol regarding soiled linen. Based on observation the allegation is deemed Substantiated at this time. Exit interview conducted. Deficiencies cited and copy of this report delivered.the state’s words, verbatim · CDSS document, Nov 3, 2023 · control 31-AS-20231023143942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Nov 10, 2023

a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To written notice of any room changes at least 30 days in advance ... This requirement has not been met as evidenced by interviews the facility failed to provide written notices to residents which poses a potential safety risk to this resident in care.the state’s words, verbatim · CDSS document, Nov 3, 2023

Plan of correction: Administrator agreed to provide a statement of understanding for the regulation cited. Administrator will send a blank copy of the 30-day advanced notification of room change notice they will using in the facility via email by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 10, 2023

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 has not been met as evidenced by observation the facility has broken tiles which poses a potential safety risk to this resident in care.the state’s words, verbatim · CDSS document, Nov 3, 2023

Plan of correction: Administrator agreed to provide pictures of fixed floor by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 10, 2023

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 has not been met as evidenced by observation the broken LPM observed towels on the floor which poses a potential safety risk to this resident in care.the state’s words, verbatim · CDSS document, Nov 3, 2023

Plan of correction: Administrator agreed to provide a copy of the new protocol regarding soiled linens issued and signed by staff and email a copy by the POC date.

Allegation investigated: Due to insufficient staffing residents' needs are not being met.

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with administrator Jessica Pelaya and explained the reason for the visit. A physical plant tour was conducted by Regional Manager (RM) Angela Kendrick, Licensing Program Manager (LPM) Nichelle Gillyard, LPA Mariana Abagan and Long Term Care Ombudsman (LTCO) Caren Williams on 10/27/2023 at 9:40 a.m. for this complaint and complaint control #31-AS-20231023143942. Allegation #1: Due to insufficient staffing residents' needs are not being met. It is alleged that the facility is short of staff and therefore are not meeting residents' hygiene needs. During the physical plant tour LPM Gillyard observed resident #1(R1) in bedroom #250A lying on soiled bedsheets. R1's under garments were observed to be soiled. Interview with administrator revealed assistance for R1 had not been provided since staff was busy assisting another resident. (Continued on LIC9099-C) Substantiated (Continued from LIC9099) LPA's review of Unusual Incident Report submitted by administrator to Community Care Licensing (CCL) revealed R1 had a change in condition and now requires assistance with incontinent care. LPM observed one (1) staff on duty in the designated memory care unit which houses twenty-five (25) residents, of which fifteen (15) have cognitive impairment according to the administrator. Staff #1(S1) had to call another staff not already in the memory care unit for assistance. LPM interview with S1 revealed S1 is a med-tech and a caregiver. At the time of the interview S1 was working in the capacity of a med-tech and not as a caregiver. In addition, LPM observed resident #2 (R2) in room #109 calling out for assistance requesting assistance with incontinent care. LPA's review of Unusual Incident Report submitted by administrator revealed R2 had a change in condition and now requires assistance with incontinent care. LPA Rios interview with administrator Jessica at approximately 11:50 a.m. revealed staff are expected to log the times they assist residents with bathing. According to Jessica residents that require assistance with bathing, are bathed twice a week. According to Jessica, staff have been known to not document consistently when they assist residents with hygiene. The facility uses an electronic database Caring Data to log hygiene assistance provided to residents. Based on observation, record review and interviews conducted, the above allegation is found to be SUBSTANTIATED at this time. Deficiencies cited (refer to 9099-D). Exit interview was conducted with administrator. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 31-AS-20231025133939

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 30, 2023

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) and (R2) who required incontinant care and S1 was the only staff observed in the memory care unit to provide assistance which poses an immediate safety risk to this resident in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Administrator agreed to (1.) submit a staff schedule that addresses the supervision of residents in the memory care unit. When applicable resident’s care plans shall be updated, and staffing scheduling shall be reevaluated. (2.) Submit proof of future staff training i.e., needs and services of residents, resident care, and supervision.

Allegation investigated: Hazardous equipment left accessible to residents in care. Use of locked/delayed egress/digress without required fire clearance. Use of common bathing implements

On 10/27/23 Licensing Program Analysts (LPA) Mariana Agban and Licensing Program Manager (LPM) NIchelle Gillyard and Regional Manager (RM) Angela Kendrick arrived at the above facility to conduct initial complaint visit. Licensing team was joined by Caren William LTCOP and upon entrance met with the Administrator and explain the reason of the visit. At approximately 9:45 AM Licensing team and LTCOP conducted a physical plant tour, to ensure health and safety of the residents are protected with Title 22 Regulations. Allegation: Hazardous equipment left accessible to residents in care. It was alleged that facility used propane tanks in residents room for bedbugs treatment. Interview with the administrator confirmed the use of propane tanks to treat bedbugs. Licensing team advised Administrator to hire a licensed company to treat bedbugs and other pests issues. Administrator stated that all propane tanks were used in empty rooms where residents were out of the room. Administrator additionally stated that the propane tanks are currently locked in the maintenance room and residents have no access to them. Substantiated Allegation: Use of locked/delayed egress/digress without required fire clearance. It was alleged that the second floor has egress door that was locked preventing residents and staff to enter and or exit. LPA file review revealed that facility has not obtained fire clearance for egress/digress door. Interview with the Administrator revealed that LIC200 has not been submit to CCLD at this time and the door was installed about a month ago. Allegation: Use of common bathing implements. It was alleged that the facility uses the same loofa for the residents in the shower room. Licensing team observed there's only one loofa is being used in the shower room during the physical plant tour. It was also observed same towels being used for multiple residents and an open trash can without lid and unclean shower floor without nonskid mat in the shower. Due to time constrains LPA is unable to complete the investigation. The Administrator was informed that additional visit will follow to render final findings. Exit interview conducted. Deficiencies and civil penalty issued and copy of this report delivered.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 31-AS-20231023143942

