Meadow Oaks of Roseville

Allegation investigated: Staff who are not appropriately skilled professionals are administering medication to residents.

On 10/26/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver investigation finding. LPA met with Executive Director (ED), Nathan Condie, and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews with facility staff and reviewed pertinent documentation relevant to the allegation listed above such as resident's (R1) physician’s report, emergency contact, appraisals, assessments, doctor's orders, hospice communication logs, medication list, control substance management policy, staff roster, and residents roster. Continue on page LIC9099-C. Unsubstantiated According to complainant, this community uses unlicensed professional staff such as medication technicians (MT) to administer Morphine on hospice resident. According to R1’s physician’s report, R1 is unable to administer own prescription medications, unable to administer own PRN medications, and unable to store own medications. R1 is unable to administer own injections, perform glucose testing, and oxygen. According to R1’s level of care assessment, R1 requires medication assistance up to 2 times a day. R1 is on hospice and currently does not require additional staff involvement. According to R1’s doctor’s orders, on 8/30/2022 Morphine 20 mg/mL liquid concentration (30 mL bottle) was prescribed to R1 per instruction administer 0.5 mL sublingually 2 times per day for pain or shortness of breath this is additional to PRN dose on 6/16/2023. On 8/4/2023, doctor’s orders indicated to discontinue Morphine 20 mg/mL oral concentration administer 0.5 mL 2 times per day. Begin Morphine 20 mg/mL oral concentration, administer 0.5 mL (10mg) sublingually 3 times per day for pain and shortness of breath, this is in addition to PRN dose. On 8/22/2023, Morphine is to be administered every 4 hours for pain and shortness of breath, this is in addition to PRN dose. The Department interviewed and received statements from a total of five (5) Med Techs. Med Techs denies administering Morphine to hospice residents. Interview statement received from Med Techs indicated the facility nurse who is a Licensed Vocational Nurse (LVN), hospice nurse, and residents' family members who are trained administer Morphine to residents who are not capable to assist themselves. Med Techs indicated, if a resident in care is capable of administering own medication without assistance Med Tech is to provide medication to resident and observe to ensure the safety of resident. On 9/18/2023, the Department received interview statement from R1's hospice nurse. Hospice nurse stated resident was prescribed Morphine and family members requested for R1 to be given additional doses for comfort. Hospice Nurse stated did not witness staff that are not skilled professional give morphine to R1. Hospice Nurse stated has worked at Meadow Oaks of Roseville for 6 years and has not witnessed unlicensed professional staff assisting R1 with Morphine. Hospice Nurse indicated Meadows Oaks of Roseville is good at contacting hospice to ensure that any medications such as narcotics are given to resident correctly with permission. Hospice Nurse indicated Meadow Oaks would always call hospice if they had any questions or concern or need recommendations/guidance. The Department finds the allegations to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 59-AS-20230717124435

Type of visit: Case Management - Incident

On 10/26/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 09/25/2023. LPA met with Executive Director, Nathan Condie, and explained the purpose of the visit. The Case Management visit is in response to an incident report that was submitted to CCLD. Incident report indicates, a bubble pack of 30 Tramadol 50mg was not in the Narcotic Drawer on 09/10/2023. Resident Care Director, Kathryn Nevin, was immediately notified and searched the entire medication room. The facility conducted an internal investigation. Roseville Police Department were notified via telephone. Case number was provided. R1's doctor notified for refill of medication. R1's responsible party was notified. The facility provided in-service on 9/23/2023 and 9/24/2023 in regards to policy on narcotic count and general medication room policies and procedures. LPA requested for in-service training for review. At this time, deficiencies are not being cited. An exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023

Allegation investigated: - Staff did not provide incontinence care in a timely manner. - Staff did not attend to resident who was vomiting in a timely manner. - Staff did not redirect resident from wandering into bedrooms. - Staff did not answer the facility door for visitors.

On 9/14/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver investigation findings. LPA met with Assistant Executive Director (AED) Allison Lopez and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed pertinent documentation relevant to the allegation listed above such as residents’ physician’s report, emergency contact, appraisals, and assessments. Continue on page LIC9099-C. Unsubstantiated Allegation- Staff did not provide incontinence care in a timely manner. – Unsubstantiated. The Department conducted extensive records review and interviewed a total of four (4) facility staff. The Department reviewed residents’ physician's reports, level of care assessments. and appraisals. Interview stated gathered from caregivers indicate care was provided as stated. Interview statement from staff (S1) indicated, there are approximately 15 residents in Memory Care Unit (The Villa) and about 6 residents are incontinence. There are 2 caregivers working the AM and PM shift. The NOC shift consist of 1 caregiver. S1 stated S1 has not observed any residents in care left in soil and feces. Staff are providing incontinence care in a timely manner. Interview statement received from S2 and S3 were consistent with S1. S2 indicated if residents in care needs incontinence care staff would regularly check on that resident. S3 indicated staff would conduct rounds on residents that needs incontinence care every 15 minutes. The Department is unable to find and or meet the preponderance, per policy. The allegation of facility staff did not provide incontinence care in a timely manner is therefore unsubstantiated. Allegation - Staff did not attend to resident who was vomiting in a timely manner. – Unsubstantiated. The Department interviewed a total of four (4) facility staff. Interview statement received from AED indicated, R2 and R3 are roommates. R3 thought R2 was vomiting and went to notify staff. Staff went to check on R2 and did not observe R2 vomiting. R2 and R3 has Dementia. The Department requested for an incident report. AED stated the incident did not occur, so the facility did not generate an incident report. Interview with staff (S1 and S3) indicated that they do not have any knowledge of the incident. Interview statement received from S2 indicated, R2 is high functioning and told staff that R2 was not vomiting and did not need any assistance. R2 is able to pull cord for help and able to communicate needs. Allegation - Staff did not redirect resident from wandering into bedrooms. – Unsubstantiated. According to complainant, a male resident had wandered into a female resident’s room in underwear and there were no staff to redirect resident. Interview statement received from S1 indicated, S1 has not observed any residents wandering into other resident’s room. There are residents who wander around the hallways and common areas of the memory care unit. S1 indicated memory care residents exhibit wandering behaviors and needs prompting. Interview statement received from S2 and S3 indicated, they have no knowledge about the incident and which residents are involved. S2 indicated there are not a lot of male residents that wears underwear at the facility. Most residents do wear briefs. Allegation - Staff did not answer the facility door for visitors. – Unsubstantiated. The Department conducted interviews with a total of four (4) facility staff. The memory care unit consist of two buildings that are connected via courtyard. The Villa is located on the side of the building and has its own entrance. According to AED, all visitors are to sign in at the front entrance and can be let into the memory care unit. If visitors head straight to the Villa and rings the doorbell staff would open the door. AED does not have any knowledge how long visitor was waiting for staff to open the door. Interview statement received from S1 indicated, it takes about 20 seconds for staff to answer the facility door for visitors, but it depends if staff are assisting the residents in care and may take a little longer but less than 5 minutes. Interview received from S2 indicated, there are two staff working in the Villa. If staff is assisting a resident there should be another staff on the floor. If both staff are assisting residents it would take longer for staff to open the door for visitors until staff knows it's safe to leave resident. Interviews gathered from S3 is consistent with S2. The Department finds the allegations to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 14, 2023 · control 59-AS-20230510083840

