Meadowbrook at Agoura Hills

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Angela Barutyan arrived on August 11, 2026, for an unannounced inspection to follow up on a substantiated allegation of death investigation. The LPA met with Executive Director (ED) Stephanie Funderburg. On May 12, 2023, the Department concluded a death report investigation regarding the following incident: Neglect/Lack of Care and Supervision: Resident sustained a fall outside of the facility while left unattended by facility staff. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services and 87405(d)(1) Administrator – Qualifications and Duties. At the time of the case management visit on May 12, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e) or (f). The Department has concluded an analysis and has determined upon further review that a civil penalty is warranted for death. This is evidenced by the facility’s failure to provide care and supervision which resulted in the resident leaving the facility unsupervised, suffering a fall and injuries including the inability to maintain and control respiratory functions without the use of long term mechanical respiratory support and that upon removal of the mechanical respiratory equipment, resulted in R1’s death. Report Continued on LIC809-C. Report Continued from LIC809. Today, August 11, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines constitutes as death in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on May 12, 2023, the amount of the civil penalty issued today will be $14,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. ED Funderburg and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 11, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced Case Management - Incident visit at 01:15 PM. The purpose of this visit is to conduct an investigation regarding self-reported incidents that occurred on 07/24/2026 and 07/25/2026. LPA met with Executive Director (ED) Stephanie Funderburg and explained the reason for the visit. During today’s visit, LPA conducted a physical plant tour to ensure there are no immediate health and safety hazards, interviewed three (3) staff members, and reviewed and obtained copies of pertinent documents. On 07/31/2026, the Department received an incident report stating that on 07/24/2026, Staff #1 (S1) observed smoke emitting from unit #102’s bathroom exhaust fan. The resident was not in their room at the time of the incident. S1 followed fire safety protocols by notifying the Memory Care Director, while Staff #2 (S2) retrieved a fire extinguisher and extinguished the fire. The ED was contacted immediately for assistance. Prior to the to the arrival of the fire department, staff entered the unit to confirm that the fire had been fully extinguished. Circuit breakers were turned off, and the sliding door and windows were opened to ventilate smoke and extinguisher residue from the room. The fire department arrived shortly after and confirmed that power to the unit had already been shut off, noting that the breaker had tripped automatically during the incident. Fire personnel inspected the wiring connected to the bathroom exhaust fan and confirmed there was no damage to the ceiling or electrical wiring. A precautionary walk-through of the property was also completed before departure. Following the incident the facility contacted Cintas, a fire protection service provider, to investigate why the fire alarm system did not activate. Report Continued on LIC809-C. On 7/25/2026 at 6 AM, a Cintas technician arrived on site to inspect and test the fire alarm system. The functional testing of smoke detectors was performed. The standalone smoke detector inside unit 102 was tested and functioned properly. The technician determined there was insufficient smoke or heat within the unit to trigger the in-room detector during the incident. The hallway smoke detector outside unit 102 was tested and successfully activated the building- wide alarm system, including audible alarms and safety mechanisms. During today’s visit, LPA observed unit 102. The bathroom exhaust fan in the unit had no visible signs of smoke or fire debris/damage. Staff indicated that the exhaust fan was replaced after the incident and that monthly cleanings of bathroom unit exhaust fans will be conducted. LPA observed three (3) other resident rooms in the Memory Care unit and bathroom exhaust fans appeared clean. LPA observed fire extinguishers throughout the Memory Care unit which were fully charged and last serviced on 05/05/2026. LPA reviewed documentation confirming the service call to Cintas on 07/25/2026. The technician tested the smoke detector inside the unit, the main hallway smoke detector, and checked the smoke detector connections to the fire panel and central station. Smoke detectors “activat[ed] audibles and alarms properly. Fire system was normal when departing from the facility.” No immediate health and safety hazards were noted. On 07/31/2026, the facility also notified the Department that on 07/25/2026, Resident #1 (R1) had eloped from the Memory Care unit following a power outage. Around 7:38 AM, the community experienced a power outage and power was restored at 7:57 AM. The delayed egress doors in the Memory Care unit did not return to normal operation after power was restored. Director of Plant Operations immediately contacted emergency service provider to troubleshoot the issue. Around 7:54 AM, the ED instructed the staff to ensure the doors were secured until the system was working. Around 9:52 AM, staff discovered that R1 was missing and had last been seen approximately 10 minutes prior, around 09:42 AM. Staff immediately initiated a search of the community including all surrounding areas. At 10:15 AM, R1’s responsible party was notified and local law enforcement was contacted to report R1 missing. At 10:31 AM, approximately forty-nine (49) minutes after R1 was presumed missing, local police located R1 down the street from the community and safely returned R1 to the facility. R1 was evaluated by paramedics and found to be stable with no apparent injuries. Following the incident, R1’s primary care provider was notified, R1 was reassessed and their Service Plan was updated, and staff received an in-service training on elopement prevention protocols and procedures for managing delayed egress door malfunctions. Report Continued on LIC809-C. During today’s visit, LPA toured the Memory Care unit. LPA observed residents in common areas with staff supervision. The Memory Care unit has three (3) delayed egress doors which have a delay set to thirty (30) seconds. Delayed egress door was tested at 02:10 PM and functioned properly. LPA observed power in the Memory Care unit and no immediate health and safety concerns were noted. LPA reviewed proof of backup batteries purchased on 08/05/2026 for the delayed egress doors. Staff stated that during an outage, the delayed egress batteries power the community, resulting in their batteries draining and the delayed egress to be nonfunctional. Staff indicated that the backup batteries will prevent the batteries in the delayed egress doors from emptying during an outage. LPA reviewed documentation of the one-hour in-service training completed on 07/27/2026 for the topic “What to do if delay egress door are not operable / Elopement procedures” conducted with all staff. LPA reviewed a Temporary Service Plan for R1 signed by staff and dated 07/28/2026 to reflect “elopement risk” and “increase supervision with wandering and location engage resident to activities.” Furthermore, R1’s care plan was updated on 07/31/2026 to include “wandering” and “exit seeking” as needing occasional support. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. An additional report may follow if warranted. Exit interview conducted. Appeal rights and a copy of the report were provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 12, 2026

1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found by law enforcement away from the facility approximately 49 minutes later which poses a potential safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 5, 2026

Plan of correction: Following the incident, R1’s primary care provider and responsible party were notified, R1 was reassessed and their Service Plan was updated, and staff received an in-service training on elopement prevention protocols and procedures for managing delayed egress door malfunctions. POC is cleared.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 01:15 PM. LPA met with Executive Director (ED) Stephanie Funderburg and explained the reason for the visit. At 01:53PM, the LPA along with the ED toured the Memory Care unit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: LPA inspected the Memory Care kitchen/food service area. Knives and sharps were inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition. COMMON AREAS: Furniture in the Memory Care common areas were observed to be in good condition. The fire extinguishers were fully charged and were last serviced 05/05/2026. LPA observed required postings throughout the common space. Activity Rooms were observed to be clean. Fireplaces were adequately screened. Surveillance cameras were observed in hallways. BEDROOMS: LPA observed four (4) randomly selected resident bedrooms in the Memory Care unit. Bedrooms were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. Bedrooms are equipped with AUGI devices for fall prevention and detection. RESTROOMS: The resident restrooms in the Memory Care unit were clean, sanitary, and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured and were between 106.0-111.4 degrees Fahrenheit, which is within the required range. The LPA will return at a later date to continue the annual inspection. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst, Valeria Conway arrived on October 21, 2025, for an unannounced inspection to follow up on a substantiated allegation of a death report investigation. The LPA met with Joeyvic "Joey" Alvarado. On May 12, 2023, the Department concluded a death report investigation regarding the following incident: neglect/lack of care and supervision and failure to seek timely medical attention. The licensee was cited for California Code of Regulations (CCR) 87465(g) Incidental Medical and Dental Care; 87628(a) Diabetes; and 87705(c)(5) Care of Persons with Dementia, and 87705(c)(6) Care of Persons with Dementia At the time of the case management visit on May 12, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49 (f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility having caused serious bodily injury to the resident by creating a “substantial risk of death” in failing to comply with the standard of care to timely summon emergency medical care. Continued on LIC 809-C Continued from LIC 809 Today, October 21, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on May 12, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Joeyvic "Joey" Alvarado signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Staff failed to treat resident with dignity or respect Staff failed to meet residents incontinent needs while in care

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced 10-day initial complaint visit to investigate the allegations listed above. Upon arrival LPA met with the Executive Director (ED), Joeyvic “Joey” Alvarado, and explained the reason for the visit. During today’s visit, between 10:55 A.M.– 4:45 P.M., LPA and administrator toured the physical plant to ensure there are no health and safety concerns. Additionally, LPA interviewed the ED and staff members, obtained and reviewed pertinent documents relevant to the investigation. The LPA reviewed all documents obtained, conducted telephonic interviews with additional credible witnesses. The following was then determined: Conitnued on LIC 9099-C Substantiated Continued from LIC 9099 Regarding allegation “Resident was left in soiled diaper for extended period of time” it was alleged that R1 was left in a soiled diaper for more than ten (10) hours. Interviews conducted reflected the R1’s family was notified by the facility ED that R1 had not been checked since 5:45 P.M. on the evening of 09/29/2025. Information gathered during the course of the investigation reflected that, the ED made a typographical error when corresponding with R1’s family and inadvertently stated P.M. vs A.M. Per the ED, the information was inaccurate as the night shift begins at 10:00 P.M. and ends at 6:00 A.M. the following day. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Resident was left in soiled diaper for extended period of time” is deemed unsubstantiated at this time. Continued from LIC 9099 It was alleged that “Staff failed to treat resident with dignity or respect”. It was reported that in March 2025, Staff #1 (S1) intentionally fed Resident #1 (R1) dog food, allegedly as a joke. After receiving a formal complaint and speaking to the Reporting Party (RP), LPA reviewed the facility’s history and determined that on 04/09/2025 a Case Management (CM) visit had been conducted by LPA E. Cortez regarding the incident involving R1. Evidence reviewed during that visit, including the facility’s incident report and the report of suspected dependent adult/elder abuse form (SOC341) submitted by the ED on 03/21/2025 to Community Care Licensing (CCL), confirmed that the incident had occurred. According to the SOC341, ED acknowledged that S1 fed R1 food from a bowl with paw prints containing dog food, rather than from the community’s kitchen bowl containing Spaghetti prepared for residents. The facility’s internal investigation further confirmed that S1 was laughing about the incident and shared details of their actions with other staff members. R1 did not ingest the dog food and reportedly spat it out immediately. Following the incident, the ED contacted R1’s responsible person and their physician and removed S1 from employment as of 03/31/25. Additionally, all staff were retrained on mandated reporting requirements and abuse prevention procedures. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. As a result, the allegation of “staff do not treat residents with dignity or respect” has been SUBSTANTIATED at this time. However, this issue was previously addressed during a case management visit conducted on 04/09/2025, at which time citations were issued. Therefore, no citations will be issued today. Regarding allegation of “Staff failed to meet resident incontinent needs while in care”. It was alleged that facility’s staff left Resident #1 (R1) covered in feces from head to toe in R1’s bed. Interviews conducted reflected that on 09/30/2025, at approximately 8:45 A.M., R1’s family member found R1 covered with urine and feces. Additionally, it was also revealed that prior to this incident R1 was often found in briefs saturated with urine in the morning. Continued on LIC 9099-C Continued on LIC 9099-C Staff interviews conducted revealed that R1 can be resistant to care at times, becomes easily agitated, and would often refuse showers or care-related assistance. Additionally, even though there is no documentation stating R1 requires frequent monitoring, staff who provide care to R1 stated that due to R1’s condition, R1 requires more frequent monitoring. Additionally, it was revealed that all staff are aware that R1 should be checked at least once every hour. During the interview, staff #2 (S2) reported that on the morning of 09/30/2025, at approximately 6:10 AM, the night shift staff (S3) verbally informed them that R1 had been cleaned and did not require further assistance at that time and proceeded with their regular morning duties, responding to other residents who called for assistance without checking on R1. An interview with the ED revealed that S2 acknowledged that they relied on the information provided by S3 and did not verify R1’s status during the transition between shifts. During today's visit, the LPA reviewed the facility's camera footage from the date of the reported incident. The footage showed that S3 entered R1's room at approximately 5:16 AM and exited at 5:17 AM. The next individual observed entering R1's room was the family member, who arrived at approximately 8:52 AM. Based on the information gathered and record reviewed during the investigation, the department has sufficient evidence to confirm this allegation occurred. As a result, the allegation of “Staff failed to meet resident incontinent needs while in care” has been SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 29-AS-20251006091242

