Maravilla

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Inspection to the above-named facility. LPA was greeted by Anna Munoz, Director of Assisted Living and explained the purpose of the visit. Christina Martinez, Director of Enliven (Memory Care) participated in the inspection. Ruth Grande, Administrator, participated in the inspection at approximately 1:15 PM. Entrance interview conducted. The facility is a three-story Residential Care Facility for the Elderly (RCFE) with a hospice waiver for 20. Currently, there are 22 residents with a dementia diagnosis, 10 residents on hospice, and 4 residents on oxygen. There are no residents who are bedridden resident at this time. The facility entrance consists of a large lobby, a concierge desk for check-in, and a hallway at the right of the lobby leading to the administration offices. Immediately past the concierge’s desk is a stairway that leads to the residential area. Residents participate independently in live entertainment and music, worship support, exercise activities, card games, lectures, Resident Council Townhall meetings, Bingo, art, reading club, pet therapy, arts and crafts, and outings to parks, restaurants, shopping excursions, museums, theater events, and other local attractions. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Health Screenings. Please continue to 809-C, Pg 2. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety and other hazards. LPA observed elevator #2 is currently out of order. LPA observed the front first floor restroom is currently out of order due to a slow leak. The leak also affects the front second floor restroom. Personnel Records were reviewed. Record review revealed Personnel Record (Application), Health Screening, and trainings including Dementia, Postural Supports, and General Topics. At approximately 2:59 pm, record review revealed Staff 1 (S1) was no longer associated to the facility as of 12/30/2025. Administrator Ruth Grande stated S1 has worked at the facility since 11/1/2024. Administrator further stated S1 was disassociated in error when disassociating another staff with a similar last name. During today’s visit, Administrator completed the association process for S1. Due to time restraints, LPA will return at a later date to continue the annual inspection. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 24, 2026

Allegation investigated: Staff left residents in soiled diapers for an extended period of time. Staff did not communicate with resident's authorized representative in a timely manner.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the allegations. LPA met with Director of AL Anna Munoz and explained the purpose of the visit. LPA Kristin Kontilis conducted the initial 10-day complaint visit on 09/25/2024 and collected records. LPA Kontilis interviewed Witness 09/27/2024 and 10/11/2024. LPA De Leon reviewed complaint records on 08/01/2025 and 08/02/2025. LPA De Leon emailed the Administrator on 08/02/2025 asking a few questions and requesting additional documentation. LPA received an email from the Administrator on 08/07/2025 answering questions and providing additional documentation. LPA De Leon reviewed additional records on 08/11/2025 and made a subsequent complaint visit on 10/14/2025 to conduct additonal interviews. Continued 9099-C Substantiated On the allegation: Staff left residents in soiled diapers for an extended period of time. The administrator stated our goal is to respond to call lights usually within 10 minutes, many times when residents use their call button it is not always an emergency. LPA De Leon reviewed Call Pendant Logs from 09/06/2024-09/25/2024 (20 Days) for Assisted Living only at the facility which revealed over 555 pendant call logs showed a clear time from 15 minutes to 81 minutes. Witness 1 (W1) stated resident 1 (R1) needs assistance with toileting and on several occasions the resident has had to sit soiled for 45 plus minutes after requesting help by pressing the pendant call button. R1 had a total of 91 calls during the 20-day period review of the logs which revealed 11 call button calls over 15 minutes to 31 minutes. LPA reviewed call button logs and for calls over 15 minutes requested and reviewed 42 resident care plans. The care plans were reviewed for Toileting which revealed out of 42 residents 15 residents had a care plan for Extensive Assistance with Toileting, 5 residents were Total Assistance with Toileting, 5 residents had Moderate/Minimal Assistance with Toileting, and 17 residents were Independent with Toileting and out of those residents 10 may still call for help if needed or needed reminders or queuing and 5 residents were completely Independent in toileting. LPA reviewed a recent call button logs for assisted living from 08/01/2025-08/07/2025 for 7 days which revealed a large amount of calls over 15 minutes and up to 40 minutes. Staff interviewed revealed in 2024 they were short staffed and as of recently are filling positions and it is getting better. Agency staff were largely used in 2024 and have been cut back some, but the facility is still using agency staff to fill in for vacant, vacations or sick call offs when needed. Staff said it is their goal to answer call buttons within 10 minutes, but that time cannot always be maintained due to the needs of the residents as many residents need standby assistance, 1 or 2-person staff transfers and 2-person Hoyer lifts. Staff said they do get a list of residents that they are responsible for daily meeting their needs but when call button alarms come in and they are busy caring for a resident they cannot take the call, and the next available caregiver takes it. Resident interviews revealed when the call button is used, and it can take a long time to get assistance. They feel the facility needs more staffing and staff at the facility work hard and try to get everything done for the residents but at times it can take a while. Residents also stated the Agency staff do not do as good of job, only do the bare minimum and are not as caring as the regular facility staff. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Staff did not communicate with resident's authorized representative in a timely manner. LPA interviewed Staff and residents which revealed the resident’s responsible parties are notified of an incident by the medication technicians (Med-Tech) or the Nurse. Most felt the notifications are being made. R1’s responsible party (RP) said there was an incident in June and September 2024 with R1 and the RP was not notified. Community Care Licensing (CCL) was provided with incident reports for both of those incidents and on the paperwork, it was written the RP was notified by leaving a voice mail message. The RP said she did not have voicemail left on either incident. A staff stated sometimes during shift change or when an emergency happens, they do feel all RP’s or families are notified because of shift change and the communication between the Med-Techs, other med-techs coming on shift and Nurse is not always good. LPA requested incident reports from the facility for the months of June and September 2024 and only 1 report was provided for R1, LPA asked again for any other reports and was told there were not any, even though in CCL records two reports were sent by the facility for R1. A recent complaint was filed and one of the allegations was regarding the reporting of incidents to the RP or family in which family members were not notified. Based on the evidence this allegation is Substantiated at this time. This will not be cited in this report due to being cited on other complaint. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Director of AL.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 29-AS-20240918090505