Allegation investigated: - Insufficient staffing to meet residents' needs. - Staff verbally abusive towards residents.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 08/30/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 05/05/2023. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as residents’ (R1, R2, R3, & R4) physician's report, admission agreement, level of care assessments, medication list, medication administration records (MAR), facility resident roster, staff roster, facility’s call logs, call logs policy, staffs’ schedules for January through May 2023. Continued page LIC-9099C. Unsubstantiated Allegation: Insufficient staffing to meet residents' needs. – Unsubstantiated. According to complainant, a resident had used their call button to ask for assistance but none of the staff were present on 04/30/2023. The same day complainant was told that between 2pm-6pm the facility would not have any staff members to assist the residents. The residents must wait until the new shift starts at 6pm. On 07/07/2020, the Department approved staffing ratio reduction waiver for Meadow Oaks of Roseville. A waiver for a reduction in the staffing ratio is granted due to the current reduced census of twenty-six residents. Per Stipulation and Order dated July 08, 2020 “… In the event of a substantial reduction in the census, respondents may request a reduction in minimum staffing ratios from licensing. In the event of a substantial increase in the census, licensing may increase minimum staffing ratios…” Terms and conditions of staffing ration reduction waiver: (2) qualified direct care employees during the morning shift, (2) qualified direct care employees during the evening shift, (1) qualified direct care employees during the overnight shift, and (1) qualified direct care employees (floater) available as needed. Per Meadow Oaks of Roseville’s policy on alert call system, this Community is equipped with a resident alert call system. Community staff will respond to resident alert call system activation. For the purpose of this policy, the term emergency is defined as “a potentially dangerous situation that calls for immediate action. “It is the policy of this Community that all resident alert call systems are periodically inspected to ensure they are operating correctly in the event that a resident needs to obtain assistance. Resident alert call systems are for emergency use only. Notwithstanding environmental emergencies such as fire or flood, resident alert call system use is intended for medical emergencies. Medical emergency examples include, but are not limited to, the resident has fallen; the resident is experiencing dizziness or shortness of breath; the resident is experiencing chest pain; and/or the resident has a high fever. When a resident alert call system is activated, a staff member will respond. Staff may not be able to respond immediately to resident alert call system activation. Non-emergency requests or needs should be directed to the Concierge. Examples include, but are not limited to, maintenance and housekeeping issues, bookkeeping and transportation questions. The Department requested and reviewed facility’s staff schedules from January through May of 2023. According to the April 2023 staff schedule, there are three (3) shifts, AM shift (6am-2pm), PM shift (2-10pm), and NOC shift (10pm-6am). On 04/30/2023, there were 1 Med Tech and 2 caregivers working the AM and PM in the memory care and assisted living unit. The Department also requested and reviewed six (6) residents’ pendant logs. Five (5) out of six (6) residents used their pendants and the response time was less than 20 minutes. On 4/30/2023, R2 used the pendant thirteen times. Two events show the response time was 54 minutes and 50 minutes. Interview statement received from R2 indicated, "it takes a while for staff to respond to R2's call." R2 explained S4 had recently assisted R2. S2 gave R2 the wrong painting R2 was working on and used the call pendant for S2 to come back and give R2 the right painting. The Department interviewed a total of six (6) facility staff and four (4) residents. Interview statement received from staff (S1) indicated that facility staff would sometimes call out; however, the facility always finds someone to cover shifts if needed. Interview statement received from S2 indicated, staff are picking up double shifts due to call outs and facility not hiring more staff. Interview statement received from S3 indicated that the facility is not experiencing any staffing shortages and if the facility needs staff to cover shifts, they will arrange it by calling the next shift to come in early. S3 stated if staff weren’t calling out staffing is adequate. Interview statements received from S4 and S5 denied staffing shortages at the facility. Interviews statement received from all 5 staff indicated residents’ needs are being met. Interviews gathered from facility staff indicated response time when resident uses the button for assistance is “as soon as possible” or about 5-10 minutes depending on the circumstances. Interviews from R1, R3 and R4 indicated that their needs are being met. Interview statement received from R1 indicated R1 has used the call pendant twice and the response time is reasonable. Interview statement received from R3 indicated, R3 uses the call pendant for assistance and the response time depends on what time of day R3 uses the call pendant. In the morning it’s very busy and the longest R3 had to wait for staff to assist R3 is 20 minutes. Allegation: Staff verbally abusive towards residents. - Unsubstantiated. According to complainant, two staff members (S4 & S6) are verbally abusive towards the residents. The Department interviewed a total of – facility staff and 4 residents in care. Interview statement received from 4 residents indicated that they have not experienced or witnessed any staff being verbally abusive towards the residents. The Department received an interview statement from S4 and S6. S4 and S6 denied being verbally abusive towards the residents at the facility. Based on the Department’s investigation as stated above, the preponderance of evidence standards has not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Aug 30, 2023 · control 59-AS-20230505092304

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 06/29/2023 to conduct a Case Management - Health Checks. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. LPA toured the facility together with ED to ensure health and safety of residents in care. LPA observed residents in the activity room participating in activities. Areas toured include but are not limited to: common areas, kitchen, residents bedrooms and bathrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with AED. A copy of the report was emailed to AED.the state’s words, verbatim · CDSS document, Jun 29, 2023