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 30, 2025

87625 Managed Incontinence (b)…Requirements for Allowable Health Conditions, the licensee shall be responsible...:(3) Ensuring that incontinent residents are kept clean and dry and that the facility... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, as facility staff failed to ensure that R1 was kept clesn and dry, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: ED conducted a in-service training with caregivers regarding R1's needs, refusals and incontinent frequently checks.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced Case Management visit at the facility in conjunction with a complaint investigation. LPAs met with Executive Director (ED) Joeyvic" Joey" Alvarado and explained the reason for today’s visit. Entrance interview conducted. During today's visit, the ED expressed concern regarding an alleged sexual abuse incident that occurred on 10/14/2025, at approximately 5:30 PM in the Memory Care Unit. The ED explained that all responsible parties involved, as well as the resident's primary physician, were notified of the event. The ED stated that an incident report will be submitted to to Community Care Licensing (CCL) by the end of the day. The LPA explained to the ED that, as a mandated reported, the ED is required to cross-report the incident to the appropriate agencies and notify law enforcement. The ED reported that, as of today, R1 has a 24-hour, one-on-one (1:1) private caregiver assigned to provide continuous assistance and supervision. The LPA gathered records pertaining to Resident #1(R1) and Resident #2 (R2), and conducted an interview with the ED. At approximately 2:30 PM, law enforcement arrived to conduct an investigation. Deputy's Name: Zavala. Report #925-04628-2223-444. Further investigation is needed regarding the alleged sexual abuse. Exit interview held. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Staff placed resident in the memory care unit without proper authorization

Licensing Program Analyst (LPA), Esther Cortez conducted a subsequent unannounced complaint visit to deliver findings for the above allegation. Upon arrival, LPA met with the Executive Director Joey Alvarado and explained the reason for the visit. On 04/14/25, between 11:20 a.m. and 4:15 p.m., the LPA toured the memory care unit, interviewed the administrator, one (1) staff, one (1) resident, one (1) resident's authorized person, conducted a file review, and collected pertinent documents relevant to the investigation. It was determined further investigation was required prior to issuing findings. On 05/16/25, the LPA conducted interviews with R1’s authorized person and a family member telephonically. Report will continue on LIC9099-C, 2nd page. Unsubstantiated Regarding the allegation, “Staff placed resident in the memory care unit without proper authorization”; it is the concern of the Reporting Party (RP) that starting in December 2024, Resident 1 (R1) a resident of high intelligence, with no significant memory issues asked facility staff for a transfer from their memory care (MC) room to an assisted living (AL) room and facility staff denied their request. It was further alleged that R1’s emotional health has declined due to living in the memory care unit and a lack of socialization opportunity. R1 has no interest in attending memory care activities as they are unchallenging and uninteresting to them and has reported “a depression” that lasted a few days after “being allowed” to go into the assisted living side of the facility to do activities. Facility staff continue to defer to R1’s, Power of Attorney for health care, who states that R1 has "frontal temporal dementia" and needs memory care. Furthermore, it is alleged that R1 denies having dementia and has stated the dementia diagnosis has been determined by a neuropsychologist to be in error and they have in their possession a multipage cognitive assessment made on 8/13/24 by Dr. Robert Duff from Insight Neuropsychology stating R1 does not have "frontal temporal dementia" or any other dementia. To investigate this complaint LPA Cortez reviewed R1’s records and conducted interviews. A review of R1’s Admission Agreement signed by R1’s POA and dated 07/31/24, revealed that R1 was admitted to the facility with a Care Authorized Representative who is their POA. File review revealed that R1 has a signed Advanced Health Care Directive and Durable Power of Attorney dated 06/2007, designating their POA for health care to make health care decisions for them in their name as authorized in the Directive, in the event they become incapacitated. As per the Directive, R1’s POA has the power and authority to make decisions as to personal care for R1, which includes making decisions relating to their personal care, but not limited to, determining where they will live, providing meals, and hiring and supervising household employees and other service providers. File review also revealed that R1 has a letter from a physician indicating R1 is not capable of making their own decisions regarding medical treatment or financial matters, dated 05/24/2024, and has a Determination of Incapacity, dated 09/04/2024, signed by a licensed physician indicating that R1 is incapacitated and unable to handle their own financial affairs. A review of R1’s admitting physician’s report, dated 05/29/24, indicated R1’s primary diagnosis was listed as frontal temporal dementia. The report indicated R1’s mental condition as confused/disoriented when sundowns, has sundowning behavior, and R1 is not able to leave the facility unassisted. A review of R1’s Neuropsychological assessment, dated 08/13/24, revealed that R1 underwent a neuropsychological assessment on 07/05/24, to evaluate their cognitive function. Report will continue on LIC9099-C, 3rd page. According to the records the clinical Neuropsychologist Licensed Psychologist concluded that there was little current evidence to suggest that R1 has frontotemporal degeneration that would lead to dementia. A review of R1’s most recent physician’s report, dated 03/13/25, indicated R1’s primary diagnosis as Frontotemporal Dementia. The report indicated R1 is not able to leave the facility unassisted. An interview conducted with the current Administrator Joey Alvarado revealed that they were not working at the facility when R1 was placed at the facility but is aware that R1 was placed in the MC unit when admitted to the facility due to their frontal temporal dementia diagnosis, Drs. recommendation, and upon R1’s POA request due to safety concerns. R1 sent them an email back in February from his psychotherapy that they do not have dementia, however R1’s Physician’s report (LIC602) indicated Dementia. She had a new physician come out to the community and assessed R1 to determine if R1 could be placed in AL. Dr. Lefferman saw R1, diagnosed R1 with Frontotemporal Dementia and suggested they could try placing R1 in AL during the day and see how it went. The community is willing to place R1 in Assisted Living when they have clearance from the doctor but have safety concerns, concerned of R1 eloping due to R1’s diagnosis and POA’s voiced concerns, and do not want to be liable if any incident occurs if R1 is placed in AL when the POA requested for R1 to be placed in MC. The Administrator stated that R1’s POA told them that the moment they move R1 to AL, R1 will leave and they will lose R1. The Administrator further revealed that R1 is very lucid, is aware, has not shown any exit seeking or aggressive behavior, is not being provided with any care other than medication management, although R1 does forget things, and there is no receptionist at night to monitor the front door if the resident left. Interviews conducted with R1’s POA and family members confirmed they placed R1 in the memory care unit due to safety concerns and R1 being diagnosed with frontotemporal dementia. They voiced concerns about the safety of R1 and the other residents if R1 gets placed in assisted living due to numerous previous incidents that had happened during the span of 6 months and are worried that R1 will have access to items that can pose a danger to them or that R1 will elope. On the allegation “Staff placed resident in the memory care unit without proper authorization,” information obtained from record review and interviews conducted revealed R1 was placed in the memory care unit upon R1’s POA request who has the authority to determine where R1 resides per the signed Advanced Health Care Directive. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 29-AS-20250411132132