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 28, 2025

(a)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interviews the Licensee did not comply with the regualtion above residents call button are not answered timely which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Admnistrator agreed to audit call button and care plans and make sure the staffing is sufficent for the needs of the residents, review policy and procdures with staff as well as trian all staff in personal rights 87468.2 provide proof of trianing an an up to date Lic 500 to CCL.

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff did not notify resident's responsible party of an incident.

Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above. LPA met with Anna Munoz Director of Assisted Living and explained the purpose of the visit. LPA Kontilis started the investigation on 09/05/2025. During the visit, LPA obtained documents, and conducted interviews with staff and residents from 11:47am to 3:30pm. LPA Kontilis conducted additional interviews by phone on 09/08/2025, and LPA De Leon conducted interviews by phone on 08/11/2025, 08/27/2025, and 10/14/2025. On the allegation: Staff did not seek medical attention for a resident in care. It was alleged Resident 1 (R1) sustained a fall and did not get timely medical attention. Continued 9099-C Substantiated On 08/31/2025 at approximately 9pm, R1 was assisted into bed by staff. R1 uses a wheelchair and requires staff assistance and a hoyer lift to be transferred into bed. R1 fell out of bed and was unable to reach their call pendant. R1 was found on the floor by staff the following morning, 09/01/2025. The staff was unable to lift R1 and obtained help from another staff. On 09/02/2025, R1’s responsible party indicated R1 complained of hip pain but the staff had not called 911 nor had R1 transported to the hospital. It was also noted R1 was on blood thinners. R1’s responsible party stated a hospice nurse indicated the facility had not sent R1 to the hospital because they were on hospice and had a DNR. R1’s responsible party also stated R1 may have indicated they were fine, but they were previously disoriented due to a UTI and believes they should have been checked at a hospital. Staff interviewed indicated the facility contacts hospice to assess residents on hospice who are found on the floor or have a change in condition, unless the injury was very serious such as heavy bleeding or being unconscious, which would warrant a call to 911. LPA reviewed care notes for R1 that stated 09/01/2025 11:09pm, Alert Charting, resident found on floor. The charting states R1 used their pendant, and notes bruising and swelling to left hip, abrasion to left elbow and above left eyebrow; hospice and family called; placed on alert charting. Interview with R1 revealed they do not remember how they got on the floor, or how long they were on the floor. R1 stated they could not reach their pendant, but a staff found them and assisted them. R1 stated they had a couple places with “severe pain,” including their hip, but did not know how to get pain pills. R1 stated a hospice nurse came over before 6am and examined them including range of motion tests with twisting and turning. R1 stated the hospice nurse determined there was no fracture and they would be ok until they can be re-evaluated as necessary by a doctor. A facility nurse interviewed stated staff informed them of R1’s fall when they arrived on shift. The nurse stated once they went to R1’s room around 7am, the hospice nurse was already in the room examining R1. The nurse stated R1 stated he was not in any pain, but they did have injuries to their hip and head. The staff who found R1 on the floor stated they responded to their call button around 4am, found them on the floor, and sought additional staff to help get R1 up. Staff stated they saw the left hip bruise, scratches to the forehead and a “rug burn” on the forehead, but R1 did not express any pain. Staff stated R1 was awake and talking to them, able to explain what they wanted, and said they were fine, therefore they called hospice instead of 911. Staff stated hospice arrived around 7am to assess the resident. Continued 9099-C Administrator stated even if a resident is on hospice, they should have been sent to the hospital for any strike to the head. Administrator stated despite a resident being on hospice or despite a family requesting they not be sent out, a resident with a potential head injury should be sent out. Based on the evidence this allegation is deemed Substantiated at this time. On the allegation: Staff did not notify resident's responsible party of an incident. It was alleged R1’s responsible party was not notified of R1’s fall that occurred overnight between 08/31/2025 and 09/01/2025. R1’s responsible party indicated on 09/02/2025 they learned about the fall when they observed injuries on R1’s left side of face, above their eyes, on their arm and left hip. R1’s responsible party indicated on a previous hospital visit for R1, the facility attempted to contact the responsible party but was trying to call phone numbers no longer in use, and had old addresses. After this, R1’s responsible party provided a letter with updated contact information for themselves as well as contact information for another responsible party for R1. When interviewed, R1 stated no one contacted their responsible party to inform them of the fall. The staff who found R1 on the floor stated they do not know who called R1’s responsible party to notify them, but believed the Med Aide was responsible for calling hospice and responsible parties. Med Aide stated they tried to call both responsible parties a few times and the call would not go through. Med Aide stated they called the two numbers on R1’s contact information, and informed the nurse at the end of their shift they had tried calling. Administrator stated every year they send an email to responsible parties to ensure their contact information is up to date, and changes inputted get automatically updated in their system. Their system is accessible on a tablet that all care staff have access to, to ensure the most recent contact information is available. Staff interviewed indicated that sometimes families were not notified timely of incidents. Staff stated sometimes there is a breakdown in communication where they leave a voicemail, but after a shift change, the calls or follow ups are not always completed. Staff interviewed indicated manual updates for resident information do not get updated timely, mostly due to the facility being short staffed and focusing on other priorities. Continued 9099-C A responsible party for another resident was interviewed and indicated they had also not received notifications from staff for two falls a resident had sustained. LPA reviewed care notes for R1 that stated 09/01/2025 hospice and family were called due to the fall. The incident report submitted by the facility for the fall states on 09/01/2025 at 5:45am, notification was attempted to contact one of R1’s responsible parties, it states “no answer” and “did not leave a voice message.” Based on the evidence this allegation is deemed Substantiated at this time. Exit interview conducted, deficiencies cited, copy of report and appeal rights printed.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 29-AS-20250903130423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2 · Plan of correction due date: Oct 28, 2025