Type of visit: Case Management - Incident

On 05/04/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident to obtain information regarding an incident that occurred at the facility on 04/25/2023. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. The Case Management visit is in response to an incident report and Report of Suspected Dependent Adult/Elder Abuse (SOC 341) that was submitted to CCLD. Incident report indicates, resident (R1) made a report to the General Program Director (GPD) that a staff (S1) was cussing and speaking rudely towards R1 and R2. GPD received a written and signed statement from R1. S1 was suspended and there is a pending investigation. LPA Keosavang requested for R1 and R2’s physician’s report, assessments, internal investigation report, and R1's written statement for review. LPA conducted interviews with facility staff. At this time, deficiencies are not being cited. An exit interview conducted and report provided.the state’s words, verbatim · CDSS document, May 4, 2023

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 03/08/2022 to conduct a Case Management - Health Checks. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff upon entering the facility. LPA toured the facility together with ED to ensure health and safety of residents in care. LPA observed residents in the activity room participating in activities. Areas toured include but are not limited to: common areas, kitchen, eight (8) resident bedrooms and eight (8) bathrooms. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with AED. A copy of the report was emailed to AED.the state’s words, verbatim · CDSS document, Mar 8, 2023

Allegation investigated: Staff did not adhere to resident's admissions agreement.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 02/10/2023 to deliver final finding for a complaint Community Care Licensing (CCL) received on 10/04/2022. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, admission agreement, identification and emergency information, level of care assessments, medication list, medication administration records (MAR), facility resident roster, staff roster, and facility’s call logs. Continued on page LIC-9099C. Unfounded According to complainant, facility did not adhere to R1’s admission agreement. In 2021, R1 had a fall resulting a broken back. R1 was discharge from hospital and was admitted to Meadow Oaks of Roseville. Complainant indicated facility staff did not ensure to call R1 and conduct status check on R1 two times per day per admission agreement. The Department reviewed R1’s physician’s report. R1’s primary diagnosis is fracture of unspecified part of scapula, left shoulder, subsequent encounter for fracture with routine healing. R1 is unable to bathe self, dress/groom self, and care for own toileting needs. R1 is unable to administer own prescription medications, administer own PRN medication, and store own medications. R1 is not receiving hospice care. The Department reviewed R1’s initial level of care assessment completed on 04/26/2021. R1 reside in the assisted living unit. Level of care assessment indicated R1 does not require status check. On 01/26/2023, facility conducted an update on R1’s level of care assessment due to a change of condition. Level of care assessment indicated R1 does not require additional status checks. The Department interviewed and received statement from a total of four (4) facility staff. Interview statement received from four (4) facility staff (S) indicated R1 uses call button on a daily basis for assistance and request for PRN medication. S1 indicated staff conduct rounds every two hours to check on R1. S2 indicated caregivers and Med Techs regularly conduct status checks on R1 four times per shift. The Department requested and reviewed R1’s call log from 09/14/2022 through 10/14/2022. According to call log, 80 events were recorded and the response time average is 7 minutes. According to R1’s MAR, PRN medication has been provided to R1 consistently from 09/14/2022 through 10/14/2022. Interview statement received from AED indicated, there is no restriction on residents using call buttons. Interview statement received from R1 indicated, staff conducts status check on R1 frequently. R1 stated R1 uses call button for assistance and to request for PRN medication. R1 stated staff delivers food to R1’s room on a daily basis and would check on R1. R1 stated facility staff are kind and R1’s needs are being met. R1 indicated response time for call button is 5-10 minutes. The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies cited during today’s visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 10, 2023 · control 25-AS-20221004182219

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 02/09/2023 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, ten (10) resident bedrooms, ten (10) bathrooms, and kitchen. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and AED completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 9, 2023