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Executive Director (ED), Joeyvic Alvarado and the reason for the visit was explained. At 11:15 a.m., the LPA along with the ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: The LPA inspected the Memory Care kitchen/food service area and the Assisted Living kitchen/food area. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced 05/06/2025. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water. At 11:15 a.m. the LPA observed a cleaning cart with chemicals accessible to the residents in care left unattended in a hallway inside the Memory Care unit. At 12:15 p.m. the LPA observed a cleaning cart unattended with chemicals accessible to the residents in care in a hallway in Assisted living. (Report will continue on LIC 809-C, 2nd page...) BEDROOMS: The LPA observed ten (10) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. Resident’s cords were tested, LPA observed staff arrive in a timely manner. Smoke detectors were checked in all observed rooms and function properly during the visit. At 11:52 a.m. the LPA observed over the counter super greens 10 gummies, a tube of Voltaren Arthritis pain reliever cream, 2 icy hot lidocaine pain relievers bottles, a tube of triple antibiotic ointment in room 256, per the resident 1's (R1's) LIC602 they cannot store their own medication. At 12:04 p.m. the LPA observed over the counter medication in room 216, per the residents LIC602, it is unclear if they can administer and store own medication, however the LIC602 is from 2022 and resident is diagnosed with Dementia. At 12:11 p.m. the LPA observed a small prescribed bottle of Nystatin 1,000,000 unit/gm in room 177, per the resident 3's (R3's) LIC602, the resident cannot administer or store their own prescribed or over the counter medications. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in ten (10) random bathrooms between 11:15 a.m. and 1:00 p.m., the temperature measured between 112 – 119.8 degrees Fahrenheit. RECORDS: At 1:30 p.m. a review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, and Emergency Disaster plan . The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The LPA observed the following: R2's LIC602 is from 2022, and there is no documentation of resident's refusal to receive an annual routine visit or their representative's refusal on their behalf. Due to time constraints the LPA will return at a later date to complete 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 issued.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Staff does not ensure that facility is free from pests.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with the Administrator Joey Alvarado and was explained the reason for the visit. During today's inspection, between 10:45 a.m. and 3:00 p.m., the LPA inspected the kitchen, interviewed the Administrator, Maintenance Director, Chef and three (3) kitchen staff, requested and reviewedrecords of the facility’s ongoing pest control services and maintenance records, and collectected pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2nd page. Unsubstantiated Regarding the allegation of ‘Staff does not ensure that facility is free from pests’; it is the concern of the Reporting Party (RP) that the facility kitchen was observed with live cockroaches even though the facility receives pest control services. To investigate the allegation, the LPA inspected the kitchen, conduced staff interviews, requested records of the facility’s ongoing pest control services and maintenance records. During the physical plant tour, the LPA observed the kitchen beginning at 11:50 AM and met with Chef Francisco Garay. During the inspection, the LPA did not observe any evidence of pests. Mr. Garay stated they were aware of recent issues pertaining to pest in the kitchen and addressed it with their kitchen staff and maintenance director to ensure the kitchen is free from cockroaches. During the interviews with three kitchen staff, they revealed that cockroaches have been recently observed in the kitchen, in the past two weeks, however some were surprised as they have not had prior cockroach issues, and they have been addressing the issue. Staff indicated that all kitchen staff is responsible for the cleanliness of the kitchen, they make sure to move furniture away from the walls to clean and have received additional training on proper cleaning since the cockroach sightings. Administrator Joey Alvarado revealed that last week on 06/11/25, a health inspector had been at the facility and found cockroaches in the kitchen. The Administrator further revealed that they were surprised of the findings as they receive monthly service from Western Exterminator Company, and they had not reported any cockroach sightings. The LPA reviewed past invoices from 06/10/2025, 05/09/2025, and 04/11/2025. All three invoices report no evidence of pest activity. Furthermore, the Administrator stated that after the visit form the health inspector, they had a third-party company come out and deep clean the kitchen, kitchen staff received an in service on Kitchen cleanliness, the facility will be increasing their services with Western exterminator to twice a month, and will be receiving extensive treatment in the kitchen for the next three months to address the cockroach sightings. Although the allegation may have happened or is valid, documentation and interviews confirmed the facility is making a continuous effort to keep the facility free from pests and insects at this time. Therefore, based on information gathered the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 29-AS-20250612100903

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 02/27/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). The report stated that on 02/25/2025, while walking on the beach with several residents, R1 lost their balance and fell. R1 was transferred to the hospital for immediate medical treatment. Furthermore, R1 returned to the community on 02/26/2025 with a back fracture. On 02/28/2025, the LPA spoke with Administrator Joey Alvarado regarding the incident via a telephonic interview. On 03/12/25, the LPA conducted a case management visit regarding the incident and issued a deficiency. During today's visit the LPA conducted an interview with the Administrator, four (4) staff, a file review and collected pertinent documents related to the incident. No citations are being issued at this time. The LPA may return for a follow up for further investigation if needed. A $500 immediate civil penalty was assessed on 03/12/25. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f). Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Facility failed to provide resident records to resident and/or their authorized person

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with Administrator Joey Alvarado and was explained the reason for the visit. Entrance interview conducted. During today's inspection, between 10:50 a.m. and 5:30 p.m., the LPA interviewed the administrator, conducted a file review, and collectected pertinent documents relevant to the investigation. Report will continue on LIC9099-C, 2nd page. Unsubstantiated Regarding the allegation "Facility failed to provide resident records to resident and/or their authorized representative," the concern raised by the reporting party is that, on 03/25/25, a request was made by Resident #1 (R1) or their authorized representative for R1's medical and billing records, and that the facility did not provide the requested records. An interview with the Administrator clarified that, on 03/25/25, the facility received a subpoena for R1's medical and billing records, which included a specified deadline of two business days for submission. The requested records were faxed to the number listed on the subpoena on 03/28/25. The Administrator further stated that, prior to releasing the records, they contacted the point of contact listed on the subpoena on 03/28/25. During this communication, the Administrator informed the individual that the records would be faxed shortly and explained that the delay was due to the need for review by the legal department before the records could be released. Additionally, the Administrator revealed that on 04/08/25, the requested documents were resent by fax (in multiple transmissions due to fax issues) to ensure receipt. The Administrator noted that they had not been contacted regarding any missing documents. A file review confirmed that the community had received a record request for R1's medical and billing records. The LPA observed a Fax Transmission page dated 03/28/25, indicating that 228 pages were faxed to the number listed on the record request, addressed to the point of contact with the comment "requested items." Furthermore, the LPA observed six additional Fax Transmission pages, each dated 04/08/25, showing that a total of 208 pages were faxed to the fax number listed on the record request. An interview with the point of contact listed on the record request, on 04/09/25, revealed that they had received R1's medical records on 04/08/25, but were still awaiting the billing records. The point of contact further stated that they had spoken to a representative at the facility, who informed them they were waiting to close out March and then the billing records would be sent. Based on the information gathered, the community provided and/or will provide the requested documents regarding R1, and are not denying production of any requested information, therefore, the above allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 29-AS-20250408090835

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 03/21/2025, Community Care Licensing (CCL) received two (2) Unusual Incident/Injury Report (LIC 624) and two Self-Reports of Suspected Dependant Adult/Elder Abuse (SOC341) pertaining to Resident #1 (R1), Resident #2 (R2), Staff #1 (S1) and Staff #2 (S2). The first Incident report and SOC341 reported that on 03/20/2025, R1 was sitting on their chair by the window with their table in front of them, on their table there was a tray with their dog's food in a bowl with paw prints and R1's food in a container from the communities kitchen. S1 and S2 were with R1. R1 pointed at their dog's bowl and told S1 to warm up their food. R1 has poor vision. S1 warmed up the dog bowl, meanwhile S2 turned around as they did not want to see R1 eat the dog food and S1 gave it to the resident. R1 spat out the food and said "this is nasty, it's my dog's food." S1 took the food away and warmed up the correct food and gave it to the resident. S2 reported the incident to management. The second incident report stated that 03/20/24, S2 observed S1 be rough with R2 as S1 was assisting R2 in moving their legs to bed. It was further reported that the Administrator spoke with R2, who denied any staff had been rough with them. On 03/21/25, LPA Cortez spoke with the Administrator on the phone. The Administrator stated that S1 was suspended, S2 will receive training on intervention, incidents were reported to ombudsman, resident, residents family, residents physician and Licensing. All the appropriate actions were taken. Report will continue on LIC809-C, 2nd page. During today's visit the LPA conducted a file review and conducted interviews with R1, R2, S1 and the Administrator. Interviews with R1 confirmed that they had been given dog food, that the staff was careless and the incident made them feel diminished. Interviews with R2 revealed that they have no concerns with the care being provided and they denied staff being rough with them. Phone interview with S1 revealed that S1 did not know that the food in the bowl was dog food, gave R1 the dog food in error as they were was just doing what R1 was asking them to do, even though S2 at one point mentioned it did not look like human food. Furthermore, S1 denied being rough with R2 or any of the residents. File review revealed that S1 had previously been given a corrective action notice for neglect/ not providing appropriate care to residents prior to this incident. The LPA was not able to interview S2. Lastly, interview with the Administrator revealed that as of 03/31/25, R1 no longer works at the community and that all staff were trained on reporting abuse. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).Civil penalty was issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Apr 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 11, 2025

Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by Based on self-reported incident reports the licensee did not comply with the section cited above when a resident was given dog food they were not treated with dignity, which posed a pontential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: S1 is no longer working at the facility. Administrator agrees to develop a plan on how they will ensure residents are treated with dignity.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Administrator Joeyvic Alvarado and explained the reason for the inspection. On 02/27/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). Please note report was submitted after hours and LPA did not receive until 02/28/2025. The report stated that on 02/25/2025, while walking on the beach with several residents, R1 lost their balance and fell. R1 was transferred to the hospital for immediate medical treatment. Furthermore, R1 returned to the community on 02/26/2025 with a back fracture. On 02/28/2025, the LPA spoke with Administrator Joey Alvarado regarding the incident. She stated R1 was out on an outing to the beach with other residents and staff, they were walking the board walk and after the fall R1 was sent to the hospital and was diagnosed with a back fracture. The Administrator stated when Staff 1 (S1) was interviewed they conveyed that they were walking holding R1, and another resident (R2) by hands and when a third resident (R3) walked passed them, R2 let go of S1's hand to follow R3. S1 let go of R1 in an attempt to go after R2 and R1 fell. The Administrator stated R1 uses a walker, however S1 did not take R1's walker to the outing as they felt confident that they were going to be able to hold on to them and S1 received a corrective action. During today's inspection, the LPA conducted file review for R1 and S1 beginning at 1:28 PM. File review revealed that per R1's Resident Appraisal (LIC603A) dated 09/24/24, R1 has balance issues, ambulatory with assistance, needs assistance in walking, and is not able to walk without any physical assistance (e.g., walker, crutches, other person), or not able to walk with a cane. Per R1's Physician Report (LIC602) dated 09/24/24, R1 has a history of mechanical fall. Furthermore, R1's file review also revealed that R1 uses a walker and is a high fall risk. Report will continue on LIC809-C, 2nd page. File review revealed that on 02/28/2025, S1 received a corrective action notice for allowing residents to get off the bus to walk on the sand during a scenic drive to the beach, and one of those residents was taken off the bus without their assistive device which caused them to fall. Furthermore, S1 received a safety in-service training on 02/28/2025. Based on the information obtained, there is sufficient evidence to support a deficiency is warranted as R1 sustained an injury as a result of S1 taking R1 on an outing to the beach without their assistive device. The following deficiency was cited (See LIC 809-D) from CA Code of Regulations, Title 22, Division 8. Failure to correct the deficiencies may result in civil penalties. An immediate civil penalty of $500 was issued. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 12, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained a back fracture due to S1 taking R1 on an outing without their assistive device which is an immediate health risk to R1 in care.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: Plan of correction cleared: S1 received a corrective action and safety training regarding the use of assistive device and scheduled programs. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1).

