Oakland Heights Senior Living

Allegation investigated: Lack of supervision resulting in resident on resident altercations

On 9/08/23 at 11:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regard to the allegation above. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation, LPA obtained the September staff schedule for Assisted Living, interviewed the reporting party (RP), the facility administrator (ADM) and 4 residents in the dining room. LPA also observed the lunch service. The staff schedule shows a total of 5 staff working the day shift, 5 staff working the pm shift and 2 staff on the noc shift. Staff are assigned to different areas of the assisted living building. There are no staff assigned specifically to the dining room. ADM stated that care staff are in the dining room from time to time during meals and a med tech does rounds in the dining room dispensing medication. ***report continues on LIC9099C*** Unsubstantiated ***Report continues from LIC9099*** LPA observed the lunch service with about 50 residents having lunch, 4 servers and 1 care staff. There were no incidents during the observation. LPA interviewed 4 residents. Three of residents (R1, R2 and R3) interviewed reported that they have never seen or heard any altercations in the dining room. All 4 residents eat lunch in the Assisted Living dining room on a daily basis. R4 reported that he has on occasion heard voiced raised and some arguments happening. He has never seen anything escalate to a physical altercation. This agency has investigated the complaint alleging lack of supervision resulting in resident-on-resident altercations. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 8, 2023 · control 15-AS-20230831080636

Allegation investigated: Staff does not prevent residents room from bed bugs.

On 8/29/23 at 11:05 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation LPA reviewed the complaint, left a voice message for the reporting party (RP) and interviewed the facility administrator (ADM). LPA also toured Unit 115. RP stated in the compliant that his sister lives in Unit 115 and has had bed bugs on and off for the past several months. On July 31, 2023, the Unit was given a heat treatment to eliminate the bed bugs by Orkin Pest Control. The Unit was then inspected and there were no signs of bed bugs. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** On August 21, 2023, R1 reported to facility staff that she felt that she had new bites on her arms. Facility nurse applied hydrocortisone to the bites and informed the ADM. ADM emailed the family of the occupants of the Unit to inform them that he would be formulating a plan. ADM then called Orkin to return and inspect the Unit. Orkin returned on August 25, 2023, and treated the Unit with a chemical dusting. Upon closer inspection Orkin discovered there were felt banners on the wall of the Unit that had been removed during the heat treatment with bed bug residue on them. On August 29,2023, Orkin the ADM met with the family of the occupants of the Unit. The Unit will be deep cleaned and then heat-treated next week. LPA toured Unit 115 and observed Orkin technicians cleaning the Unit. This agency has investigated the complaint alleging staff does not prevent residents room from bed bugs we have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 29, 2023 · control 15-AS-20230821111804

Allegation investigated: -Facility in disrepair. -Residents left in soiled diapers for an extended period of time. -Facility staff are not cleaning residents room.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations, and close the complaint. LPA met with Executive Director Anthony Garcia, and informed the purpose of visit. During the course of investigation, LPA obtained copies of resident rosters and staff schedule. LPA conducted inspection including but not limited to kitchen, residents rooms, bathrooms/toilets, dining room, activity and common areas in the Assisted Living and Memory Care Units. LPA conducted interviews on 8/18/21, 12/01/21 and 8/25/23. Allegation: Facility in disrepair. It was alleged that the sink faucet water backs up when the water is turned on. .....continued on 9099C (page 2) Unsubstantiated Page 2 During inspection, LPA turned on the faucets and flushed the toilets in residents rooms in Assisted Living and Memory Care Units, and didn't observe any clogging and water in the sink was observed draining properly. Executive Director stated that no pipe broke or have issue where water backed-up. If residents flushed paper towel in the toilet, the toilet clogged and they fix the problem right away. One out of six (6) staff interviewed stated that residents may at times use the sink in the toilet to clean cups, and food scraps may cause draining problem but they take care of the problem immediately. Four out of 5 residents interviewed stated didn't have clogging issue, and 1 was not able to provide information. Allegation: Residents left in soiled diapers for an extended period of time. Four staff interviewed who had or still have direct contact and/or provided/providing care to the residents stated residents' diapers are changed at least 3x during shift. The other 2 staff indicated they have not observed any residents in soiled diapers. Five residents interviewed indicated either not using diaper, can toilet on their own or use diaper and being assisted or changed by staff. Allegation: Facility staff are not cleaning residents room. It was alleged that residents rooms were not cleaned, and their garbage not removed. Staff interviewed stated that rooms in Memory Care Unit are cleaned and trash taken out everyday while the the Assisted Living rooms are cleaned once a week. One out of 5 residents interviewed was not able to provide information on the cleaning of the room. LPA conducted inspection and although observed 2 rooms in Assisted Living unit with residents' belongings on the floor, the flooring was observed clean. ....continued on 9099C (page 3) Page 3 Based on information gathered, the allegations of facility in disrepair, residents left in soiled diapers for an extended period of time, and facility staff are not cleaning residents room are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 15-AS-20210813150529