Allegation investigated: Facility did not refund as specify on Admission Agreement.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 12/28/2022 to deliver final finding for a complaint Community Care Licensing (CCL) received on 04/13/2022. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as resident’s (R1) physician's report, level of care assessments, discharge medical documents, 30-day notice, R1 and R2 ledgers, copy of refund check, unusual/ injury incident reports, R1’s admission agreement, and email communication between R1’s responsible party (RP) and facility. Continued on page LIC-9099C. Substantiated According to R1 and R2’s admission agreement, both residents moved into the facility on 03/27/2022. R1 and R2 moved into a shared room in the Memory Care unit (the Villa) with a capacity of twelve (12) bedrooms. Total monthly rate for both residents is $8945. Monthly rate for residential service for R1 is $4495, monthly rate for cares services for R1 is $3500, and monthly rate for residential services for R2 is $950. The Department requested for R1’s medical documents for review. On 04/07/2022, R1 was transferred to the hospital due to a fall and was discharged same day noting no serious injuries. On 04/08/2022, R1 had a fall and fell onto right hip area witnessed by R2. R1 was transferred to the hospital for further evaluation due to pain. R1 had a resent periprosthetic fracture on right femur admitted in February. R1 has been observed for the following conditions: right hip periprosthetic fracture, now admitted for right hip dislocation. R1 was discharged to a Skilled Nursing Facility. R1 returned to the community on 04/28/2022. R1 was out of the community for 18 days. According to R1’s admission agreement, if you are absent from Meadow Oaks of Roseville for more than fourteen (14) consecutive days, you will receive a pro-rated credit towards your Monthly Care Fee starting on day fifteen (15). No credit is given for an absence that is less than fourteen (14) consecutive days. The facility is responsible to refund RP for the remaining 3 days the resident was out of the community. On 05/02/2022, R1’s responsible party (RP) gave the facility a 30-day notice via email. Facility received 30-day notice and indicated that R1 and R2 will move-out on 05/31/2022. According to Business Office Director (BOD), Rayna Gabriel, R1 and R2’s RP had moved residents out before move-out date. RP physically moved R1 and R2 out of the community on 05/08/2022. According to complainant, the facility did not refund R1’s RP for the remaining 22 days that resident had officially moved out of the community. According to R1’s admission agreement it states, you or the responsible person shall remain liable for the monthly fee until the later of the date on which this agreement terminates; or the date in which your apartment is vacated and all property removed from it. Interview statement gathered from BOD indicated R1’s RP is responsible to pay for the remaining days although R1 has moved out of the facility. This is facility’s policy and it’s stated in R1’s admission agreement. The Department requested for R1’s and R2’s ledger for review. R1’s ledger indicated the total amount due for the month of April 2022 is $10,752.90. R2’s ledger indicated the total amount due for the month of April 2022 is $929.03. R1 and R2’s RP sent a check to the facility in the amount of $9645.97. The facility used the check to pay R2’s fee of $929.03 and the remaining amount was paid towards R1’s fees. The total balance due for R1 was $1106.93. The facility charged R1’s RP a late fee of $75.00. R1’s RP had reached out to BOD via email requesting for a refund for late fee. BOD responded stating that the facility will refund RP late fee. RP confirmed that RP did not receive a refund of $75.00. The new balance for R1 for the month of May was $5676.03 which included the balance for the month of April ($1,106.93), late fee of $75, and room and board for $4495. Due to R1 being out of the community, the facility did not charge for care. R1’s RP paid the facility a total of $9101.93. R1’s RP overpaid the facility which resulted in a refund of $3425 and the facility had credited RP a 60% community fee move-out of $1200. The facility refunded RP in the amount of $4625. The Department received a copy of the check to confirm facility did in fact sent the refund to R1’s RP. Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and a copy of the report left at the facility. Allegation: - Facility does not have adequate staffing to meet resident’s needs. – Unsubstantiated. Interview statement gathered and received from Complainant indicated, there were no staff to assist R1 in April and May of 2022. Complainant stated resident requires a two- person transfer. Complainant expressed concerns that residents needs services were not met. On 4/1/2022, Complainant was at the facility and observed R1 alone on the toilet with no care staff in sight. Complainant pushed call button and S3 arrived. S3 was there to assist in changing R1 without another staff to assist. Complainant explained to S3 that R1 requires two-person assist and that R1’s leg was broken. Second staff did not show up to assist and complainant had to assist S3 with changing R1. Interview statement from S3 confirmed that complainant was present at the facility and helped S3 with assisting R1 in changing into new brief and transferring R1 to a wheelchair. S3 stated S3 was not aware R1 was a two-person assist and received assistance from complainant. S3 stated if care staff needed assistance transferring R1 care staff can use a walkie-talkie to call for help. The Department requested and reviewed R1’s level of care assessments. The facility conducted R1’s initial move-in assessment on 04/03/2022. The level of care assessment indicated R1 needs assistance with grooming, bathing, dressing, medication, toileting, and transfers. R1 requires 1-person assistance. On 05/03/2022, the facility conducted a 30-day evaluation. The 30-day evaluation level of care assessment indicated R1 requires 1-person assist with grooming, bathing, dressing, medications, transfers, and toileting. The Department gathered interview statements from facility staff (S). S1 indicated the Villa in Memory Care unit has one (1) staff scheduled to provide care and supervision during the NOC shift. S1 stated facility policy of staff ratio in the Villa is one (1) staff per ten (10) residents. S1 stated during the time R1 resided at the facility the Villa had less than ten (10) residents. S1 assisted R1 in repositioning every two (2) hours. Interview statement gathered from S2 indicated during the PM shift two (2) staff would assist R1 and during the NOC shift one (1) staff would assist R1. S2 stated staff would conduct rounds every two (2) hours. S2 confirmed that there were six (6) residents total that resided in the Villa during the time R1 was at the community. S2 assisted R1 with repositioning. S2 stated there has been multiple occasions where R2 would try and assist but was told not to assist to prevent injuries. S2 stated R1 was not able to walk on their own but would try to walk and care staff would try to redirect to prevent a fall. Interview statement gathered and received from AED indicated, the Villa were fully staffed. AED stated R1 requires two-person assist. AED stated if there were a time the facility needed staff to cover the facility would use Agency staff. The facility provided staff schedule and agency staff schedule for review. Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Assistant Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.the state’s words, verbatim · CDSS document, Dec 28, 2022 · control 25-AS-20220705110233

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 4, 2023

87507(f) Admission Agreement The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on documentation review, Licensee did not adhere to admission agreement and did not provide refund to R1’s RP. This poses a potential potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: Assistant Executive Director agrees to provide RP refund and submit proof to CCL by POC due date, 1/04/2023.