87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when they did not seek timely and appropriate medical attention for R1, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Representative agrees to review facility procedures for seeking timely medical attention and hold a training with all staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Oct 28, 2025

(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. Based on interview and record review, the licensee did not comply with the section cited when they did not inform R1’s responsible party of a fall with injury, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Representative agrees to review facility procedures for updating contact information timely and procedures for notifying responsible parties timely. Representative agrees to hold a training with all staff on the updated procedures

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Inspection to the above-named facility. LPA was greeted by Anna Munoz, Director of Assisted Living and explained the purpose of the visit. Ruth Grande, Administrator participated in the inspection at approximately 2:45 PM. Entrance interview conducted. The facility is a three-story Residential Care Facility for the Elderly (RCFE) with a hospice waiver for 20. Currently, there are 21 residents with a dementia diagnosis, 18 residents on hospice and 7 residents on oxygen. There are no bedridden residents at this time. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the facility for fire safety and other hazards. The facility entrance consists of a large lobby, a concierge desk for check-in, and a hallway at the right of the lobby leading to the administration offices. Immediately past the concierge’s desk is a stairway that leads to the residential area. Residents participate independently in live entertainment and music, worship support, exercise activities, card games, lectures, Resident Council Townhall meetings, Bingo, art, reading club, pet therapy, arts and crafts, and outings to parks, restaurants, shopping excursions, museums, theatre events, and other local attractions. The fire extinguishers were charged and last serviced on 12/9/2024. LPA observed elevators are in good working order. LPA observed the kitchen and dining area were clean and sanitary. LPA observed a sufficient amount of perishables for two days and non-perishables for seven days for all residents in care. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Health Screenings. Due to time restraints, LPA will return at a later date to continue the annual inspection.the state’s words, verbatim · CDSS document, Feb 5, 2025

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

Licensing Program Analyst (LPA) Kristin Kontilis conducted a subsequent complaint visit to issue final findings. During today’s visit, LPA met with Ruth Grande, Executive Director and explained the reason for the visit. LPA initiated the investigation on 7/15/2024 from 12:28pm to 4:30pm. During the visit, LPA toured the facility, interviewed staff and residents, and obtained relevant documents. LPA also conducted additional interviews by phone on 7/29/2024 and 7/30/2024. On the allegation: Staff did not safeguard resident's personal belongings. It was alleged some of Resident 1 (R1)’s jewelry went missing from their room while R1 was in the hospital. R1 went to the hospital on 6/21/2024 and returned on 7/5/2024. R1 resides in the assisted living portion of the facility and does not have a diagnosis of dementia per their physician’s report. When R1 returned to their room on 7/5/2024, they went to their jewelry box to put their watch away and found a total of 11 items were missing, comprised of gold chains and rings including their wedding band. R1 stated all their “best jewelry” was gone, including rings that were kept on one side of the drawer. Additionally, there was approximately $400 in cash in an Please continue to 9099-C, Pg 2 Unsubstantiated envelope missing from the same drawer. R1 stated the cash consisted of $20s, $10s, and $5s. R1 showed LPA where they kept each piece of jewelry, and LPA noted R1 was very meticulous and detailed in how they kept the jewelry, with each item having a specific place. R1 searched the entire room for the pieces but found none. R1’s private caregiver called the local police to report the theft. Staff were informed of the missing items. The private caregiver has worked for R1 for approximately one and a half years, and assisted R1 privately at home before R1 moved into the facility. Private caregiver stated they knew where R1 kept their jewelry, and they often helped R1 put the jewelry away. Private caregiver stated R1 was “extremely picky” about where the items were put and every item had a specific space, and R1 watches everyone closely. Private caregiver stated they helped R1 search their entire room for the jewelry but didn’t find it. Private caregiver described the experience as “traumatic” and stated R1 knows where they put things. Private caregiver indicated while R1 was at the hospital, they went to R1’s room around 6/22/2024 to put some of R1’s belongings back in their room for safekeeping, such as a wheelchair, handbag, and clothes. Private caregiver stated they went back to the apartment a second time to gather some items for the resident, such as face lotion and glasses. Private caregiver stated they do not remember the exact day but signed into the guest book. When the private caregiver went back to the apartment, they noticed “small movements” of items in the room. Private caregiver stated the wheelchair had been left in the living room, but was now in the closet, and the curtains were partially open as well as the window. There was also mail was put on R1’s desk. They believed it could have been due to housekeeping or laundry service but were confident someone else had been in the room. Private caregiver corrected the items that had moved “because [R1] is so picky.” Private caregiver stated they went back to the room two more times while the resident was in the hospital, and “each time something was different,” such as the windows and/or curtains open, a door was open, and R1’s plants were outside. R1’s family member also stated the private caregiver informed them of this same information directly and gave a very similar account of the items moved around and jewelry missing. Staff interviewed also noted another resident lost a $100 bill around the same time R1 was in the hospital. Additionally, one staff interviewed indicated an incident where R1 said Staff 1 (S1), who had been working double shifts, was sleeping in R1’s room on their sofa during their shift. S1 later “joked” to R1 that R1 should have given S1 “something for free, something expensive” from R1’s yard sale. Please continue to 9099-C, Pg 3 Administrator stated R1’s room was kept locked and housekeeping typically cleaned R1’s room on Mondays. Administrator stated R1’s room was cleaned on 6/24/2024 by staff and the room was not cleaned again prior to R1 returning from the hospital. Law enforcement was contacted in regards to the missing items but has not charged anyone with a crime as of yet. At this time, there is insufficient evidence to prove who took the missing jewelry or where it went, and there was insufficient evidence to prove it was a facility staff. Therefore the allegation is deemed Unsubstantiated at this time. If further evidence is brought forward, this case may be reopened. Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 25, 2024 · control 29-AS-20240711102809