Allegation investigated: Staff are not responding to resident's call buttons in a timely manner

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with Administrator Joey Alvarado and was explained the reason for the visit. Entrance interview conducted. During today's inspection, between 11:30 a.m. and 4:00 p.m., the LPA interviewed four (4) staff, ten (10) residents, tested three (3) randomly selected resident's pendants, reviewed and obtained copies of pertinent documents relevant to the investigation Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation, "Staff are not responding to resident's call button in a timely manner"; it is the concern of the reporting party that in case of an emergency a resident can die due to pendant calls not being answered in a timely manner. It was further reported that on 02/09/25 resident 1 (R1) around 7:30 a.m. pressed their call button and no one went, R1 then called the front desk and left a message, and waited for an additional 30 minutes until someone went to their room. Interviews conducted with staff revealed that caregivers are primarily the ones that respond to the resident’s call buttons and try to respond as quickly as they can but MedTechs and other staff will assist as well with the pendant calls to ensure they are answered in a timely manner. However staff interviews revealed that even though it does not happen often, residents have waited over 15 minutes to be assisted, it all depends if they are short staffed and how busy they are. Interviews conducted with ten (10) randomly selected residents revealed that four (4) out of the ten (10) residents do not use their pendant button as they are independent. Two (2) residents revealed staff gets to them as timely as possible, and four (4) residents revealed that it can take staff a long time to respond to their pendant calls with some revealing that they have waited over 30 minutes for assistance. Additionally, a review of the pendant call log response times revealed that on 2/09/25, R1 did not have a registered pendant call around 7:30 a.m., however, R1 did have two (2) pendant calls that took over 25 minutes to respond to on that same date. Furthermore, the pendant call log revealed that in about 21 pendant calls from various residents on 02/09/25, residents waited over 20 minutes for assistance including 12 calls that were answered after 30 minutes of waiting. Based on the information gathered through interviews, and file review, the allegation Staff does not respond to resident's call button in a timely manner is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D).Civil penalty was issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 29-AS-20250212152447

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

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on interviews, andrecords review, the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 20, 2025

Plan of correction: Licensee will submit a plan on how they will ensure residents pendant calls are answered in a timely manner. Licensee will provide plan to LPA via email by COB 2/28/2025. If training will be held, licensee will submit proof of training.

Allegation investigated: Facility staff are unable to provided medication as prescribed to residents during an evacuation.

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. Upon arrival, LPA met with Administrator Joeyvic Alvarado and was explained the reason for the visit. Entrance interview conducted. On 01/15/2024, between 11:20 a.m. and 4:30 p.m., the LPA conducted a tour of the physical plant, interviewed four (4) staff, thirteen (13) residents, one (1) residents family member, conducted a medication audit for three residents, and collected pertinent documents relevant to the investigation. During today's visit the LPA interviewed four (4) staff, and conducted a file review. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation " Licensee did not provide the facility with an up to date and readily available emergency disaster plan"; it is the concern of the reporting party (RP) that the community had no evacuation plan, and that it was complete chaos during an evacuation. To investigate the allegation the LPA conducted file review and interviews. Information obtained revealed that on 01/09/2025 the community had to evacuate due to the Kenneth Fire. File review revealed that the community has an Emergency and Disaster Plan (LIC610E) on file. A review of the LIC610E indicated that the community had temporary shelter locations, evacuation procedures and staff assignments during an emergency disaster. File review also revealed that the community conducts monthly emergency and fire drills with their last drill conducted on 12/03/2024. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and that the staff were knowledgeable on the evacuation process. All staff interviewed revealed that the community trained them and has a third-party individual that comes and educates them on what to do during an emergency and/or disaster such as a fire. Additionally, staff interviewed that were present during the evacuation revealed that considering the emergency they were prepared to the best of their ability, the community was getting ready for an evacuation days prior, all residents had evacuation bags ready to go, and they ensured the safety of the residents. Based on the information gathered, the above allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued. On the allegation, “Facility staff are unable to provide medication as prescribed to residents during an evacuation”; it is the concern of the reporting party (RP) that residents had no medication or care during an evacuation. To investigate the allegation the LPA conducted interviews and a medication audit for three residents. Information obtained revealed that on 01/09/2025 the community had to evacuate to three relocation sites and several residents left with family members due to the Kenneth Fire. Staff interviewed revealed that medications and incontinence supplies were relocated to the relocation sites, and/or provided to family members that took residents home with them. Eleven (11) out of thirteen (13) randomly selected residents that were interviewed revealed that they had no concerns regarding the evacuation, it was well handled, they were well taken care of, the staff did the best they could, and medications were provided. However, two (2) out of thirteen (13) residents revealed that they were not provided medications during the evacuation. On 01/15/2024, the LPA conducted a medication audit for three residents and observed the following; Resident 1 (R1) had their evening medications, Eliquis 2.5 MG and Potassium CL ER 20MEQ , still in the bubble pack for 01/09/2025 and 01/10/2025. Resident 2 (R2) had their evening medication, Xarelto 20MG medication still in the bubble packs for 01/09/2025 and 01/10/2025. Additionally, based on a pill count for Resident 3 (R3) conducted by the Memory Care Director, the LPA observed that R3 was not provided their morning Letrozole .25MG medication on 1/10/2025. R1 and R2 were evacuated to one of the relocation sites, and R3 went home with family. An interview conducted with R3’s family member revealed that they were not given R3’s medications during the evacuation. Based on the information gathered through interviews, and medication audit, the allegation above is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Jan 21, 2025 · control 29-AS-20250113083252

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 3, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not dispense prescribed medication to three residents during an evacuation which posed an potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2025

Plan of correction: Licensee will schedule medication training for all med-techs that includes medication distribution during an evacuation and submit proof to CCLD no later than POC due date.

Allegation investigated: Staff are not responding to resident's call button in a timely manner

Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, LPA met with the Michelle Greenburg Bussiness Office Manager, and Lauria Gallagher Director of Resident Service and was explained the reason for the visit. Entrance interview conducted. During today's inspection, between 01:45 p.m. and 6:00 p.m., the LPA interviewed four (4) staff, two (2) residents, and tested a resident's pendant. Report will continue on LIC9099-C, 2nd page. Substantiated On the allegation, "Staff are not responding to resident's call button in a timely manner"; it is the concern of the reporting party (RP) that resident 1’s (R1’s) pendant that they push for help is not being answered promptly consistently. RP revealed that R1 has waited 40 minutes to an hour for help. Interviews conducted with staff revealed that caregivers are the ones that respond to the resident’s call buttons and try to respond as quickly as they can; however, if the caregivers are assisting other residents, residents have waited over 15 minutes to be assisted. Staff revealed that residents have also waited over 30 minutes for assistance. Interviews conducted with two (2) residents revealed that they use the pendant for assistance and there have been occasions where they had to wait over 30 minutes, and it has happened constantly. Additionally, a review of the pendant call log response times revealed that 26 times that pendants were pressed on 12/01/2024, residents waited over 30 minutes. Furthermore, a resident had pressed their pendant during the interview with the LPA and after waiting over 30 minutes the LPA left and staff had not responded to the resident’s pendant. Based on the information gathered through interviews, file review, and observation the allegation Staff does not respond to resident's call button in a timely manner is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 29-AS-20241204122034

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 26, 2024

87468.2(a)(4)residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidence by: Based on interviews,records review, and observation the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Business Office Manager agreed to have an in service with all staff regarding how to respond resident calls in a timely manner and will also develop a plan to ensure that pendant calls are answered in a timely manner. Will submit proof of inservice and plan to CCL by 12/26/2024.

Allegation investigated: Resident was inappropriately touched by staff

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, the LPA met with Business Office Manager II Michelle Greenburg and Director of Resident Services I, Lauria Gallagher and explained the reason for the visit. On 08/26/2024, the Woodland Hills North Adult and Senior Care Regional Office received a complaint regarding sexual abuse. The complaint alleged Staff #1 (S1) sexually abused Resident #1 (R1) by touching R1’s vagina. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Christine Ferris. On 08/28/2024, from 10:45am to 4:30pm, Licensing Program Analyst (LPA) Esther Cortez conducted an initial visit to investigate the allegation listed above. LPA Cortez arrived at the facility at 10:45am and met with Diane Lugar, Operations Specialist/Interim Administrator, and explained the reason for the visit. Report will continue on LIC9099-C, 2nd page. Unsubstantiated During the visit, the LPA interviewed the Interim Administrator at 11:00am, obtained copies of resident and staff records and other pertinent documents relevant to the investigation, toured the facility with Memory Care Director at 2:16pm and interviewed one staff at 3:30pm. The Operations Specialist/Interim Administrator was advised that the Community Care Licensing Division (CCLD) Investigations Branch (IB) Investigator Christine Ferris was assigned to investigate the allegation. Investigator Ferris conducted interviews on 09/26/2024, from approximately 11:00am to 1:40pm, with the facility Operations Specialist/Interim Administrator, R1, Memory Care Director, residents, and staff; on 10/24/2024, from approximately 1:30pm to 2:15pm, with staff and a resident; and on 11/05/2024, at approximately 10:00am, with S1. In addition, Investigator Ferris reviewed Los Angeles County Sheriff’s Department Report #024-04236-2223-139 and Supplemental Report; and facility file documents related to R1 and S1. According to the review of R1’s facility file documents, R1’s Physician Report, dated 09/14/2022, stated R1 is diagnosed with diabetes and heart failure, auditorily and visually impaired and wears hearing aids and glasses, is sometimes confused and disoriented, is able to follow directions and communicate needs, uses a walker and a wheelchair, and is non-ambulatory. R1’s placement in the assisted living portion of the facility was listed as 09/15/2022. According to the Special Incident Report (SIR) submitted by the facility, on 08/17/2024, R1 told two facility staff that S1 touched R1. The staff reported this to the Memory Care Director (MCD), who then spoke to R1. R1 stated that S1 was changing R1’s brief (diaper) as R1 lay in bed. R1 stated S1 touched R1 while pointing to R1’s vagina area. The MCD asked R1 to explain, who stated S1 was rubbing R1. When asked if S1 could have possibly just been cleaning R1, R1 stated “no, I am not dumb, I can tell the difference”. The MCD asked if R1 told S1 to stop and R1 stated they said no to S1 and moved S1’s hand. R1 said S1 did it 2 or 3 more times. No one observed the incident. When the Operations Specialist/Interim Administrator interviewed R1, R1 repeated the same story. R1 was asked if R1 wanted to see a doctor or contact the police, R1 declined. R1’s resident representative was contacted about the incident. S1 was interviewed and denied the allegation. S1 was suspended pending investigation. On 08/27/2024, S1 was terminated. Report will continue on LIC9099-C, 3rd page. The Department’s investigation did not provide sufficient evidence to substantiate sexual abuse against S1. R1’s statement changed during the Department’s interview from what R1 initially reported to staff and the Los Angeles County Sheriff’s Department. There were no witnesses to the incident. Staff interviewed stated there were no safety concerns with S1 prior to the incident. The Los Angeles County Sheriff’s Department closed the case with no further action. S1 denied the allegation. Therefore, the allegation “Sexual Abuse: Resident #1 (R1) was inappropriately touched by Staff #1 (S1)” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 29-AS-20240826174337

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Deficiencies inspection due to deficiencies observed during the investigation for Complaint control #29-AS-20240826174337 which were unrelated to the complaint allegation. the LPA met with Business Office Manager II Michelle Greenberg and Director of Resident Services I, Lauria Gallagher and explained the reason for the visit. During the complaint investigation of complaint # 29-AS-20240826174337, the following deficiency was observed: The Operations Specialist/Interim Administrator stated they have worked at the facility for a couple of months and work Monday through Friday from 9:00am to 9:00pm, however was not found to be finger printed cleared and associated to the facility per the Licensing Information System report and Guardian online system. An Immediate $500 Civil Penalty is assessed today. Citation issued, Immediate $500 Civil Penalty issued, exit interview, appeal rights given.the state’s words, verbatim · CDSS document, Dec 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1-2) · Plan of correction due date: Dec 13, 2024

87355(e) All individuals subject to a criminal record review ... shall prior to working, residing ... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2)Request a transfer of a criminal record clearance This requirement is not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above. The Operations Specialist/Interim Administrator is not finger printed cleared and associated to the facility, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: The licensee will submit a plan describing how they will ensure staff are fingerprint cleared and associated to the facility prior to working. Submit proof to CCL by 12/13/2024 Immediate $500 civil penalty assessed.