Allegation investigated: Resident is not changed and bedroom smells of urine.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced 12/08/2022. LPA met with Resident Care Director, Allison Lopez, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as residents’ physician's report, level of care assessments, medication administration record (MAR), and medication list. Continued on page LIC-9099C. Substantiated On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. According to R1’s level of care assessment, R1 needs assistance with grooming, bathing, dressing, eating, medications, and toileting. R1 is on hospice but does not require additional staff involvement. R1 requires a status check 4-6 times per day. House keeping is required daily (bed making or minor tidy up such as emptying trash). R1 also requires additional laundry 2 times weekly. On 04/19/2022, LPA Keosavang toured the Memory Care Unit (the Villa) with Executive Director, Debra Duval. The facility has two (2) Memory Care Unit, and the Villa is a separate building which has a total of 12 residents’ bedrooms. LPA Keosavang observed a total of three (3) bedrooms in the Villa. During the tour, LPA observed R1’s bedroom has strong urine odor. On 10/19/2022, LPA Keosavang conducted interviews and gathered statement from facility staff. Interview statement received from S1 indicated, R1 requires assistance with toileting and that R1 would try to independently use the toilet on his or her own. R1 would defecate and urinate on self. Facility care staff would assist R1 in changing into new clothes. After assisting R1 with change into clean clothes staff would remove filthy clothes from room and put them in the laundry room. Interview statement received from S2 indicated, there has been a time where staff did not change R1 during a shift change. S2 conducted rounds during start of shift and observed R1’s incontinence brief were soiled and have not been changed. S2 mentioned it to staff that was working on the earlier shift and offered to assist. S2 stated, R1 had many incidents where R1 would stand up and urinate on the floor. After assisting R1, filthy clothes may not have been put in the laundry room and washed immediately which may cause the strong urine odor in R1’s room. Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and a copy of the report left at the facility. Allegation: Resident not re-evaluated for change of condition. -Unfounded According to Complainant, prior discharge from Skilled Nursing Facility about 6-8 months ago R1 was able to walk, talk, and use restroom on their own. R1 was also able to meet their own activities of daily living (ADLs) needs. Complainant’s concern is that R1 had declined since moving to Meadow Oaks of Roseville and facility did not re-evaluate R1 for any changes in eating, walking, and slurred speech for further medical care. R1’s admission date was on 04/30/2021, The Department requested and reviewed R1’s level of care assessments. A total of four (4) level of care assessment were conducted by Resident Care Director, Kathryn Nevin. The initial move in assessment was completed on 04/30/2021. The facility conducted a 30-day level of care assessment on 06/06/2021. On 06/06/2021, facility conducted R1’s 30-day level of care assessment. On 08/31/2021, the facility completed R1’s 90-day level of care assessment. On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. On 05/12/2022, R1 passed away and the facility submitted R1’s Death Report to CCL. The Department interviewed and gathered statement from R1’s responsible party (RP). RP stated R1 is 97 years old and health was declining due to old age. RP stated the facility is very communicative and often would notify RP regarding R1’s change of condition. RP stated the facility had re-evaluated R1’s change of condition multiple times. RP had to sign off on the re-evaluation, fees were updated, and adjusted based off the assessments. The Department received R1’s Vitas Team Telecare admission orders/ hospice certification and initial plan of care for review. On 12/16/2021, R1 was placed on hospice. The facility did their due diligence by re-evaluating R1 when there was a change of condition and initiated hospice. Allegation: Resident did not receive medical attention. – Unfounded. According to Complainant, R1 did not receive medical care for change of condition. Complainant expressed concerns regarding R1’s abilities to conduct their own activities of daily living (ADL). Prior to R1 moving into the facility R1 was able to conduct their own ADL. After R1 moved into the facility R1 showed signs of decline in eating, walking, and slurred speech. According to R1’s initial move in level of care assessment, R1 needs assistance with grooming, bathing, medications, and housing keeping. On 02/28/2021, the facility completed R1’s level of care assessment due to a change of condition. According to R1’s level of care assessment, R1 needs assistance with grooming, bathing, dressing, eating, medications, and toileting. R1 is on hospice but does not require additional staff involvement. R1 requires a status check 4-6 times per day. Housekeeping is required daily (bed making or minor tidy up such as emptying trash). R1 also requires additional laundry 2 times weekly. The Department interviewed and gathered statement from Memory Care Director (MCD), Kathryn Nervin. MCD stated R1 had a change of condition. R1 was not eating, walking, and had slurred speech. MCD indicated that R1’s decline is due to further Dementia and confusion. R1 was not gaining any weight and it was a concern. Hospice was initiated. The Department interviewed and gathered statement from R1’s responsible party (RP). R1 stated the facility staff observed R1’s decline in health then acted by providing medical attention and notified all R1’s RPs. R1’s RP indicated that the facility had initiated hospice once R1 showed signs of declining. The Department request for R1’s hospice documents for review. On 12/16/2021, R1 was placed on hospice due to a change of condition. Based on information above, department concluded that all these allegations are UNFOUNDED, A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. No citations were issued today. Exit interview conducted and copy of report provided. On 12/14/2022, LPA arrived at the facility and amended the report. Allegation: Resident is over medicated. – Unsubstantiated. The Department requested and received R1’s hospice medical list and medication administration record (MAR) from the facility. The Department reviewed the medication list matches the MAR from the facility. There were no discrepancies observed. The Department request for R1’s hospice documents for review. On 12/16/2021, R1 was placed on hospice due to a change of condition. The facility provided R1’s hospice nurse’s email address. On 11/01/2022, LPA reached out to hospice nurse via email and requested for a telephone call to gather additional information to help with the investigation. LPA did not receive a response from hospice nurse. On 11/02/2022, the Department reached out to R1’s hospice home health (Vitas Team Telecare) and requested to speak to R1’s hospice nurse. LPA spoke to team manager who confirmed hospice nurse provided care to R1. Team manager stated she will provide LPA’s contact information to hospice nurse. Team manager stated she cannot provide LPA nurse’s contact information. LPA was unable to interview hospice nurse regarding alleged allegation. On 10/19/2022, the Department interviewed and received statements from two (2) facility staff. Interview statement received from Memory Care Director (MCD), Kathryn Nervin, indicated that the medication provided to R1 are orders for hospice patients. Interview statement received from Assistant Executive Director (AED), Allison Lopez, stated standard medications were provided to R1. Medications provided to R1 are medication that are usually prescribed to hospice residents. On 11/29/2022, the Department conducted interview with R1’s RP. According to RP, R1’s Primary Care Physician prescribed medication that was the lowest dosage for R1. The facility and hospice home health has the medication list for R1. RP does not have any knowledge of the facility staff giving medication that was not on the list to R1 or R1 being over medicated. Due to the information above, CCL finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.the state’s words, verbatim · CDSS document, Dec 8, 2022 · control 25-AS-20220413110121

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Dec 15, 2022

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews and observation the licensee did not ensure R1’s room is free of odor which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Dec 8, 2022

Plan of correction: Resident Care Director agrees to maintain all incontinence resident bedrooms to be free of odor. RCD agrees to review section 87625 and submit letter of understanding to CCL by POC due date. On 12/14/2022, LPA amended LIC 90999-D.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 12/08/2022 to conduct a Case Management - Health Checks. LPA met with Assistant Executive Director (AED), Allison Lopez, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff upon entering the facility. LPA toured the facility together with ED to ensure health and safety of residents in care. LPA observed residents in the activity room participating in activities. Areas toured include but are not limited to: common areas, five (5) resident bedrooms and five (5) bathroom. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with AED. A copy of the report was emailed to AED.the state’s words, verbatim · CDSS document, Dec 8, 2022

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/01/2022 to conduct a Case Management- Health Checks. LPA met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff upon entering the facility. LPA toured the facility together with ED to ensure health and safety of residents in care. LPA observed residents in the activity room participating in activities. Areas toured include but are not limited to: common areas, twelve (12) resident bedrooms and three (3) bathroom. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with ED. A copy of the report was emailed to ED.the state’s words, verbatim · CDSS document, Sep 1, 2022