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kristin Kontilis conducted a case management – deficiencies visit to reissue a report originally provided on LIC 9099 for 29-AS-20240711102809, due to a technical glitch. The other report has been amended and deficiency removed. During record review and interviews conducted, it was revealed that a background check for private caregiver (PC1) for Resident 1 (R1) has not been completed. Interviews conducted revealed PC1 has offered companionship duties to R1 since 5/3/2024. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 27, 2024

87355(e)(1) Criminal Record Clearance: ...Obtain a California clearance or a criminal record exemption as required by the Department...This requirement is not met as evidenced by: Based on record review the licensee did not comply with regualtion above as R1's private caregiver has not completed a criminal background clearance which poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Sep 25, 2024

Plan of correction: Administrator agrees to provide a notice to all residents that a private caregiver hired by a resident and/or family member must have a criminal background clearance or criminal exemption prior to working, residing, or volunteering in a facility. Administrator agrees to provide a written statement of understanding acknowledging CCR 87355 in its entirety. . Administrator already provided documents on original citation. POC cleared.

Allegation investigated: Staff did not assist resident to the correct room.

Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on January 16, 2024. On June 7, 2024. LPA issued final findings on the allegations above. During the investigation, LPA Miller, toured the facility and interviewed staff on January 16, 2024, from 1:00 p.m. to 3:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Ruth Grande, administrator and explained the purpose of the visit. On the allegation: Staff did not assist resident to the correct room. It was alleged that caregivers mixed up two male residents in the memory care unit (Resident 1 and Resident 2). LPA interviewed R1’s visitor, who stated on January 6, 2024 they visited the facility and asked staff where R1 was. Staff replied R1 was in their room being changed. When the visitor arrived at R1’s room, visitor saw R2 being changed in R1’s room. Visitor stated they found R1 across the hall in R2’s room, sleeping. (Cont.on 9099-C) Substantiated Interviews determined the staff who mixed up R1 and R2 was from a caregiver agency. Staff interviewed stated sometimes agency staff are not reminded to look in resident binders to confirm who the resident is. LPA reviewed residents’ Service Plan, which stated Resident 1 (R1) requires two-person total assistance for transferring, dressing, and toileting. Staff interviewed stated the agency staff failed to follow policy by disregarding the transferring policy of R1. Agency staff toileted, dressed and transferred R1 without assistance and resulted in R1 being returned to wrong room and bed. Staff stated the agency staff worked on their own and did not collaborate with the other facility staff, and had a bad attitude about the incident. Following the incident, facility management decided this agency staff would not work in memory care and later not in the facility at all. Neither staff nor Administrator denied that the incident took place. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview, deficiencies cited 9099-D, report given, appeal rights given. Documents provided indicated in January 2024, the facility had 16 residents in the memory care, 8 of which required two-person assist. During January 2024, scheduled indicated there were two caregivers and one med tech. Effective February 2024, three caregivers and one med tech were assigned. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Technical Assistance is issued to remind the facility they should adjust their staffing ratio appropriately based on resident’s needs. Exit interview conducted, copy of report issued.the state’s words, verbatim · CDSS document, Jun 7, 2024 · control 29-AS-20240110084949

