Leisure Living Inc.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with staff Tina Santos and explained the reason for the visit. Administrator was also notified of the LPA's visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance. KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Bedrooms were furnished appropriately; beds were observed with clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 10:30 a.m., water temperature measured at 112.8 F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Smoke detectors and common monoxide detector were operable at the time of the visit. Fireplace in the living room was covered. Fire extinguishers were fully charged and purchased 10/2021. The backyard had furniture and a covered area for resident use. The side gate door was self-latching. No bodies of water noted. The garage is attached, but was locked. Inside the garage was the washer and dryer, cleaning supplies, and Personal Protection Equipment (PPE). INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and in the facility. The facility’s cleaning protocol is sufficient. Staff continue to document temperatures of staff and residents on a daily basis. There was record of staff and resident vaccinations. The LPA discussed department changes around testing, visitation and vaccine requirements. The policies and procedures pertaining to infection control were adequate. No deficiencies. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 30, 2022

Allegation investigated: Staff are not following masking protocols to prevent the spread of COVID-19

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10-day visit. The LPA met with staff and explained the reason for the visit. To investigate, the LPA conducted a physical plant tour at 8:30 a.m., and interviewed staff at 8:35 a.m., 9:05 a.m., 9:10 a.m., and 9:17 a.m. It was alleged that staff in the facility were not wearing masks while in close contact with the residents. Upon arrival to the facility, the three staff on site, including Staff #1 (S1) were wearing masks. Yet information obtained from a credible witness confirmed on 5/10/2022, a credible witness noted that S1 and other staff were not wearing masks while in close proximity of residents. Per conversations with staff, the licensees are conducting an in-service for all the facilities under the licensee's jurisdiction. Based on the investigation, there is sufficient evidence to support the claim that staff were not following masking protocols to prevent the spread of COVID-19. This allegation is deemed Substantiated at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D). Exit interview conducted. A copy of the report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Jun 7, 2022 · control 29-AS-20220606165124

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 9, 2022

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: This requirement was not met as evidenced by: Based on observations from a credible witness, the licensee did not comply with the section cited above, as staff were not wearing face masks in the facility, which poses an immediate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 7, 2022

Plan of correction: The Administrator agreed to do the following: Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 6/9/2022.

Type of visit: Office

An Informal Conference was conducted today in the Woodland Hills North Adult and Senior Care Regional Office. The purpose of this Informal Conference is to discuss deficiencies cited in complaint control #29-AS-20210604095550 and complaint control #31-AS-20200316103126. Present at today's meeting included licensee representatives Ross Hashemi Pam Hashemi, and Michelle Maurer, Licensing Program Manager (LPM) Jeralyn Pfannenstiel and Licensing Program Analyst (LPA) Ashley Smith. The informal conference process was explained to the licenses. The licenses was also informed that this Informal Conference is a part of the administrative action process and that further citations may result in a Non-Compliance Conference, which could lead to a referral for Administrative Review by the Department. Brief History: The facility was first licensed in 11/15/2002, for a capacity of six residents. LPM Pfannenstiel discussed deficiencies cited during the complaint investigation, which included failure to assist residents with the self-administration of medication as prescribed, failure to follow the hospice care plan as described; failure to ensure that the facility was kept in good repair; and, failure to issue a legal eviction. At this time, the licensee has cleared the Plan of Corrections in a timely manner. All parties discussed the complaint investigation and potential ramifications of the complaint findings. The licensee communicated their due diligence in maintaining voluntary compliance with applicable licensing regulations. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 4, 2022

Allegation investigated: Staff are not properly trained. Staff did not seek timely medical treatment for resident in care. Staff mismanaged resident's medication(s).

Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint inspection to deliver the findings for the above allegations. The LPA met with staff Tina Santos and explained the reason for the visit. Administrator Michelle Maurer was notified regarding the reason for the visit. During the initial visit conducted on 6/11/2021, the LPA conducted a physical plant tour at 12:03pm, reviewed records at 12:17pm, conducted interviews at 12:29pm, 12:39pm, and 1:12pm; and, reviewed the medication closet along with staff at 12:56pm. In addition, the LPA interviewed a medical professional whom provided care for Resident #1 (R1) on 11/09/2021 at 10:02 a.m. During a subsequent visit on 3/25/2022, the LPA conducted a physical plant tour at 11:30 a.m., reviewed facility records at 12:00 p.m., reviewed the facility file at 1:05 p.m., and conducted interviews at 11:25 a.m. Lastly, the LPA subpoenaed medical records pertaining to the case. Substantiated Regarding the allegations: Staff did not seek timely medical treatment for resident in care AND Staff are not properly trained. It was alleged that on 5/19/2021, timely medical attention was delayed for R1 as staff called the wrong hospice agency when R1 had episodes of vomiting. Interviews and records review revealed that on 5/19/2021 at approximately 1:00 a.m., R1 began to vomit intermittently. Staff #2 (S2) was working night shift at that time and therefore was tasked with identifying the medication to treat R1’s condition. However, S2 was unable to find the medication needed for R1’s vomiting. It was discovered that the medication needed for R1 was in the hospice comfort kit, which is separate from R1’s routine medication. S2 did not know this at the time. During this time, S2 attempted to call R1’s hospice agency to inform them of R1’s condition. However, interviews confirmed that S2 was calling the wrong hospice agency. Interviews confirmed that the licensee posts important numbers on the wall as it was intended to be easily accessible for staff. However, it was revealed that R1’s hospice agency had changed and the name of the hospice agency that was posted on the contact sheet on the wall had not been updated. It wasn’t until R1’s family member arrived and informed S2 that they were calling the wrong hospice agency that the correct agency was contacted. Staff admitted that the numbers on the wall were not updated; rather than S2 grabbing R1’s hospice folder, S2 was mistakenly calling the wrong number. Once R1’s family member contacted the correct hospice agency, the hospice nurse arrived at approximately 3:00 a.m. Based on the information obtained, due to S2 mistakenly calling the wrong hospice agency, there was a delay in R1 receiving timely medical attention. In addition, S2 did not know that the medication to treat R1’s vomiting was placed in the hospice comfort kit, which caused a delay in R1 receiving the necessary medication. Whereas S2’s training hours were up to date at the time of the incident, S2 was unable to locate the medications without assistance, nor did S2 know to obtain R1’s hospice folder in emergency situations. Interviews revealed that whereas many of the staff were aware of the hospice contact, S2 was unaware. Records confirmed that R1 had been with this specific hospice agency since 12/29/2020, and the incident took place in May 2021. All staff are expected to be trained and up-to-date regarding a resident’s hospice care plan, including knowledge of the resident’s primary contact person at the hospice agency. As it pertains to the protocol surrounding the care, services, and necessary medical intervention needed for R1, the allegation ‘Staff are not properly trained’ is Substantiated at this time. In addition, allegation ‘Staff did not seek timely medical treatment for resident in care’ is Substantiated at this time. Regarding the allegation: staff mismanaged resident’s medication It was alleged that R1 did not receive medication as prescribed. In addition, it was alleged that staff were unable to locate medication, which caused a delay in R1 receiving their medication timely. Interviews and records review revealed that on 5/19/2021 at approximately 1:00 a.m., R1 was experiencing episodes of vomiting. The investigation revealed that Staff #2 (S2) was working night shift at that time, however, S2 was unable to find the medication needed for R1’s vomiting. It was further discovered that the medication needed for R1 was in the hospice comfort kit. However, S2 did not know this at the time. The investigation further revealed that on 5/19/2021 at approximately 11:00 a.m., the hospice nurse assisted R1 with the self-administration of Morphine and Lorazepam. Interviews revealed that later in the afternoon, R1 once again began to vomit. Interviews revealed inconsistent details regarding how often R1 should receive assistance with the self-administration of Morphine. Whereas staff believed R1 could receive Morphine every six hours, a review of the prescription confirmed that as of 5/19/2021, R1 had an order to receive Morphine and Lorazepam every four hours. The investigation revealed that at approximately 4:00 p.m. on 5/19/2021, the hospice nurse advised S1 to assist R1 with the self-administration of medication – specifically Morphine and Lorazepam. However, records review and interviews revealed that S1 did not assist R1 with the self-administration of medication until approximately 5:00 - 5:30 p.m., when the hospice nurse called S1 a second time to check on R1’s condition. Based on the information obtained, there is sufficient evidence to support the claim that staff mismanaged resident’s medication. This allegation is deemed Substantiated at this time. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. Exit interview conducted with both Tina Santos and Administrator Michelle Maurer. A copy of the report was issued, along with appeal rights.the state’s words, verbatim · CDSS document, Apr 22, 2022 · control 29-AS-20210604095550

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 25, 2022

87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not assist R1 with the self-administration of medication in a timely manner, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2022

Plan of correction: The Administrator agreed to do the following: 1. Submit a Statement of Understanding, indicating how the facility will maintain compliance with the duties and responsibilities of assisting residents with the self-administration of medications. Submit statement by 4/25/2022. 2. Conduct a medications training with staff, including those who work during the night shift. Training needs to be completed by an appropriately skilled professional (ie. LVN, RN). Submit sign in sheet no later than 5/6/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(b)(4) · Plan of correction due date: Apr 25, 2022

87633(b)(4) Hospice Care of Terminally Ill Residents. A current ... hospice care plan shall … include...: (4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff were unable to fulfill duties pertaining to contacting the appropriate agency or locating medication, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2022

Plan of correction: The Administrator agreed to the following: 1. Submit a Statement of Understanding, indicating how the facility will maintain compliance with the duties and responsibilities of caring for residents receiving hospice services. Submit statement by 4/25/2022. 2. Conduct an in-service training with staff, including those who work during the night shift. Review the duties and responsibilities pertaining to residents receiving hospice services. Submit sign in sheet no later than 5/6/2022.