Allegation investigated: Staff did not assist resident with hygiene needs. Resident was not provided with adequate incontinence care. Staff left the facility and residents were left unattended. Staff did not provide adequate food service to residents. Resident sustained pressure sores due to lack of care and supervision. Facility is in despair.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 8/17/2022 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 02/02/2022. LPA met with Administrator, Debra Duval, and explained the purpose of the visit. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents, such as residents’ physician's report, level of care assessment, emergency contact, and photographs. Continue on page LIC-9099C. Unsubstantiated Allegation: Staff did not assist resident with hygiene needs. – Unsubstantiated. The Department interviewed a total of five (5) facility staff and reviewed four (4) resident records. Interview with staff (S4) indicated that Memory Care residents sometimes refuse assistance with hygiene needs, but the facility staff will follow up with resident later to make sure hygiene needs are made up for that same day. Three (3) facility staff indicated staff assist residents with hygiene needs by assisting residents with brushing their teeth in the morning and remind residents to wash their hands with soap after going to the toilet. Allegation: Resident was not provided with adequate incontinence care. – Unsubstantiated. Statement received from Complainant indicated that facility staff failed to provide adequate incontinence care to four (4) residents. Complainant stated facility staff are not changing residents’ depends, leaving residents soaked in urine and feces. The Department interviewed a total of five (5) facility staff and reviewed four (4) resident records. According to residents’ Physician’s Report, R1 and R2 have bowel and bladder impairment. R1 and R2 use depends and are unable to care for their own toileting needs. R1’s Level of Care Assessment was completed on 02/28/2022. Assessment indicated R1 requires 1-person total assistance with toileting. R2’s Level of Care Assessment was completed on 05/03/2022. Assessment indicated R2 requires stand-by assistance while toileting. R3 and R4 do not have bowel or bladder impairment. According to R3’s Assessment, which was completed on 11/24/2021, R3 requires 1-person total assistance with toileting. Interview with S3 indicated, Memory Care residents can be combative at times which can make it difficult for staff to provide incontinence care. Staff would try their best to redirect and convince residents to allow incontinence care. LPA received consistence statement from facility staff indicating that rounds are conducted every 2 hours to make sure residents care is being met. Allegation: Staff left the facility and residents were left unattended. - Unsubstantiated. Statement received from Complainant indicated two facility staff, S1 and S2, from Memory Care Unit had walked-off their scheduled shift, leaving residents without care and supervision. Interview statement received from S3 indicated a facility staff (S4) had witnessed S1 and S2 leave the community and reported S1 and S2 to management. Interview statement received from S5 indicated that S5 has worked the same shift as S1 and S2 and did not witness the two staff leaving their shift. According to Executive Director and Generations Program Director, they have never witness staff walk-off from duty at Memory Care Unit. Continue on page LIC9099-C. Allegation: Staff did not provide adequate food service to residents. – Unsubstantiated. LPA Keosavang interviewed two (2) kitchen staff, three (3) care staff, resident (R5) and R5’s son. It was discovered that the facility provided adequate food service to residents in care. No expired milk or moldy foods were being provided to residents to consume. On 8/17/2022, LPA interviewed R5’s son at the facility. He stated he had lunch at the facility twice with R5 and had no complaints about the food. According to facility chief, fresh food is delivered every week and milk is delivered every Wednesday and Saturday. According to the three (3) care staff, food is adequate and there are no complaints from residents or any concerns. Allegation: Resident sustained pressure sores due to lack of care and supervision. – Unsubstantiated. According to Complainant, R4 had been left in disarray and has sores that are stageable. The Department received and reviewed R4’s documents such as Physician’s Report, Emergency Contact, and Level of Care Assessments. R4’s primary diagnosis is Alzheimer. According to R4’s Physician’s Report, R4 has history of skin breakdown. R4 can care for personal needs such as bathing, grooming, feeding, and toileting. R4 is not receiving hospice care. Interview with S3 indicated R4 had a small open wound which the facility called Home Health to come out to evaluate which they indicated was not a pressure sore. R4 was provided a cream for open wound. Interview statement received from ED, indicated R4 only requires reminders for activities of daily living. ED indicated R4 did not obtain pressure sore while at the facility and does not currently have any pressure sores. Allegation: Facility is in despair. -Unsubstantiated. On 02/14/2022, LPA Michael Hood conducted a tour at the facility with Generations Program Director Kathryn Nevin. LPA observed the facility to be clean, safe, sanitary, and in good repair. LPA Keosavang interviewed facility staff (S5) who indicated facility is in good repair. S5 stated facility has a maintenance person who works at the community. S5 indicated if something needs to be repaired at the facility, the maintenance person would fix it right away. According to Maintenance Director, Dale Garrett, he is on call 24/7 and if he receives a work order then he would repair it right away. Maintenance Director stated the only time it may take longer than a day to repair is if he needs to order parts. Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.the state’s words, verbatim · CDSS document, Aug 17, 2022 · control 25-AS-20220202093531

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 06/09/2022 to conduct a Case Management- Health Checks. LPA met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. LPA wore a N-95 mask and were screened by facility staff upon entering the facility. LPA toured the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, six (6) resident bedrooms and one (1) bathroom. In the areas toured no immediate health, safety, or personal rights violations were observed. Facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Jun 9, 2022

Allegation investigated: Facility does not have adequate staffing to meet residents' needs.

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 04/07/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 10/13/2021. LPA met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA arrived at the facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. Throughout the course of the investigation, the Department conducted interviews and reviewed pertinent documentation relevant to the allegation listed above such as R1’s Physician’s Report, PRN Authorization Letter, Diet Request Form, Level of Care Assessments, Service Agreement, Admission Agreement, facility’s staff and resident rosters, and employee timecards. Unsubstantiated Interview statement received from Complainant indicated, the facility has only one (1) caregiver providing care to thirty (30) residents. The Department interviewed and received statements from a total of three (3) facility staff from the Memory Care Unit. Through interview statements received from facility staff it was discovered the facility had hired staffing agency to cover shifts. The Department had received and reviewed facility’s employee timecards. In September of 2021 the employee timecards display one (1), caregiver was assigned to work a shift, two (2) agency staff were paid to cover shifts, and one (1) Med-Tech is always on the floor. This agency has investigated the above listed allegation. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation to be UNSUBSTANTIATED. An exit interview conducted. On 10/20/2021, the Department arrived at the facility and conducted an interview with Executive Director. It was discovered that Executive Director allowed entry to a Health Care worker without proof of vaccination. Executive Director stated that she had review the PIN 21-40-ASC and that’s why she granted VA Health Care worker entry to the community. According to PIN-40-ASC, the vaccination and testing requirements, and verification and recordkeeping conditions do not apply to: Visit from CDSS, CDPH, CDDS or local health department officials, mental/healthcare provider (e.g., home health and hospice agencies), and essential government authorities needing to enter or conduct investigations at the facility. Allegation: Facility raised resident’s rate without proper notice. – UNFOUNDED. According to complainant, the facility had increased R1’s rate to $1895.00 without notice. The cost of rent had been the same and consistent for 3 years. The Department had requested for the facility to provide proof of notice that was sent out to R1’s responsible party. It was discovered that the facility sent out a notice of increase in monthly rate to R1 and R1’s responsible party on 04/22/2021. The facility stated the reason for rate increase is due to increase in food, utilities, transportation, technology, and the most impactful, an increase in labor costs. Due to these factors the facility will be charging R1 with a new rate of $5265.00. The letter states that this new rate will go into effect on 07/01/2021. R1’s responsible party had signed the agreement on 04/30/2021. According to Title 22, modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. This agency has investigated the complaint allegations above. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview conducted.the state’s words, verbatim · CDSS document, Apr 7, 2022 · control 25-AS-20211013124652

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 2/15/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment at the facility with the ED. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, eight (8) resident bedrooms, two (2) bathrooms, kitchen, and medication room. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Feb 15, 2022

Allegation investigated: - Resident was physically abuse while in care. - Staff failed to treat resident with dignity and respect.