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 7, 2024

Additional Personal Rights of Residents...(a)Residents shall have rights...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with this section when staff lacked competency in mixing up R1 & R2, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: Agency staff involved in the incident was asked to not return to the facility. Administrator reminded other staff to follow policies and care plans for all residents on 1/9/24 and 2/23/24.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Inspection to the above-named facility. LPA was greeted by Staff 1 (S1) and explained the purpose of the visit. Ruth Grande, Administrator participated in the inspection at approximately 12:55 pm. Entrance interview conducted. The facility is a three-story Residential Care Facility for the Elderly (RCFE) with a hospice waiver for 20. Currently, there are 20 residents with a dementia diagnosis, 18 residents on hospice, 10 residents on oxygen, and 3 bedridden residents. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for fire safety and other hazards. The facility entrance consists of a large lobby, a concierge desk for check-in, and a hallway at the right of the lobby leading to the administration offices. Immediately past the concierge’s desk is a stairway that leads to the residential area. Residents participate independently in live entertainment and music, worship support, exercise activities, card games, lectures, Resident Council Townhall meetings, Bingo, art, reading club, pet therapy, arts and crafts, and outings to parks, restaurants, shopping excursions, museums, theatre events, and other local attractions. The fire extinguishers were charged and last serviced on 12/28/2023. LPA observed elevators are in good working order. Please continue to 809-C, Page 2. During today’s visit, the medication inventory and Medication Administration Record (MAR) for Resident 1 (R1) revealed an overcount of Metropolol XL 100mg. R1’s prescribed medication of Metropolol XL 100mg medication began on 10/31/2023 with a bottle count of 150 tablets. R1’s prescribed medication is 1x per day in the AM administered from 10/31/2023 through 2/7/2024. At approximately 2:46 pm, Staff 1 (S1) conducted a medication count and determined there were 125 tablets remaining in the bottle. At approximately 2:55 pm, Staff 2 (S2) confirmed a medication count of 125 tablets remaining in the bottle. At approximately 3:12 pm, Staff 3 (S3) also confirmed a medication count of 125 tablets remaining in the bottle. S3 stated there is no record of R1 refusing medications from 10/31/2023 through 2/7/2024 and the MAR reflects the am medication was given in the am from 10/31/2023 to 2/7/2024. Due to time restraints, LPA will return at a later date to continue the annual inspection. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 7, 2024

Allegation investigated: Facility staff handled resident roughly Facility staff verbally abused Resident(s) Facility did not accord Resident(s) with dignity Facility did not meet Resident's needs Facility failed to safeguard Resident(s) belongings