Allegation investigated: Facility is dirty. Staff are sleeping in common spaces in the facility Staff failed to safeguard resident's personal belongings upon death of a resident

Licensing Program Analyst (LPA) Ashley Smith conducted a subsequent complaint inspection. The LPA met with staff Tina Santos and explained the reason for the visit. Administrator Michelle Maurer was notified regarding the reason for the visit. During the initial visit conducted on 6/11/2021, the LPA conducted a physical plant tour at 12:03 p.m., reviewed records at 12:17 p.m., conducted interviews at 12:29 p.m., 12:39 p.m., and 1:12 p.m.; and, reviewed the medication closet along with staff at 12:56 p.m. In addition, the LPA interviewed a medical professional whom provided care for Resident #1 (R1) on 11/09/2021 at 10:02 a.m. During today’s visit, the LPA conducted a physical plant tour at 11:30 a.m., reviewed facility records at 12:00 p.m., reviewed the facility file at 1:05 p.m., and conducted interviews at 11:25 a.m. and 12:10 p.m. Unsubstantiated Regarding the allegation: Facility is dirty It was alleged that the facility was dirty, and that resident belongings were covered in dust. During an initial visit conducted on 6/11/2021, the LPA conducted a physical plant tour and observed the facility to be clean. Resident personal items were observed, and they appeared to be well maintained and were not coated in dust at the time of the visit. However, interviews with staff revealed that prior to the 6/11/2021 visit, the facility had recently undergone a deep cleaning. Hence, during today’s visit, the LPA conducted a physical plant tour of all resident rooms and common spaces. Areas observed included the common areas, dining room, kitchen, resident bedrooms, bathrooms, baseboards, countertops, and resident personal care items. During today’s visit, areas were observed to be appropriately cleaned and the LPA did not observe dirty or unsanitary areas.. Yet, it was further alleged that due to the presence of bed bugs, the facility was unclean. The facility was cited for having bed bugs on 6/11/2021, in which the licensee cleared the deficiency and treated the facility in a timely manner. However, the presence of bed bugs is not a direct correlation or indication of a ‘dirty’ facility, as bed bugs can unknowingly travel into a location via clothing, luggage, purses, backpacks, or other items. Based on the information obtained through the course of the investigation, there is insufficient evidence to support the claim that the facility is dirty. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff are sleeping in common spaces in the facility It was alleged that staff were sleeping in the garage and in the reclining chairs in the living room. Staff interviews revealed that there is a staff room, which is adjacent to the garage. Staff interviews claimed that they slept in their designated room. During the 6/11/2021 visit, the LPA observed the staff room, which is accessible via the garage door. The LPA reviewed the facility file to identify if the staff quarters were indicated on the facility sketch and approved by the Department. The facility file review revealed that the bedroom, which is accessible through the garage, was identified and approved as a staff room since 2003. Information obtained from interviews with representatives from collateral agencies whom had been in the facility denied claims that staff were observed sleeping in common spaces. Based on the information obtained through the course of the investigation, there is insufficient evidence to support the claim that staff are sleeping in common spaces in the facility. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff failed to safeguard resident's personal belongings upon death of a resident It was alleged that upon the passing of R1, staff removed items that were placed in Resident #1’s (R1) personal trash baskets. Information obtained revealed that as R1 passed away on 5/19/2021, staff had begun cleaning R1’s room and had emptied R1’s personal trash baskets. Staff interviews revealed that staff were unaware that R1 had stored personal belongings in the trash can and had assumed that items in the trash cans needed to be disposed. Additional interviews revealed that staff were able to retrieve the items that were removed from the R1’s personal trash can, and they were given to R1’s responsible party. Whereas the personal trash cans belonged to R1, staff claimed they were unaware that R1 kept personal items in the trash can and assumed items in the trash can were disposable. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff failed to safeguard resident's personal belongings upon death of a resident. Upon notice that the items in the trash can belonged to R1, staff were able to retrieve the items in a timely manner. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted with both Tina Santos and Administrator Michelle Maurer. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 25, 2022 · control 29-AS-20210604095550

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.