This is an amended report which is reflected on the 9099-D. Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 1/21/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 12/18/2020. LPA met with Executive Director, Debra Duval, and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA were screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents relevant to the allegation listed above. The Department had requested the facility to submit staff roster, resident roster, Resident’s Physicians Report (R1), Admission Agreement, Identification and Emergency Information, Level of Care Assessment, Unusual Incident/Injury Report, and Associate Termination Form. ********************************************* Continue on page LIC 9099-C ******************************************* Substantiated Allegation: Resident was physically abuse while in care. – Substantiated. On 02/25/2021, the facility submitted an Unusual Incident/ Injury Report to CCL. The Unusual Incident/ Injury Report indicated that a care staff (S1) witnessed another care staff (S2) twisting R1’s wrist while trying to change R1 on 02/23/2021. The facility had notified R1’s RP and Local Long-Term Care Ombudsman of the incident. The facility also conducted an internal investigation. The Department had received a copy of S1’s written statement of the incident and had reviewed it. According to the written statement, S2 had asked S1 for assistance with changing R1. During the change R1 had become somewhat agitated and tried to hit S2. R1 had hit S2 in the eye and S2 grabbed R1’s hand hard to move it away. S2 appeared to twist R1’s right index finger in the process. According to S1, R1 had cried out in pain and showed S1, R1’s hand. S1 then reported the incident to Med-Tech and the ED during morning stand up. Interview statement received from S4 indicated there was another incident that occurred in December of 2020. S4 had witnessed S2 physically abuse incontinence Memory Care residents. S4 observed S2 “open hand smacked their hands” and hear residents cry out in pain. S4 also stated S2 would “yank their wrist and grab it hard.” According to S4, the incident was reported to Med-Techs and management. S4 stated a written report was submitted to the facility. The Department had requested for S4’s written statement, but the facility was unable to locate it. It was discovered that S2 was put on suspension pending an investigation on suspected resident abuse on 02/23/2021. On 03/02/2021, S2 had resigned from the facility. Allegation: Staff failed to treat resident with dignity and respect. – Substantiated. The Department had interviewed and received statements from a total of five (5) facility care staff. It was discovered that S2 had verbally abuse residents in care and did not treat R2 with dignity and respect. Interview with S4 indicated, S2 would call R2 “stupid and dumb” while changing R2. According to S4, S2 had verbally abused R2 on multiple occasions. Interview statement from S5 revealed that there were multiple complaints to from other care staff about S2 verbally and physically abusing residents. Care staff notified management of S2’s inappropriate behavior towards residents in care. Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and a copy of the report left at the facility. Allegation: Staff did not assist a resident with hygiene needs. – Unsubstantiated. The Department interviewed five (5) facility staff and reviewed resident’s (R1’s) records. According to R1’s Physician’s Report, R1 has bowel and bladder impairment. R1 is not able to care for own toileting needs. The Department reviewed R1’s the Level of Care Assessment completed on 11/25/2020, R1 needs assistance with bathing twice per week and grooming including full assist 4-7 times weekly. Interview with staff (S3) indicated that Memory Care residents sometimes refuse assistance with hygiene needs, but the facility staff will follow up with resident later to make sure hygiene needs are made up for that same day. The Department received an interview statement from R1’s Responsible Party (RP). R1’s RP stated the care that was provided to R1 was good. Allegation: Staff did not provide adequate food service to residents. – Unsubstantiated. Throughout the course of the complaint investigation the Department conducted interviews with four (4) residents (R). It was discovered three meals a day with a range of items being served to residents in care. Interview statements received from care staff indicated food service provided to residents in care is not adequate. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the report will be sent via email to Executive Director, Debra Duval, and a signed copy is to be returned to LPA. Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director. Appeal rights were printed and given with the report.the state’s words, verbatim · CDSS document, Jan 21, 2022 · control 27-AS-20201218135459

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 21, 2022

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on interview the licensee did not ensure that resident was afforded their personal rights which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2022

Plan of correction: Administrator agrees to conduct a training for all staff on abuse, neglect, and mandate reporting. Facility to submit scheduled training by end of day 1/21/22. In addition staff no longer works at the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 16, 2022

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted facility did not ensure staff were trained on how to treat resident with dignity and respect. Resulting in S1 grabbing/twisting R1's arm.the state’s words, verbatim · CDSS document, Jan 21, 2022

Plan of correction: Administrator agrees to conduct a training for all staff on abuse, neglect, and mandate reporting. Facility to submit scheduled training by end of day 02/16/22. In addition staff no longer works at the facility.

Allegation investigated: Lack of supervision resulting in resident wandering away from the facility.