On 10/10/2023, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above. LPA arrived at the facility, met with Christina Martinez, LVN, as the Administrator was not available, and announced the purpose of the visit. On the allegation: Facility Staff handled resident roughly. It is alleged by the Reporting Party (RP) that Facility Staff used forceful behavior towards residents who were clearly in physical pain. RP alleged Staff were overly aggressive with forcing resident(s) to sit down in specific places. Staff would forcefully take away items from residents. RP alleged that Staff members told RP they needed to use force with residents to get them to do what the Staff wants such as changing them, seating them, etc. Staff would allegedly stand in front of a seated resident so they couldn’t get up, grabbing the residents harshly allegedly causing bruising on 2 residents on their arms. RP additionally alleged that Staff would roll the residents over in bed, smacking their faces on the metal assisting bars. Continued on 9099-C Unsubstantiated RP stated that a resident once had a chipped front tooth and Staff explained that the resident “fell” but RP was not convinced since RP had seen how forcefully residents are turned over when being changed and felt like that was the reason why the resident had a chipped tooth. On 07/13/2021, the original LPA assigned to the complaint could find no evidence through interviews with Residents, Staff, Witnesses, LPA observation, and record review to confirm that Staff had handled resident(s) roughly while in care at the facility. On 09/19/2023, a second LPA conducted interviews with Staff members and residents of the facility while investigating a separate complaint at the facility. No interview divulged any evidence that a resident had sustained an injury while in care at the facility. No resident stated they had sustained a wound in care, or ever seen another resident sustain a wound in care due to rough handling on the part of the Staff of the facility. No Staff member stated that they had ever physically mishandled/handled roughly a resident. On 09/19/2023, Record review by the second LPA did not discover any evidence that a resident sustained a wound while in care. LPA received Physicians Orders/Audits from the primary care physician of certain residents dated from September of 2023 on a consistent basis (every day to every other day/occasionally every 3 days). LPA received copies of Medical Services provided to residents, regarding any wound a resident might have received while in care. LPA also received documentation of medical examinations for residents in September 2023. LPA received a copy of residents’ discharge summary from the hospital in August and September of 2023. LPA received detailed Doctor's Progress Notes from August 2023 and September 2023. LPA also received documentation of the facility 24 Hour Chart Check for the Resident for the months of August and September 2023. Interviews with facility staff members indicated that fragile or thin skin that tears easily is a concern with individuals at a certain age, but no resident had been moved by Facility Staff resulting in a wound opening on the resident that bled. From the record review of the medical documentation, 2nd LPA found no evidence of physical marking on any residents due to handling by Staff. On 09/19/2023, LPA interviewed residents about the allegation and no resident interviewed by the LPA stated that they had been mistreated and/or treated roughly by the staff of the facility at any time while in care. There is no evidence of Staff mishandling residents in a physically rough manner. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms, this included changing residents, seating residents, etc. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be handled roughly after requesting or needing assistance. Continued on 9099-C This is corroborated by the record review documentation of the facility call button system usage. There is no evidence to corroborate/confirm the allegation that the facility staff handled resident(s) roughly. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility staff verbally abused Resident(s). It is alleged that Staff members referred to the residents as the following: “They’re fucken crazy” “They have no idea what the fuck is going on” “such a bitch” “They shit so much and all they do is complain.” RP alleges that there were multiple incidents where Staff referred to the residents as: “So annoying” “I’m surprised they haven’t died yet” “They always do this shit and think we’re going to immediately run to their room when they need something” “They paged like 4 times now, they better be dying or some shit like that hahaha” “They can wait, the soiled sheets aren’t going anywhere.” “…you’ll see they’re all fucking irritating and you’ll start to hate them too” “They can’t hear shit… what’s the saying for ‘blind as a bat’ but for hearing? Hahaha.” There is no evidence to corroborate the allegation that Facility Staff verbally abused resident(s). On 07/13/2021, the original LPA assigned to the complaint could find no evidence through interviews and record review to confirm that residents had been verbally abused by Staff. On 09/19/2023, the second LPA conducted interviews with Staff members and residents of the facility. No interview divulged any evidence that a resident had been verbally abused by a Staff member while in care at the facility. No resident stated they had been verbally abused while in care, or ever seen/heard another resident verbally abused while in care. On 09/19/2023, a second LPA received documented records of the facility call button system usage for each resident from September 2023. The facility Call History documentation lists the call type: Emergency calls, Area, Room, Floor, Call Time, Wait Time, and name of the resident calling. From the documented facility call history, all resident call button usage was responded to by staff members. Wait time for each call varied depending on the type of call, as Emergency calls were responded to immediately. On 09/19/2023, LPA interviewed residents about the allegation and no resident interviewed by the LPA stated that Staff ever said anything about not wanting to assist the resident when they pressed their call button. There is no evidence of neglect by Staff during the hours recorded on the call button documentation, and there were no long wait times by residents. This evidence contradicts the alleged verbal abuse by Staff members about making residents wait for assistance. The facility call button history documentation shows that the wait times for residents in the facility did not increase in length in proportion to the number of calls a resident made on the call button sequentially. Continued on 9099-C The Call Button History Documentation shows that all residents had a wait time from less than a minute to approximately under half an hour. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be left for hours or more after having pressed the call button for assistance. This is corroborated by the record review documentation of the facility call button system usage. Through interview & record review the LPA observed that Staff are meeting the incontinence needs, changing needs, bathing needs, etc. of the resident(s) in care. There is no evidence to corroborate/confirm the allegation that Staff members verbally abused residents in care at the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility did not accord Resident(s) with dignity. It is alleged that Staff members at the facility were pushing residents in wheelchairs when the resident clearly had their feet on the ground. It is also alleged that Staff members neglected specific residents because they were “annoying.” RP alleges to have heard the Staff members walking out behind the residents while laughing/mocking them. On 07/13/2021, the original LPA conducted an initial complaint investigation visit to the facility above. LPA found no evidence that the facility did not accord residents with dignity. On 09/19/2023, a separate LPA conducted interview, observation, and record review at the facility above. LPA found no evidence that corroborated the allegation the facility did not accord the residents with dignity while in care. There is documented evidence including interview, observation, and record review that the facility treats the residents with dignity and respect. During both complaint investigation visits by two (2) separate LPA’s, 07/13/2021 & 09/19/2023, all Staff members were observed to be treating each and every resident with dignity/respect. This included polite tone of speech & respectful manner of body language while speaking to residents, not speaking about a resident in a derogatory tone, privacy during treatment and personal care, the residents right to receive and make phone calls in private, send and receive mail unopened, and the right to associate privately with persons of resident’s choice. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C On the allegation: Facility did not meet Resident's needs. It is alleged by RP that the Staff members of the facility are rough, harsh, and neglectful with the residents. RP alleges that a resident with a history of falls requested help one day by screaming “help” when found lying on the ground. Once the Staff arrived, they stated that the resident was “faking it”. RP alleged that residents needed to be showered by Staff regardless of if they wanted to shower or not. Staff allegedly stated, “just sit them in the shower chair and shower them, it doesn’t matter if they want to shower or not.” RP alleged there were multiple occasions where residents were completely soiled in their own urine to the extent that it would go through to the sheets, therefore requiring RP to change the resident and the bed. Staff would then walk in and claim they “had just changed her and it hasn’t been that long” when that was clearly not the case. On 07/13/2021, the first LPA assigned to this complaint conducted an initial complaint investigation visit to the facility above. LPA interviewed staff members and residents in the facility. Neither staff members nor residents confirmed the allegation. Staff interviewed stated they had not observed any resident being forced into a situation they did not want to do. LPA did not observe any evidence of the allegation while at the facility. On 09/19/2023, a separate LPA conducted record review of the records/documentation for bathing for residents and the Staff logs from the facility on 09/19/2023. LPA requested & received the Call Button Logs from the facility and there is no evidence of neglect or ignoring residents by Staff during the hours recorded on the call button documentation. Additionally, there were no long wait times by residents. The facility call button history documentation shows that the wait times for residents in the facility did not increase in length in proportion to the number of calls a resident made on the call button sequentially. The Call Button History Documentation shows that all residents had a wait time from less than a minute to approximately under half an hour. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be left for 3 hours or more after having pressed the call button for assistance. This is corroborated by the record review documentation of the facility call button system usage. There is no evidence to corroborate/confirm the allegation that the facility staff are not meeting the needs of the resident(s) in care. On 09/19/2023, the second LPA interviewed residents who stated that they had never failed to have specific needs met by the Staff such as changing, bathing, cleaning linens, eating, medication management assistance, etc. On 09/19/2023, LPA obtained copies of resident medication records and physician order reports for residents, maintained in each resident’s record/file. Upon observation & record review, there were no unmet needs identified by a physician that were not being appropriately addressed by the facility Staff. Contd. 9099-C There is no documented evidence to corroborate the allegation that the facility did not meet the resident(s) needs. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility failed to safeguard Resident(s) belongings. It is alleged by RP that there was stealing going on in the facility. RP stated that allegedly an electric temperature checker had been stolen from the facility, and that previous thefts of resident belongings by Staff members had occurred. On 07/13/2021, the first LPA conducted an initial complaint investigation visit to the facility above. LPA conducted both Staff member & resident interviews, direct observations, and record review of pertinent information/documentation. LPA could find no evidence through interviews with Residents, Staff, Witnesses, LPA observation, and record review to confirm that facility failed to safeguard resident(s) belongings. On 09/19/2023, the 2nd LPA assigned to the complaint investigation obtained and reviewed the facility Residence and Care Agreement regarding Property Rights, Conduct & Respect of Accommodations, and the Personal Property/Theft and Loss Policy. The facility shall not be responsible for the loss of any personal property (including, without limitation, money, valuables, and other personal effects) belonging to residents, guests, or invitees, due to theft, fire, or any other cause, except to the extent the loss or damage was caused by facility negligence or intentional misconduct, including that of the Staff members. The facility strongly recommends that each resident obtain, at their own expense, insurance for the replacement value of their personal property, at adequate coverage and liability limits. This provision will survive termination of this Agreement. Residents are encouraged to carry personal property insurance to cover any loss due to fire, theft, or other casualty. A general inventory of personal belongings will be conducted at time of move-in, but the facility is not responsible for any loss of money, jewelry, or other valuables. Residents are encouraged to leave valuables/money with family members or in a bank. No witnesses interviewed indicated seeing staff take any resident property from any resident room at any time. The facility does not maintain LIC621 Client/Resident Personal Property and Valuables documentation. The facility does not maintain LIC405 Record of Client’s/Resident’s Safeguarded Cash Resources documentation. Theft of resident belongings/money will be documented and upon request by the resident, theft and loss records will be made available to governmental and law enforcement agencies. In this instance, the resident did not request any action taken on the part of the facility according to the Residence and Care Agreement. Contd. 9099-C LPA was unable to obtain any evidence of a resident missing or having any personal property stolen. No resident had any record of missing money from their bank account. The facility was unaware of any alleged missing money or missing personal property of any resident, and all Staff members interviewed stated that they had not seen or heard of any Staff member failing to safeguard residents’ belongings. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of the report provided to the facility.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 29-AS-20210709104343