Allegation investigated: Facility is not preventing the spread of COVID-19.

Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent visit to investigate the allegation listed above. LPA Cortez arrived at the facility at 10:45 a.m., and the LPA met with Operation Specialist Diane Lugar and explained the reason for the visit. Executive Director Jeff Labelle joined the LPA and Operation Sepcialist mid visit. On 08/28/2024, between 01:30 p.m. and 4:30 p.m., the LPA interviewed the Interim Administrator, one staff, toured the facility with Memory care director and obtained copies of pertinent documents relevant to the investigation. During today's visit the LPA conducted a file review, one (1) staff and four (4) resindent interviews. Report will continue on LIC9099-C (2nd Page.) Unsubstantiated On the allegation "Facility is not preventing the spread of COVID-19."; it is the concern of the reporting party that on August 16th, 2024, there was an outbreak of Covid-19, and that the facility is not testing the residents. It was further reported that the facility does not have any protocols in place and Covid-19 is spreading. To investigate the allegation the LPA conducted a tour of the facility, interviews, and file review. On 08/28/24, during a plant tour the LPA observed an adequate supply of Personal Protective Equipment (PPE), and Covid tests and staff informed the LPA the community can obtain additional supplies as needed. In addition, the LPA observed PPE stations outside resident rooms who were Covid positive to allow for staff to promptly don and doff PPE when entering and exiting those rooms. File review revealed that the community has an approved infection control plan in place. The community’s infection control plan does not require mass testing of the residents. The facility’s policies and procedures as it pertains to infection control are adequate. In addition, staff and resident interviews revealed that residents were informed that there were Covid positive cases at the community. Furthermore, staff shared with the LPA the letter that was sent on 08/16/2024 via a mass email blast to the residents and the resident families informing them that the community was experiencing multiple Covid-19 positive cases, that the communal dining and group activities had stopped, and infection control practices were shared. Staff interviews also revealed that residents that had been exposed or presented symptoms were tested for Covid-19 and isolated if tested positive. Lastly, interview with an LA’s public health nurse during today’s visit revealed that testing closed contacts is recommended however, mass testing is not required unless specifically asked for. Based on the information gathered, the above allegation is deemed unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 29-AS-20240827001844

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. Upon arrival, the LPA met with Operation Specialist Diane Lugar and the reason for the visit was explained. Entrance interview conducted. Executive Director Jeff Labelle joined mid visit. At 11:35 a.m., the LPA along with the Operation Specialist toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: KITCHEN: The LPA inspected the Memory Care kitchen/food service area and the Assisted Living kitchen/food area. Knives and sharps were stored and inaccessible at the time of the visit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 1:04 p.m the hot water in the Kitchen of Assisted Living measured at 129.9 degrees Fahrenheit, and the LPA did not observed the required sign. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. The fire extinguishers were fully charged and were last serviced 05/08/2024 and 05/22/2024. The LPA observed required postings throughout the common space. The LPA observed the stairwells and they each had an emergency evacuation chair. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. The LPA observed an adequate supply of emergency food and water. BEDROOMS: The LPA observed eleven (11) randomly selected resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a sufficient supply of towels and linens. Resident’s cords were tested, LPA observed staff arrive in a timely manner. At 12:31 p.m. the LPA observed the smoke detector in the living room of resident room #274 (AL) inoperable and at 1:30 p.m. the LPA did not observed a smoke detector in resident room #103 in memory care. (Report Continued on LIC 809...) (Report Continued from LIC 809...) At 11:45 p.m., the LPA observed a Lysol spray bottle, and a bottle of Maximum Strength Blue-Emu pain relief spray in resident room #150, and per the residents physician's report they cannot store or managed medications. At 11:49 p.m. the LPA observed a can of Lysol disinfectant spray, a bottle of Lysol hydrogen peroxide spray, and a Resolve pet stain and odor remover bottle in resident's room #156. At 11:52 p.m. in the same room the LPA observed prescribed medication on the residents counter, and per the residents physician's report they cannot store or managed medications. At 12:14 p.m. the LPA observed Lysol, Pinesol, Febreze, and a bottle of Lysol power toilet bowel cleaner in residents room #165. At 12:18 p.m. the LPA observed an unlocked storage room that contained a bottle of LA's totally Awesome all purpose cleaner, a bottle of carpet cleaner, a bottle of Magnum Blue Degreaser, a bottle of WanoX stain remover spray, a bottle of Zep all purpose carpet shampoo, and machines accessible to the residents in care. At 12:21 p.m. the LPA observed Imodium multi-symptom relief, Pepto bismol, Aleve pain relieving lotion, hydrocortisone cream, and prescribed Arthritis Pain Reliever Topical gel, and per the residents physician's report they cannot store or managed medications. RESTROOMS: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water temperature was measured in ten (10) random bathrooms between 11:45 a.m. and 2:00 p.m., the temperature measured between 108.9 – 125.6 degrees Fahrenheit. RECORDS: The LPA initiated record review at 3:15 p.m. However, due to time contraints the LPA will return at a later date to complete 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 issued.the state’s words, verbatim · CDSS document, Sep 10, 2024

Allegation investigated: Staff are not following a resident's physician's order.

Licensing program Analysts (LPAs) Sandra Urena, Trevor Byrne, and Erica Mosley conducted an unannounced 10-day visit to investigate the allegation listed above. The LPAs arrived at the facility at 09:55 a.m. The LPAs met with Diane Lugar, Operations Specialist, Ruth Austin, Divisional Director Health & Wellness, and Shari Lefevre, Regional Director of Operations, and explained the reason for the visit. The LPAs interviewed Ruth Austin, Divisional Director Health & Wellness, and Shari Lefevre, Regional Director of Operations from 10:11 a.m. to 11: 10 a.m. and requested records pertinent to the allegation at 10:45 a.m. The interviews revealed that the facility does have a policy and prohibits the use of bed rails. Furthermore, the interviews revealed that management became aware that the previous Executive Director did not have residents’ responsible parties sign the bed rail policy; consequently, residents are not aware of the facility’s policy. Continues on LIC 9099C… Substantiated Staff are not following a resident's physician's order. On the allegation that staff are not following a resident’s physician order; the Reporting Party (RP) stated that on 8/6/2024, a staff removed the bed rails from the resident's (R1) bed because the facility's corporate office stated that bed rails are prohibited at the facility. LPA Urena interviewed the RP on 08/12/2024 from 2:49 p.m. to 3:20 p.m. The RP stated that R1 had a physician’s order for the half bed rails since October 2023; the bed rails were ordered by the physician due to R1 having a history of falling, and R1 is currently receiving hospice care and have a hospice care plan that specifies the need for half bed rails. Furthermore, the RP stated that facility’s corporate office staff made a visit to the facility and ordered bed rails to be removed as of August 6, 2024. The facility’s corporate office staff made the decision to return the bed rails and installed them back on R1’s bed. However, the RP stated that they have witnessed on several occasions that the bedrails are always in the lower position, versus the raised position to prevent R1 from falling out of the bed. R1 stated that they are not aware of the facility’s policy on prohibiting bed rails. The admission agreement signed by the RP does not have the facility’s policy stated on the agreement. To investigate the allegation, the LPAs reviewed R1’s physician report (LIC 602A), Admission Agreement (LIC 604A), Hospice Plan, physician’s order for bedrails, facility policy on bedrails and/or notification to residents in care about the facility’s bedrail policy. The record review revealed that R1 has a physician’s order for half bed rails dated 12/26/2023. The Admission Agreement (21 pages) does not specify the facility’s policy on bed rails. Based on the information obtained through interviews and record review; the information revealed that although the half bed rails were removed only temporarily and have been re-installed on R1’s bed, the facility staff failed to inform the R1’s responsible parties of the facility’s policy implementation, and the facility staff failed to follow the resident's physician's order. Therefore, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Aug 14, 2024 · control 29-AS-20240809125133

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(A) · Plan of correction due date: Aug 19, 2024

87608(a)(5)(A) (a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1’s half bed rails were removed, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

Plan of correction: Administrator agreed bedrails will beput back on as of 08/14/2024 and provide a 30 day notice abou the bedrail policy to residents responsible parties and submit documentation to CCL by POC due date.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA) Sandra Urena, Trevor Byrne and Erica Mosley conducted an unannounced case management-other visit. The LPAs arrived at the facility at 09:55 a.m. The LPAs met with Diane Lugar, Operations Specialist (OS), Shari Lefevre, Regional Director of Operations, and Guadalupe Santos, Memory Care Director, and explained the reason for the visit. The purpose of the visit is to gather additional information about the death report (LIC 624) for R1, which was submitted to the Community Care Licensing (CCL) department on 08/05/2024. It is unclear as to what caused the death of R1. R1 had a fall (witnessed by staff) on 08/3/2024 at approximately 9:15 p.m., prior to being hospitalized. R1 died at the hospital the following morning after he fall. The LPAs interviewed Guadalupe Santos, Memory Care Director (MCD) and Diane Lugar from 10:34 a.m. to 10:40 a.m. and requested records pertinent to the case at 10:45 a.m. Per the MCD, they requested the death certificate(DC) from the family members on 08/07/2024; however the family member stated that they not had obtained a DC yet , but as soon as they received a copy they would send it to the facility. Further investigation is needed at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 14, 2024