Licensing Program Analysts (LPAs) Sarena Keosavang and Melissa Parks arrived at the facility unannounced on 12/02/2021 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 10/26/2020. LPAs met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. Prior to initiating the visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and LPAs arrive at the facility and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask and N-95 Mask. Additionally, LPAs were screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents relevant to the allegation: lack of supervision resulting in resident wandering away from the facility. The Department received R1’s Physician’s Report, Level of Care Assessment, Medication Administration Records, Admission Order, Progress Notes, and Preplacement Appraisal Information. *************************************** Continue on page LIC 809-C *********************************************** Substantiated According to Complainant, R1 was admitted into the assisted living side of the facility beginning of August 2020. The 3rd week of August, R1 was able to leave the facility and did not notify facility staff. After the incident R1 was transferred to the memory care side to make sure there was more supervision for R1. R1 was able to leave the facility again without staff’s knowledge. Complainant had to call the facility to notify them that R1 had left the facility. Records review revealed, on 08/03/2020 an initial level of care assessment was completed by the facility. It was discovered, R1’s elopement history and concerns were reviewed by facility’s Resident Care Director (RCD). On 09/07/2020, a second level of care assessment was completed by the facility due to R1 being moved to Memory Care Unit. The level of care assessment states that R1 requires staff to escort up to 3 times daily and requires checks at regular interval. On 10/02/2020, a third level of care assessment was completed by the facility. Changes in the level of care assessment indicated an increase in R1’s required checks at frequent intervals. The Department interviewed and received statement from Resident Care Director (RCD), Allison. RCD was asked to elaborate on R1’s level of care assessment which states that R1 requires staff to escort up to 3 times daily. RCD stated R1 is being escorted to breakfast, lunch, and dinner. RCD was asked to elaborate requires checks at regular intervals. RCD stated, if resident was on status check then staff is to check on resident throughout the day and night. RCD was asked if staff is required to check on R1. RCD answered, yes. It was discovered that on 07/29/2020, R1 moved into the assisted living unit of the facility. On 09/05/2020, R1 was moved to memory care unit. The Department reviewed facility’s communication with R1’s Physician. On 10/03/2020, the facility notified R1's Physician that R1 had left the community on 10/02/2020 at 2 PM and was taken to his former residence by a good Samaritan. R1 was transported back to the community in good condition. No c/o pain or discomfort. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D. Appeal rights provided to the facility. An exit interview was conducted with Debra Duval, Executive Director, and a copy of this report will be provided to the facility via email. CCL received an Unusual Incident/Injury Report from the facility indicating R1 was sent to Roseville ER due to a medical emergency. On 10/13/2020, staff found R1 significantly weaker and unable to get out of chair. R1 made complaints of dizziness, difficulty breathing, and difficulty seeing. Staff called 911 at 4:10 p.m. and remained with R1 until emergency response arrived at 4:20 p.m. R1’s Responsible Party (RP) was notified. According to the facility, R1 did not return to the community and was moved to a higher level of care facility. The facility conducted a total of three (3) Level of Care Assessments on R1. On 08/03/2020, R1’s Level of Care Assessment revealed R1 has moved into the Assisted Living Unit and does not require hospice services. On 09/07/2020 and 10/02/2020, another Level of Care Assessment was performed on R1. Documents revealed R1 moved out of the Assisted Living Unit to the Memory Care Unit. Changes in the Level of Care Assessment include the facility requiring staff to check on R1 at regular intervals due to elopement history. There is no indication on the Level of Care Assessment of change in health condition or require hospice services. The Department reviewed the facility’s communication with R1’s Physician on 10/13/2020. Documents revealed that the reason for communication was due to R1’s change in behavior and later that day was transferred to the hospital. R1 has been very confused for the last few days. R1 was complaining about shortness of breath, not able to get put of chair, has been having delayed response to questions, and when calling R1’s name. Facility reported to R1’s Physician that R1 is not able to do something that R1 was doing before. Facility asked for R1’s Physician’s advice. Physician responded back to the facility that R1’s responsible party was notified of change of condition and 911 was to be called. This agency has investigated the above listed allegations. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegations to be UNSUBSTANTIATED. An exit interview conducted, and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Dec 2, 2021 · control 27-AS-20201026091059

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 3, 2021

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided ... that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on records review and interviews, R1 left the facility and was driven to wife's residence by a good samaritan. This poses an immediate threat to the health and safety of the resident in care.the state’s words, verbatim · CDSS document, Dec 2, 2021

Plan of correction: Executive Director agrees to conduct staff training regarding elopment. Facility to submit scheduled training by end of day 12/3/2021. Training to be completed by all care staff by 12/31/2021.

Allegation investigated: Resident obtained a pressure injury at facility due to neglect.

Licensing Program Analysts (LPAs) Sarena Keosavang and Melissa Parks arrived at the facility unannounced on 12/02/2021 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 12/17/2020. LPA met with Administrator, Debra Duval, and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and LPAs arrives at the facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask and N-95 Mask. Additionally, LPAs were screened by facility staff upon entering the facility. Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents such as resident's (R1) physician's report, level of care assessment, medical discharge paperwork, outside home health agency ntoes, and communication logs relevant to the allegation: Resident obtained a pressure injury at facility due to neglect. ******************************************* Continue on page LIC-809C ************************************* Unsubstantiated Records review revealed, R1 has a history of skin integrity. It was discovered that R1 was ambulatory, independent, and was able to perform most ADLs. LPA was unable to find any documentation related to any pressure injury. Specifically, Home Health Nurse documentation revealed that no wound could be found 5 days after hospital discharge. Staff interviews conducted revealed that R1 had a history of dry skin and rash which was being treated by prescription ointment. Staff interviews did not reveal any history of wounds or issues with skin integrity due to neglect. LPA interviewed R1's POA who acknowledged that R1 had a history of skin issues and skin tears due to skin fragility. LPA additionally interviewed R1's assigned Home Health Nurse who acknowledged that R1 was mostly independent of ADLs, active, and never observed any pressure injuries. Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted with Executive Director, copy of report was provided via email. Appeal rights were printed and given with the report.the state’s words, verbatim · CDSS document, Dec 2, 2021 · control 27-AS-20201217161702

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 10/20/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Executive Director (ED), Debra Duval, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA arrived at the facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the facility together with ED to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, two (2) bathrooms, kitchen, and courtyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and ED completed the infection control domain and facility was found to be in substantial compliance at this time. LPA requested for ED to submit documents to Community Care Licensing by 10/27/2021. LIC 200 Designation of Administrative Responsibility LIC 308 Liability Insurance Facility Floor Plan LIC 999 Fire Clearance Control of Property- Rental Agreement No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Oct 20, 2021

Allegation investigated: Staff did not ensure resident's colostomy bag was changed.

Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 07/27/2021 to deliver complaint findings. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted licensee and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPAs met with Administrator Debra Duval and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed pertinent documentation relevant to the allegation listed above. The results are as follows: ***Continuation on LIC9099-C*** Unsubstantiated Allegation: Staff did not ensure resident's colostomy bag was changed. Complaint alleged R1 was not receiving assistance with their colostomy bag. On 05/28/2021 LPA reviewed resident (R1)'s records. R1's medical assessment (dated 3/17/2020) indicates R1 is able to self manage colostomy bag. R1's care assessment conducted by the facility indicates R1 is able to self manage colostomy bag. On 05/28/2021 LPA interviewed R1's spouse who stated R1 was managing their own colostomy bag and did not have issues regarding his hygiene. On 06/08/2021 LPA interviewed three (3) of three (3) facility staff. Majority of staff stated R1 was responsible for their colostomy bag and was able to empty it themself but needed daily reminders. Due to R1's passing on 10/17/2020, LPA was unable to interview R1. No further evidence was provided. LPA finds the allegation to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jul 27, 2021 · control 27-AS-20210105104630