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Oct 30, 2023

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by:the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Administrator agreed to lock all the propane tanks and hire a professional company to treat pests issue.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(2) · Plan of correction due date: Oct 30, 2023

87705(k)(2)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of delayed egress devices. This requirement has not been met as evidence by LPA's observation. Facility failed to notify CCLD and provide a complete LIC 200 form within the appropriate time framethe state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Administrator agreed to sumbit LIC 200 by the POC date and email the LPA a copy of complete LIC 200.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Oct 30, 2023

(a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: based on LPAs obervation the facility failed to provide hygine items to residents.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Administrator agreed to purchase new non skit matts and provide picture of new loofahs/bath cloths for residents and provide enough towels for the capacity of the facility and trash pins with lids in the shower rooms. Administrator will submit to LPA a proof of purchase and a picture of towels and loofas by the POC date

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Evelin Rios and Mariana Agban conducted an unannounced Case Management - Deficiencies visit in conjunction to Complaint #31-AS-20231025133939 and 31-AS-20231023143942. LPAs met with administrator and explained the purpose of the visit. LPA Agban toured the facility at 9:40 a.m. with the Administrator and observed the following: At 10:05 a.m., LPA observed chemicals for cleaning in a cart in a hallway in the designated memory care unit unattended. LPA observed a housekeeper in a resident's room cleaning. LPA observed housekeeper did not have a line of sight of chemicals used for cleaning. Based upon LPA's observations a deficiency was cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights and a copy of the report provided to Administrator.the state’s words, verbatim · CDSS document, Oct 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Oct 28, 2023

87705(f)(2) Care of persons with Dementia Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observation chemicals used for cleaning where left unattended in a hallway in the designated memory care unit accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: The Administrator agreed to purchase either a lock box or carts with compartments that lock Proof of purchase and picture must be submitted to LPA by POC date.

Allegation investigated: Resident belongings are not being safeguarded. Staff withholding residents PNI funds Staff not providing a safe environment for resident.

This is an amended copy of the report previously issued on 9/10/2021 and 10/20/2022. This report supersedes reports previously issued. The findings for this complaint remain the same. Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. At the time of the initial visit, LPA signed in at the sign in station and was greeted by Administrator Jessica Pelaya. LPA explained to Administrator the above allegations. The investigation consisted of the following: On 9/10/2021, LPA Spaeth conducted a 10-day visit, toured the physical plant, requested documents, interviewed Administrator and client (C1). On 10/20/2022, LPA interviewed staff, clients, and Administrator. Unsubstantiated Regarding the allegation: Resident belongings are not being safeguarded. It’s being alleged that staff wanted clients to leave their doors open and a client (C1) stated their personal belongings were missing. C1 was interviewed and stated they left the facility, observed Administrator locked their door when they left, returned, and observed items were missing. LPA interviewed the Administrator and three staff members who stated there were no clients who reported personal items missing from their room. Staff also stated some clients do not lock their rooms when leaving. Clients are encouraged by staff to always lock their room door. LPA interviewed thirteen clients who stated staff always encourage clients to lock their room door when leaving. The thirteen clients stated they did not have any personal items missing because they lock their own rooms. Facility confirmed residents are responsible for their personal belongings. Regarding the allegation: Staff withholding residents personal and incidental funds (P&I). It’s being alleged that a client did not receive P&I for the last three months. During LPA’s 9/10/2021 visit, LPA spoke to C1 who stated P&I was up to date. LPA interviewed thirteen clients who stated there have not been any issues regarding receipt of P&I. LPA interviewed five staff members who stated clients receive P&I and there have not been any reports from clients stating there are issues with their P&I. Staff (S5) stated they give P&I to clients twice a month. LPA Spaeth received copies of the P&I ledgers on 10/06/2023. LPA observed the P&I ledger which indicates each client received P&I twice a month, the clients signed the report indicating they received the money and the P&I balance is up to date and accurate. Regarding the allegation: Staff not providing a safe environment for a resident. It’s being alleged a client has been bullying other residents and been bullying C1. LPA interviewed C1 who stated other client did not hit C1 and stated C1 and the other client worked out their differences. LPA interviewed thirteen clients who stated another client has not bullied them. LPA interviewed five staff members who stated clients have not reported abuse by another resident. Based on LPA’s observation, interviews conducted, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 31-AS-20210909151146