Allegation investigated: Resident sustained injury while in care. Staff did not follow medication protocol as prescribed. Staff did not respond to resident's call pendent timely. Staff did not afford a resident respect in their relationship. Staff did not clean resident's room. Resident's room was malodorous. Staff did not safeguard a resident's property.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 01/12/2022 by LPA Z. Chochian and subsequent visits were conducted on 02/15/2022 by LPA K. Lopez, and 02/12/2024 and 02/29/2024 by LPA M. Arroyo. During today's visit, LPA met with Executive Director (ED), Joeyvic Alvarado. Entrance interview. During the initial visit on 01/12/2022, LPA Chochian requested and obtained pertinent records. On 02/15/2022, LPA Lopez conducted interviews with three staff members between 10:44 a.m. and 4:00 p.m. and reviewed facility records. On 02/12/2024, LPA Arroyo conducted an interview with the ED at 9:35 a.m., conducted a resident file review at 9:55 a.m., and obtained copies of pertinent documents. On 02/29/2024, LPA Arroyo conducted interviews with one staff member, eight residents, and two family members between 1:03 p.m. and 2:05 p.m., and obtained copies of pertinent documents. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... It was alleged that resident sustained injury while in care. It was reported that Resident #1 (R1) fell in their room on a table which broke and there was blood all over the table and books. Information obtained and reviewed revealed that R1 was admitted to the facility on 08/31/2021. Per R1’s Physician’s Report dated 08/20/2021, it lists R1’s primary diagnosis including hypotension, chronic systolic (congestive) heart failure, and mild cognitive impairment. Additionally, physician’s report indicated R1 was able to follow instructions, able to communicate needs, required assistance with bathing, toileting needs, and is ambulatory. Records review revealed that facility was communicating with R1’s Primary Care Physician (PCP) to report any falls R1 had had while living at the facility. Interviews conducted with staff revealed that staff would ask R1 to use their pendant if they needed to get up; however, R1 would still get up on their own without asking for help and fall. Furthermore, the facility continuously tried to lessen R1’s falls and even placed R1 on hourly checks to prevent R1 from getting out of bed on their own and getting hurt. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “resident sustained injury while in care”. Therefore, this allegation is deemed Unsubstantiated at this time. It was alleged that staff did not follow medication protocol as prescribed. It was reported that the facility was provided pre-measured vials of morphine and arazapan and although R1 was either hysterical or catatonic, facility staff was not administering R1’s medication to keep them comfortable. Records review of R1’s physician’s orders dated 12/15/2021, indicated to administer morphine sulfate for shortness of breath and breakthrough pain, and lorazepam for agitation and restlessness. Per R1’s progress notes, staff was contacting R1’s hospice nurse to report R1’s symptoms. At any time when a hospice nurse was not available to come to the facility, staff was given instructions to administer either morphine or lorazepam, depending on the symptoms R1’s was projecting. Review of R1’s Electronic Medication Administration Record (eMAR) revealed that R1 was being administered lorazepam for restlessness and anxiety and when R1 was having shortness of breath and pain, morphine was being administered to R1. Continued on LIC 9099C... Continued from LIC 9099C... Interviews conducted with staff revealed that when a resident is on comfort care, they usually call hospice, and they will communicate with them on what to do. Staff added that they don’t just administer morphine, which is a PRN, until hospice has given them permission to administer to resident. Additional staff interviews revealed that comfort meds are administered to the resident if the hospice nurse is not available and are pre-measured with the PRN order on file. Staff stated morphine was not given to R1 every single time because R1 was agitated and for agitation, R1 was prescribed lorazepam. Staff added that unless R1 had shortness of breath or pain, R1 was not given morphine. Interviews conducted with residents revealed that staff bring their medications to them in a cup and as far as they know, they are getting all their medications correctly. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “staff did not follow medication protocol as prescribed”. Therefore, this allegation is deemed Unsubstantiated at this time. It was alleged that staff did not respond to resident's call pendent timely. It was reported that R1 had pressed their pendant; however, facility staff did not respond for hours. Interviews conducted with staff revealed that caregivers are the ones that respond to the resident’s call buttons; however, if the caregivers are assisting other residents, the med-tech will assist the residents. Staff stated they have a device that notifies them when a resident has pressed their pendant. Staff stated that they try and get to the residents as soon as possible, but sometimes it might take a bit longer because they are assisting another resident or taking them to the dining room. Interviews conducted with residents revealed that they use the pendant all the time. Residents stated that it takes about fifteen (15) minutes for staff to respond, although sometimes it might take shorter or longer. Further interviews with residents revealed that staff usually respond timely to their pendant calls, and it depends on the time of day. Additionally, a resident had pressed their pendant during the interview with LPA and caregiver responded within ten (10) minutes. Resident stated the longest they have waited was about fifteen (15) minutes. Continued on LIC 9099C... Continued from LIC 9099C... Interviews conducted with a family member revealed that resident had called them after pressing their pendant, they called the front desk to notify them of the incident, and they were notified that a caregiver was already on their way to the resident’s room. Family member stated everything happened within fifteen (15) from receiving the telephone call from the resident. Furthermore, both residents and family members reported having no concerns with the facility staff. Based on interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “staff did not respond to resident’s call pendant timely”. Therefore, this allegation is deemed Unsubstantiated at this time. It was alleged that staff did not afford resident respect in their relationship. It was reported that after R1 had fallen, Staff #1 (S1) could be heard in the background laughing hysterically. Records review of R1’s progress notes revealed that R1 had suffered an unwitnessed fall in their room on the morning of 12/27/2021. Per progress notes, S1 started accidentally calling R1’s family while the paramedics assessing R1. S1 stated they passed their cell phone to the paramedics to talk to R1’s family as R1 was refusing to be taken to the hospital to receive medical care. Interviews conducted with staff revealed that they try to be nice to all the residents because they don’t know what they might be going through. Staff stated that they try and cheer up the residents at times if they know that they are not having a good day for some reason. Interviews conducted with residents revealed that staff treat the residents very nicely and treat them well. Residents stated no one at the facility yells or treats them poorly. Additionally, residents stated that staff is nice and have never made them feel uncomfortable. Residents also added that staff have been courteous and treats them with respect. Furthermore, residents reported having no concerns with either the facility or facility staff. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not afford resident respect in their relationship”. Therefore, this allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C... Continued from LIC 9099C... It was alleged that staff did not clean resident's room and that resident's room was malodorous. It was reported that R1 had rotten food on a tray inside their room, the room had trash, and from the outside R1’s room had a bad odor. Interviews conducted with staff revealed that housekeeping for each room is scheduled on a weekly basis. Staff stated that they routinely take out the trash, change the sheets, do laundry, and vacuum the carpet. Additionally, staff stated R1’s room was dirty with trash and added that there would also be feces and pee on the floor. Staff added that R1 was encouraged to press their pendant if they needed help or needed to get up; however, R1 was not pressing their pendant to ask for staff help. Staff also stated that while working at the facility, they have not gone into any room that had bad or foul odors. Interviews conducted with residents revealed that housekeeping comes into their rooms to do laundry and take out the trash. Additionally, residents stated that facility staff take out the trash every day and have not smelled any bad odors while walking though the facility. Furthermore, residents stated that housekeeping has been maintaining their apartments clean and reported having no concerns living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegations of “staff did not clean resident’s room” and “resident’s room was malodourous”. Therefore, these allegations are deemed Unsubstantiated at this time. It was alleged that staff did not safeguard a resident's property. It was reported that R1’s debit card had gone missing. Records review of R1’s Admissions Agreement signed on 08/25/2021, Page 18 indicates R1’s Power of Attorney (POA) signed and acknowledged receiving a copy of the facility’s “Theft and Loss Policy” and on the Client/Resident Personal Property and Valuables form for R1 was filed; however, neither R1 nor R1’s POA listed R1’s debit/credit card upon admission to the facility. Interviews conducted with residents revealed that they have not had anything missing since moving into the facility. Residents stated no one usually goes inside their room unless it is housekeeping to clean; however, as soon as they are done, they leave. During an interview, resident reported thinking they had had something gone missing at one point; however, it was found later after realizing they had moved the item to another location. Furthermore, during interviews, residents reported having no concerns about living at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not safeguard a resident’s property”. Therefore, this allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 29-AS-20220107092349

Allegation investigated: Staff did not adequately care for resident's wound. Staff did not ensure facility is free of insects.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 09/08/2023, and a subsequent visit was conducted on 02/29/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Joey Alvarado. Entrance interview. During the initial visit on 09/08/2023, at 9:40 a.m., LPA Arroyo conducted a tour of the facility to ensure there were no health and safety concerns, toured the kitchen/dining room/food area at 9:43 a.m., conducted interviews with the Administrator and two staff between 8:50 a.m. and 9: 45 a.m., conducted a file review at 9:15 a.m., and obtained copies of pertinent documents. On 02/29/2024, LPA Arroyo conducted interviews with one staff, eight residents, and two family members between 1:03 p.m. and 2:05 p.m. and obtained copies of pertinent documents. Hospital records were also requested and reviewed. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... It was alleged that staff did not adequately care for resident’s wound. It was reported that Resident #1 (R1) had come into the hospital with an open wound that had maggots in it. Information obtained during the course of the investigation revealed that R1 was admitted to the facility on 08/31/2021. Additionally, per R1 Physician’s Report dated 08/20/2021, it indicates R1 is able to follow instructions, able to communicate needs, does not require assistance for activities of daily living (ADL’s), is able to administer their own medications, and is ambulatory. Hospital records reviewed revealed that R1 was admitted to the hospital on 09/06/2023 due to left thigh cellulitis. Per hospital report, maggot infestation in chronic left lower leg wound located on lateral aspect of left shin. Visualized maggot movement while in the emergency room during admission. R1 reported this was a chronic wound that had been there for less than a year and was unaware of any maggot infestation. Additionally, records review of resident notes revealed that R1 had reported to facility staff that they were not feeling well; however, refused to have paramedics be called to the facility and assist. Instead R1 decided to wait for a family member to arrive and take them to the emergency room. Furthermore, R1 did not report cellulitis or wound to facility staff at any time prior to leaving the facility. And although R1 had cellulitis that became infected, R1 was independent while living at the facility and was capable of reporting wound to facility staff so that it could have been properly cared for. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not adequately care for resident’s wound”. Therefore, it is being deemed Unsubstantiated at this time. It was alleged that staff did not ensure facility is free of insects. It was reported that a fly must have gotten into the dining area. During the facility walkthrough on 09/08/2023, the LPA observed the dining rooms and food areas in both assisted living and memory care. There were no flying insects or flies observed inside the facility at the time of the visit. Interviews conducted with staff revealed that the back door where all food deliveries are made has a large fan that blows air to keep flying insects out. Continued on LIC 9099C... Continued from LIC 9099C... Additionally, inside the kitchen on the walls, there are blue lights that also kill flying bugs if they were to get inside. Interviews conducted with residents revealed that they have not observed flies or insects either in their bedrooms or while at the dining room. Furthermore, records review revealed that facility has been utilizing Western Exterminator Company on a monthly basis with no concerns noted after maintenance treatment. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff did not ensure facility is free of insects”. Therefore, it is being deemed Unsubstantiated at this time. Exit interview. No citations issued. Report was reviewed with the ED and a copy was issued.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 29-AS-20230907163503

Allegation investigated: Licensee retaliated against resident. Facility staff failed to bathe resident. Facility staff failed to clean resident's room. Administrator does not respond to responsible party in a timely manner.

Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 12/22/2023, and a subsequent visit was conducted on 02/29/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Joey Alvarado. Entrance interview. During the initial visit on 12/22/2023, at 10:35 a.m., LPA Arroyo conducted a tour of the facility to ensure there were no health and safety concerns, conducted interviews with the ED, one staff member, and one resident between 10:20 a.m. and 10:57 a.m., conducted a file review at 11:25 a.m., and obtained copies of pertinent documents. On 02/29/2024, LPA Arroyo conducted interviews with one staff member, eight residents, and two family members between 1:03 p.m. and 2:05 p.m., and obtained copies of pertinent documents. Continued on LIC 9099C... Unsubstantiated Continued from LIC 9099... It was alleged that licensee retaliated against resident. It was reported that shortly after Resident #1 (R1) had returned to the facility, R1’s family had received a notice that rates were being increased. Information obtained and records reviewed revealed that R1 was admitted to the facility on 08/31/2021. Records review revealed that R1 has had an annual increase for the last consecutive three (3) years, and R1 has been receiving notice for increase in monthly fees at about the same time every year at least sixty (60) days before the annual increase will take in effect for the following year. These notices were sent to both the resident as well as their responsible party. Furthermore, the annual monthly increase was not only sent to R1, but to many other residents currently residing at the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “licensee retaliated against resident”. Therefore, this allegation is being deemed Unsubstantiated at this time. It was also alleged that facility staff failed to bathe resident. It was reported that Resident #2 (R2) was supposed to be bathed twice a week, but the facility neglected R2’s care. Records review of R2’s physician’s report dated 08/18/2021 indicated R2’s primary diagnosis is Alzheimer’s disease and has no capacity for self-care requiring assistance with all activities of daily living (ADL’s). Interviews conducted with staff revealed that showers are included for all memory care residents. All memory care residents have scheduled shower rotation twice a week and for R2, their shower rotation was scheduled for Tuesdays and Thursdays. Additionally, shower sheets are filled out for each resident after each resident has been showered. Additionally, during an interview with R2’s family member, they reported that R2 was always clean, and the facility was still taking care of R2 and bathing R2 twice a week while they were out of the facility. Furthermore, R2’s family member stated they were happy at the facility and had no concerns. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility staff failed to bathe resident”. Therefore, this allegation is deemed Unsubstantiated at this time. Continued on LIC 9099C... Continued from LIC 9099C... It was also alleged that facility staff failed to clean resident's room. It was reported that facility did not clean R1’s room even after feces had gotten on the floor and was stepped on for days. Information obtained and records reviewed revealed that R1 and R2 shared a bedroom in the memory care unit. Interviews conducted with staff revealed that housekeeping is done once a week; however, it will be done more often if needed. Additionally, staff stated that although R1 was fairly independent, R1 had had a few incontinence accidents but did not report it to staff or allow staff to assist. This prompt staff to check R1’s and R2’s room occasionally and request housekeeping to come in and either clean or change the linens. Interviews conducted with residents revealed that housekeeping comes into their rooms, clean, change the bed sheets, and take out the trash. Additionally, residents added that housekeeping does their job by maintaining their rooms clean. Furthermore, during an interview with R1, R1 stated that housekeeping was being done a couple times a week as they were trying to keep the place clean and did not report having any concerns about the facility. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility staff failed to clean resident’s room”. Therefore, this allegation is being deemed Unsubstantiated at this time. It was further alleged that Administrator does not respond to responsible party in a timely manner. It was reported that the Reporting Party (RP) had contacted the Administrator regarding the 30-day notice, but the Administrator did not call the RP for several days and was not responding to RP’s messages. Information obtained during the course of the investigation revealed that the RP had emailed the Administrator on the evening of 12/03/2023 stating that had called the facility and left several voicemails for the Administrator to return their call. Records review revealed that the Administrator replied to the RP the following morning apologizing for not having access to the voicemails as they were sick and out of the office; however, the Administrator informed the RP that they were able to answer any questions they had via email. Additionally, the email interaction revealed that the Administrator was replying to RP’s emails the same day, if not the following day. Continued on LIC 9099C... Continued from LIC 9099C... Furthermore, interviews conducted with family members revealed that the Administrator is good at getting back to them and addressing their concerns in a timely manner. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “Administrator does not respond to responsible party in a timely manner”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview. No citations issued. Report was reviewed with the ED and a copy was issued.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 29-AS-20231218160810

Allegation investigated: Staff hit resident Resident bit another resident's leg Facility did not notify resident's family of incident Insufficient staffing

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for an investigation initiated by LPA K. Lopez on 11/01/2021. During today’s visit, LPA met with Executive Director, Joeyvic Alvarado and the reason for the visit was explained. During the initial visit on 11/01/2021, LPA met Regional Director Joann Gange and Assistant Administrator Walter Cline. During the visit, the LPA conducted a physical plant tour of the memory care unit beginning at 12:54 PM with Walter Cline. Between 1:08 PM and 2:40 PM the LPA conducted interviews with Staff #1 (S1) and Staff #2 (S2). The LPA attempted to interview Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3) during this time but was unable due to their cognitive impairments or due to the resident sleeping. At 3:07 PM the LPA reviewed facility records and obtained pertinent copies of records. On 11/10/2021, the LPA conducted interviews with two staff members during a visit for another complaint investigation and obtained information for this investigation also. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) On 08/11/2023, LPA Lopez conducted a subsequent inspection at the facility. The LPA initially met with Health and Wellness Director Alex Alvarado and explained the reason for the inspection. Administrator Joey Alvarado arrived during the inspection. During the inspection, the LPA conducted a tour of the memory care unit, at 11:32 AM, reviewed facility records and interviewed the Administrator and Health and Wellness Director. Allegation: Staff hit resident. The allegation alleges Staff #3 (S3) hit Resident #1 (R1). The Interview with Regional Director Joann Gange revealed she was not aware of any complaints regarding a staff hitting a resident but about four weeks prior, she was informed by Staff #2 (S2) that R1 was holding the frame of their door and S3 forcefully pushed R1 in their wheelchair into their room. Ms. Gange interviewed S3 and S3 denied the incident but was placed on suspension immediately. Ms. Gange stated she investigated and found out that R1 always holds the door frame when staff are pushing R1 into their room. Ms. Gange said she reviewed the surveillance video afterwards and did not observe S3 pushing R1 forcefully into their room. The LPA was advised during the 11/01/2021 visit that S3 no longer works at the facility. During the interview with S2, S2 stated they heard a loud noise and went into R1’s room. S2 said when they got there, they observed that S3 had pushed R1 in their wheelchair into R1’s room. S2 stated they did not observe the incident although heard a loud noise and R1 say “ouch”. S2 stated they did not document the incident in writing. The LPA attempted to interview R1 during the investigation but was unable to due to cognitive impairments. On 11/10/2021, the LPA conducted interviews with two staff members during a visit for another complaint investigation and these staff members had no additional information regarding this incident. Based on the information obtained there is insufficient evidence to support the allegation of S3 hit R1 occurred. Therefore, the allegation is deemed unsubstantiated at this time. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) Allegation: Resident bit another resident's leg. The allegation of “Resident bit another resident's leg” alleges Resident #2 (R2) bit the leg of Resident #3 (R3) resulting in injury. Record review revealed on 04/07/2021 the facility completed a Report of Suspected Dependent Elder Abuse Report (SOC 341) which stated on 04/06/2021 staff walked into R3’s room and observed R2 pulling on R3’s leg creating a large skin tear. Staff immediately paged for assistance, redirected R2 and called 911. R3 was taken to the hospital and received sutures and returned the next day. The report states R3’s physician and family member was informed. Hospital records reviewed indicated R3 was seen on 04/06/2021 for a skin laceration. Facility progress notes state on 04/06/2021, staff observed a resident scratching and pulling on R3’s leg causing a big skin tear. 911 was called. The administrator notified the family. During the 11/01/2022 visit, the LPA met with R2 and R3 briefly. R2 was sleeping and R3 was in their bedroom. Both residents reside in the memory care unit and are unable to be interviewed due to cognitive impairment. Interview with Ms. Gange revealed she had no information regarding a biting incident between R2 and R3 and was only aware of R2 scratching R3 and due to R3 having fragile skin they called 911 because they could not stop the bleeding. Ms. Gange said the family members of R3 are aware of the incident because they brought it up when discussing R3’s history with Ms. Gange. Staff interviewed were either not present when the incident occurred or did not work at the facility when the incident occurred, although no staff were aware of R2 being physically aggressive to other residents prior to this incident and R2 only being aggressive with staff members. Based on the information obtained there is insufficient evidence to support the allegation of Resident bit another resident's leg occurred. Therefore, the allegation is deemed unsubstantiated at this time. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) Allegation: Facility did not notify resident's family of incident The allegation of Facility did not notify resident's family of incident alleges the family members of R3 were not made aware of the 04/06/2021 incident between R2 and R3 until two weeks after the incident occurred. Record review revealed the facility completed a report of Suspected Dependent Elder Abuse form on 04/07/2021 and cross reported to the Ombudsman’s Office and Community Care Licensing. On this report, it states the resident’s daughter and physician were notified of the incident. Medical records from West Hills Hospital also indicate that the resident was hospitalized on 04/06/2021 for a laceration to their leg and discharged on 04/07/2021. Hospital Admissions records had R3’s daughter listed as the resident’s contact person. Furthermore, progress notes for R3 indicate on 04/06/2021, a former administrator was notified of the incident they contacted the family to advise 911 had been contacted for R3 due to the incident. During the interview with Ms. Gange, she said the family members of R3 were aware of the incident because they brought it up when discussing R3’s history in the past. Based on the information obtained, there is insufficient evidence to support the allegation of Facility did not notify resident’s family of incident. Therefore, the allegation is deemed unsubstantiated at this time. Allegation: Insufficient staffing The allegation of Insufficient staffing alleges the facility is short staffed in the memory care. During the 11/01/2021, visit the LPA conducted interviews with two memory care staff members who stated on this day they were fully staffed in the memory care. Interviews revealed it is harder when they have agency staff working because they have to teach them about the residents but lately there have been 2-3 permanent staff on shift. Interview also revealed there were issues in the past with insufficient staff but currently there is not a problem. Review of the staff schedule revealed one med tech and three caregivers scheduled during the day shift and two caregivers and one med tech on the overnight shift. Based on the information obtained, there is insufficient evidence to support the allegation of Insufficient staffing occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided (Report Continued from LIC 9099...) On 08/11/2023, LPA Lopez conducted a subsequent inspection at the facility. The LPA initially met with Health and Wellness Director Alex Alvarado and explained the reason for the inspection. Administrator Joey Alvarado arrived during the inspection. During the inspection, the LPA conducted a tour of the memory care unit, at 11:32 AM, reviewed facility records and interviewed the Administrator and Health and Wellness Director. Allegation: Facility is not reporting staff abusing resident to proper agencies The allegation of facility is not reporting staff abusing resident to proper agencies alleges there was an incident between Staff #3 (S3) and Resident #1 (R1) that was not reported to the appropriate agencies. Record review revealed Community Care Licensing (CCL) was not notified of an alleged incident between S3 and R1. The Interview with Regional Director Joann Gange revealed she was not aware of any complaints regarding a staff hitting a resident but about four weeks prior, she was informed by Staff #2 (S2) that R1 was holding the frame of their door and S3 forcefully pushed R1 in their wheelchair into their room. Ms. Gange interviewed S3 and S3 denied the incident but was placed on suspension immediately. Ms. Gange stated she investigated and found out that R1 always holds the door frame when staff are pushing R1 into their room. Ms. Gange said she reviewed the surveillance video afterwards and did not observe S3 pushing R1 forcefully into their room. Interview of S2 revealed they did not witness the incident but only heard a loud noise R1 say “ouch”. S2 stated they did not document the incident in writing. The LPA was advised during the 11/01/2022 visit, that S3 no longer works at the facility. The LPA inquired why the alleged abuse was not reported to CCL, law enforcement, or LTCO. Ms. Gange said she did not feel the need to document and report it because the nurse did a body assessment and R1 did not have any redness or sign of injury. Based on the information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of facility is not reporting staff abusing resident to proper agencies is deemed substantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 29-AS-20211025115308