Allegation investigated: Facility staff not meeting the incontinence needs of the resident(s) in care. Resident sustained injury while in care. Staff does not communicate with authorized representative. Staff failed to give medications as prescribed. Staff is insufficient in numbers/knowledge to meet the residents needs.

On 09/29/2023, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above. LPA arrived at the facility, met with Licensed Vocational Nurse Jessica Hernandez as the Administrator was not available, and announced the purpose of the visit. On the allegation: Facility staff not meeting the incontinence needs of the resident(s) in care. It is alleged by the Reporting Party (RP) that a resident pressed the call button for incontinence assistance but was left for three hours in a soiled diaper as no Staff member responded. RP reported that they have observed old, soiled linens in the laundry basket of the resident. On 09/21/2022, Licensing Program Analyst (LPA) conducted an initial complaint investigation visit to the facility above. Through interview of Staff members and residents, LPA observation, and record review the LPA found no evidence of the allegation that the facility Staff were not meeting the incontinence needs of the residents in care. Continued on 9099-C Unsubstantiated On 09/19/2023, a second LPA received documented records of the facility call button system usage for each resident from September 2023. The facility Call History documentation lists the call type: Emergency calls, Area, Room, Floor, Call Time, Wait Time, and name of the resident calling. From the documented facility call history, all resident call button usage was responded to by staff members. Wait time for each call varied depending on the type of call, as Emergency calls were responded to immediately. On 09/19/2023, LPA interviewed residents about the allegation and no resident interviewed by the LPA stated that they had been ignored by the staff of the facility when they pressed their call button. There is no evidence of inadequate staffing during the hours recorded on the call button documentation, and there were no long wait times by residents. The facility call button history documentation shows that the wait times for residents in the facility did not increase in length in proportion to the number of calls a resident made on the call button sequentially. The Call Button History Documentation shows that all residents had a wait time from less than a minute to approximately under half an hour. All residents interviewed by the second LPA on 09/19/2023 stated Staff members were very good with bathing procedures and the changing of linens in the residents’ rooms. Staff members interviewed stated that residents are checked up on regularly/periodically and there is no time a resident would be left for 3 hours or more after having pressed the call button for assistance. This is corroborated by the record review documentation of the facility call button system usage. There is no evidence to corroborate/confirm the allegation that the facility staff are not meeting the incontinence needs of the resident(s) in care. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Resident sustained injury while in care. It is alleged that a resident had a wound on their hand that staff re-opened when they grabbed the resident by their hand to help the resident. RP stated that the wound bled from the incident. There is no evidence to corroborate the allegation that a resident sustained injury while in care. On 09/21/2022, the original LPA assigned to the complaint could find no evidence through interviews and record review to confirm that the resident had received the wound while in care at the facility. On 09/19/2023, the second LPA conducted interviews with Staff members and residents of the facility. No interview divulged any evidence that a resident had sustained an injury while in care at the facility. No resident stated they had sustained a wound in care, or ever seen another resident sustain a wound in care. Continued on 9099-C No Staff member stated that they had ever re-opened a wound in care on a resident. Record review by the second LPA did not discover any evidence that a resident sustained a wound while in care. LPA received Physicians Orders/Audits from the primary care physician of certain residents dated from September of 2023 on a consistent basis (every day to every other day/occasionally every 3 days). LPA received copies of Medical Services provided to residents, regarding any wound a resident might have received while in care. LPA also received documentation of medical examinations for residents in September 2023. LPA received a copy of residents’ discharge summary from the hospital in August and September of 2023. LPA received detailed Doctor's Progress Notes from August 2023 and September 2023. LPA also received documentation of the facility 24 Hour Chart Check for the Resident for the months of August and September 2023. Interviews with facility staff members indicated that fragile or thin skin that tears easily is a concern with individuals at a certain age, but no resident had been moved by Facility Staff resulting in a wound opening up on the resident that bled. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff does not communicate with authorized representative. It is alleged that the Staff members of the facility did not let the authorized representative of a resident know about the wound on the resident’s hand that had been re-opened due to the Staff grabbing the hand of the resident. The allegation also states that there is currently no management person that a resident or family member can contact for any reason. The facility does not contact family members in cases of medical or residential emergencies. RP alleges that the facility does not know what medications they are giving to their residents who are under medication management. On 09/21/2022, LPA conducted an initial complaint investigation visit to the facility above. LPA found no evidence that the facility had no management individual that a resident or family member could contact. The Administrator was listed on the LIC 500 Personnel Report, including the hours that the Administrator would be in the facility. At the time of the LPA visit, the Administrator was present in the facility and spoken with. According to interviews with Staff members and residents, the Administrator was in contact with Authorized Representatives on a continuing basis. On 09/19/2023, a separate LPA conducted interview, observation, and record review at the facility above. LPA found no evidence that corroborated the allegation of the facility not contacting family members of residents in cases of medical emergencies. Continued on 9099-C There is documented evidence including interview and record review that the Administrator of the facility does contact relatives/representatives in cases of resident medical emergencies, and the Administrator of the facility is very open about contact with family members. This includes having signs in the facility which detail contact information the family members/representatives can use to communicate with the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff failed to give medications as prescribed. It is alleged by RP that medications were not given to residents due to being out and were not refilled timely. RP requested if staff could let them know if the resident’s medications are current, but staff did not have knowledge of the medication. RP alleges that the facility cannot provide a record, over the course of 5 days of what medications they have provided to certain residents. On 09/21/2022, the first LPA assigned to this complaint conducted an initial complaint investigation visit to the facility above. LPA interviewed staff members and residents in the facility. Neither staff members nor residents confirmed the allegation. Staff interviewed stated they had not observed any resident being given incorrect medications. LPA did not observe any evidence of the allegation while at the facility. On 09/21/2022, LPA received documentation of daily medications given to residents, as well as the Centrally Stored Medication & Destruction Record. On 09/19/2023, a separate LPA conducted record review of the records/documentation of medication for residents and the Centrally Stored Medication and Destruction Record received by separate LPA from the facility on 09/19/2023. No errors or questionable staff marking were found in any of the resident medication documentation. LPA saw no incidents between 09/06/2022 through 09/22/2022 in which wrong medications had been documented being given to any resident. On 09/19/2023, the second LPA interviewed residents who stated that they had never been given any wrong medication at the facility or heard of any other resident receiving any incorrect medication. On 09/21/2022, LPA interviewed staff members and obtained records/documentation of medication for residents and the Centrally Stored Medication and Destruction Record. Medication records for September 2022 are documented appropriately with no inconsistencies or absence of documentation. There is no documented evidence to corroborate the allegation. No witnesses interviewed stated seeing or receiving any incorrect medications. On 09/19/2023, separate LPA reviewed the Centrally Stored Medication and Destruction Record for the assisted living portion of the facility. LPA also obtained copies of resident medication records and physician order reports for residents, maintained in each resident’s record/file. Continued on 9099-C LPA observed that all the correct/proper medications were logged as having been given to each resident, and an audit of the actual medications stored in the assisted living portion of the facility matched the records maintained by the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Staff are insufficient in numbers/knowledge to meet the residents’ needs. It is alleged that there are no facility staff on in the evenings or weekends that are employed by the facility. There are no caregivers that work for the facility that assist residents from Friday nights through Monday mornings. Outside agencies are trying to provide care but are minimal in their numbers. On 09/21/2022, the first LPA observed the Staff of the facility while at the facility for the initial complaint investigation visit. The LPA observed all staff members answering radio calls and attending to residents on a consistent basis. On 09/19/2023, the second LPA interviewed witnesses who indicated that staff members are attentive to the needs of residents in a timely manner at the facility. LPA did not observe any received radio call by facility staff members go unanswered or ignored. On 09/19/2023, LPA observed staff members answering all calls for assistance in a timely manner and attending to residents when/if needed. LPA did not observe any staff refusing or neglecting residents at the facility. LPA received documentation from the facility regarding employed Staff members including an LIC 500 Personnel Report and Staff schedule. LPA found no evidence to corroborate the allegation that there are not enough Staff members to meet the needs of residents in the facility. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of the report provided to the facility.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 29-AS-20220913135747