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Dec 29, 2023

(a) Each licensee shall furnish to the licensing agency such reports as the Department...written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... ...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by:the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: The Licensee has agreed to review regulation 87211 and submit a statement of understanding to CCL no later than 12/29/2023. Based on interview and record review, the licensee failed to comply with the section above as the licensee failed to submit a written report to the appropriate agencies regarding the alleged abuse between S3 and R1 which is a potential health and safety risk to residents in care.

Allegation investigated: Questionable death. Medications are not being administered as prescribed. Insufficient staffing.

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced subsequent complaint inspection to the above facility. The purpose of the visit is to deliver findings for an investigation initiated by LPA M. Arroyo on 01/24/2022. During today’s visit, LPA met with Executive Director, Joeyvic Alvarado and the reason for the visit was explained. During the initial inspection, LPA met with Executive Director Joeyvic Alvarado and obtained pertinent documents relevant to the investigation. On 02/15/2022 between 10:44 a.m. and 2:30 p.m., LPA KaSandra Lopez conducted a subsequent inspection and conducted interviews with three (3) staff members and one (1) resident. Additional interviews were also conducted with two (2) staff in July 2023. (Report Continued on LIC 9099C...) Unsubstantiated (Report Continued from LIC 9099...) The allegations of ‘Questionable Death’ and ‘Insufficient Staffing’ alleges when Resident #1 (R1) passed away they were already stiff and cold when they were found. Furthermore, it is alleged that staff did not assist R1 properly when they were needing assistance the day prior to R1’s death. It is also alleged that R1 was not checked during the night prior to death, due to only one staff member working on the night shift. On 01/13/2022, the Administrator submitted a Death Report (LIC 624) for R1 stating on 01/11/2022 at approximately 9:00 a.m., Staff #1 (S1) observed R1 to be unresponsive in their bed. Cardiopulmonary Resuscitation (CPR) was performed and 9-1-1 was contacted. R1 was last seen responsive around 6:00 a.m. The Death Certificate for R1 was obtained. The hour of death noted was 7:40 a.m. The immediate cause of death listed was Cardiopulmonary Arrest, mins. The underlying causes of death were listed as Chronic Hypoxic failure, months, Acute on Chronic Heart Failure, years, and Pulmonary Emphysema, years. The Department requested a copy of R1’s autopsy report but one was not available for review. Facility record review revealed R1 had a diagnosis of Congestive Heart Failure, COPD, and Mild Cognitive Impairment. R1’s most recent needs and service plan dated 10/12/2021, indicated R1 was independent with all aspects of R1’s oxygen use and was primarily independent except for assistance with medications. Interviews conducted revealed the day before R1’s passing on 01/10/2022, R1 only drank orange juice for breakfast which was normal and only had lunch. Additionally, R1 was observed to be in bed during meal service delivery approximately around 12:00 p.m. Staff interviews also reflected that R1 stated they “tired and not feeling well” however, this was nothing unusual from R1’s day to day behavior. Staff also reported R1 appeared to be in pain however, R1 was breathing normal and was not observed to be struggling with breathing. Additionally, it was revealed R1 used oxygen every day and night. Moreover, medication records reviewed revealed R1 received their scheduled dose of Oxycodone/Acetaminophen at 8:00 a.m. and 2:00 p.m. on 01/10/2022. (Report Continued from LIC 9099...) (Report Continued from LIC 9099C...) During the interview with S1, they could not recall the time they went into R1’s room to give them their medications but said they start their day at 6:00 a.m. and it was before breakfast. S1 stated when they entered the room, they found R1 in bed, unconscious with no vitals. S1 stated they called 9-1-1 and were asked to perform CPR which they did until paramedics arrived. S1 stated R1 was cold and purple when they found R1. S1 stated R1 used oxygen but could not recall if it was on or not when they found R1. S1 stated R1 had a decline in health prior to death but R1 had no sudden medical changes. R1 was pronounced deceased by paramedics. Additional interviews with staff revealed, approximately between 6:00 a.m. and 7:30 a.m. they were advised that S1 needed assistance with R1. When they arrived S1 was on the phone with paramedics and was being directed to perform CPR. Staff stated they did not observe any obvious trauma to R1 but could tell by the color of their skin that they had passed away. The overnight staff interview revealed R1 was last check between 4:00 a.m. and 4:30 a.m. and was observed to be breathing and sleeping in their bed. During the interview the overnight staff stated they check on all the residents at night. Interviews and email correspondences with Executive Director, Joey Alvarado revealed although R1 was not receiving hospice care, R1 was declining in health leading up to their death, including eating less and having more pain. The Administrator stated R1 was checked at 6:00 a.m. as part of the morning routine and was observed to be waking up. When staff went into R1’s room for the morning medication pass they observed R1 to be in bed unresponsive and 9-1-1 was called. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegations may have happened or is valid, there is insufficient evidence to support that R1’s death was a result of staff neglect. Additionally, there is also insufficient evidence to support the allegation of facility was not staffed sufficiently resulting in R1 not being checked during the night shift. Therefore, these allegations are deemed unsubstantiated at this time. (Report Continued on LIC 9099C...) (Report Continued from LIC 9099C...) The allegation of ‘Medications are not being administered as prescribed’ allege Resident #2’s (R2) medication Warfarin is not being administered to R2 correctly. The reporting party stated one of the errors was documented in R2’s progress notes. During the interview with R2 on 02/15/2022, R2 reported no issues or concerns with medications or not receiving their medications correctly. On 02/15/2022, LPA Lopez reviewed medications and records for R2. Record review revealed R2’s Warfarin dosing is contingent on laboratory results and doctor’s orders. During the interview with medication technician staff, they stated they were not aware of any issues with R2 getting the correct dose of Warfarin. Staff stated the issue they have been having is the outside company who sends the facility the medication administration records (MAR) is not updating the MAR with the correct dose when it changes but stated the resident is getting the correct dose. The LPA reviewed the progress notes for R2 and did not see any documented medication errors written by staff. The LPA also reviewed medications and medication records for R2 on 02/15/2022 and did not observe any medication errors. Based on the information obtained, there is insufficient evidence to support the allegation of Medications are not being administered as prescribed occurred. Therefore, the allegation is deemed unsubstantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 29-AS-20220121142026

Allegation investigated: Insufficient staffing

On 09/21/2022, LPA Lopez initiated the investigation and conducted interviews with four staff members and the Administrator, reviewed records, and conducted a physical plant tour of the memory care between 12:35 p.m. and 3:30 p.m. The allegation of Insufficient staffing alleges there have been numerous falls in the memory care unit due to insufficient staffing, as there are days there are only two caregivers on shift which is insufficient. A review of the staff schedule during the month of August and September 2022, revealed during the AM shift there are three (3) caregivers and one (1) med tech scheduled, during the PM shift there are three (3) caregivers and one med tech scheduled, and during the NOC shift there are two (2) caregivers and one (1) med tech scheduled. The census in the memory care is 28 residents. (Report Continued on LIC 9099C...) Substantiated (Report Continued from LIC 809...) During the interview with the Administrator Joeyvic Alvarado, she stated Resident #1 (R1) had a fall on 08/15/2022 and went to the hospital. When the resident was discharged the family opted to move them to a board and care and where R1 subsequently passed away. The Administrator showed the LPA surveillance footage of R1 when they fell. The LPA observed the resident to be walking in the hallway when they pulled on their sweater causing them to lose their balance and fall. Video footage went on to show that staff was nearby the resident when they fell and provided aid to the R1 right away. The Administrator was not aware of R1 having any other recent falls. Interview with a staff present near R1 when they fell stated R1’s fall had nothing to do with staffing. They said R1 was agitated that day and they just happened to fall. Additional interviews with all four staff revealed that there are times when there are only two caregivers during the day shift which makes it difficult to care for the residents, especially when assisting residents who are a two person assist. Interviews also revealed there are some days three caregivers is not enough either to assist residents because that only leaves one person on the floor. The Administrator stated there are always three caregivers scheduled on shift during the day but there are times when a staff will call out sick and there will be only two caregivers on shift. The Administrator stated it may take an hour or two for agency staff to arrive although a manager will stay and assist, or the medication technician will assist until more staff are available. Based on the information obtained, although there is not sufficient evidence to support insufficient staffing resulted in resident falls, staff interviews revealed there are times when they only have two caregivers on shift which is insufficient to meet the residents needs. Therefore, the allegation of Insufficient staffing at the time the complaint was filed is deemed substantiated at this time. Exit interview conducted. A copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 29-AS-20220916125453

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 22, 2023

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as interviews revealed there are times when only two caregivers are on duty in the memory care with 28 residents which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: The Licensee has agreed to review regulation 87411 and submit a statement of understanding to CCL no later than 12/29/2023.