Allegation investigated: Staff failed to change residents’ diapers in a timely manner Staff not repositioning resident Resident had unexplained weight loss Facility elevator is inoperable Resident fell resulting in a bruise

On 8/10/23 at 12:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a complaint investigation and deliver findings in regard to the allegations above. LPA met with Anthony Garica, Administrator (ADM) and explained the purpose of the visit. During the course of investigation, LPA interviewed the complainant (RP), R2’s family, the facility's administrator, the Resident Service Director (RSD) and S1. LPA toured the memory care unit with ADM and RSD. LPA was unable to obtain any additional information from R2’s family. While in the memory care unit LPA observed R2 being feed her lunch by S1. S1 stated that she works the day shift in memory care 5 days a weeks and feeds R2 her lunch every day. S1 also stated that it is sometimes hard to get R2 to eat as she has a poor appetite. If R2 doesn’t eat her lunch S1 brings her a snack or Ensure later in the afternoon. ***reort continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Staff failed to change residents’ diapers in a timely manner. RSD stated that residents in memory care that are incontinent are checked every 2 -3 hours and changed as needed. This is not documented as it is part of the daily schedule for care givers. Staff not repositioning resident R2 is wheelchair bound and spends most of her day in her wheelchair. When R2 needs to be changed R2 is taken by staff to her bedroom and placed in her bed to be changed. RSD stated there is no record of R2 having any pressure sores. Resident had unexplained weight loss. R2 weighed 134.8 lbs. on 3/3/22 and 127 lbs. on 3/01/23 for a weight loss of 7.8 lbs. which is 5.7 percent. This is with-in the normal range of a person in their late 80’s. R2 also takes Ensure daily to help with weight maintenance. Facility elevator is inoperable. ADM reported that the memory care elevator was out of service for a period of 6 – 8 weeks while the elevator was getting an upgrade. The elevator was back in service on 4/04/23. Resident fell resulting in a bruise. RSD reported that R2 bruises easily due to the medications she takes. R2 is a fall risk but hasn’t had a fall in over 1 year. This agency has investigated the complaints alleging staff failed to change residents’ diapers in a timely manner, staff not repositioning resident, resident had unexplained weight loss, facility elevator is inoperable, and resident fell resulting in a bruise. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 10, 2023 · control 15-AS-20230403155305

Type of visit: Case Management - Annual Continuation

On 8/10/23 at 1:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to complete annual inspection. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. LPA toured the facility including but not limited to 4 residents’ apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. The hot water temperature in a sample of residents’ shared bathroom were measured at 110.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. LPA interviewed 5 residents and 5 staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 10, 2023

Allegation investigated: Staff did not ensure that facility garage gate is operational. Staff did not ensure that resident's original residence has been fixed since it was flooded over 6 months ago. Staff did not ensure that facility front gate is operational.

On 8/02/23 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings for the above allegations. LPA met with Anthony Garcia, Administrator (ADM) and explained the purpose of the visit. On 7/13/23 LPA interviewed the ADM and R1. LPA received a copy of the repair order for the front gate from R&S Overhead Garage Door, Inc. dated 7/10/23. LPA also toured R1's apartments 102 and 117. LPA has investigated all of the allegations as follows: Staff did not ensure that facility garage gate is operational. ADM stated that the gate to the garage is sometimes put in a “locked open” status for deliveries. LPA observed that the gate is operational on today’s visit. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Staff did not ensure that resident's original residence has been fixed since it was flooded over 6 months ago. R1 lived in SW102. R1’s kitchen was flooded in 10/2022. Roto Rooter was called but issue wasn’t resolved, and the kitchen keep flooding. R1 was moved to a larger apartment (SW117) down the hall from her former residence. During December 2022 and January 2023, the facility was trying to get Roto Rooter to take responsibility for the damage they did to the plumbing in the kitchen of SW102. During February and March 2023, the facility was getting bids for the needed repairs which were extensive. In April 2023 the plumbing under the kitchen floor was repaired. During May 2023 the facility again was getting bids to re-model the kitchen. A contractor was chosen in July 2023 and the scope of work is being finalized. Re-model work has started and currently a new floor is being installed. LPA interviewed R1 at the facility. R1 stated that there are a few things she doesn’t like about her current apartment but that she is “making do.” R1 is happy that she can go back to her old apartment several times a week to take care of her plants. R1 further stated that she is confident that the facility staff are working hard to get her back into her apartment. Staff did not ensure that facility front gate is operational. R&S Overhead Garage Door Company repaired the front gate on 7/20/23. LPA observed the gate to be operational during today’s visit. This agency has investigated the complaints alleging staff did not ensure that facility garage gate is operational, staff did not ensure that resident's original residence has been fixed since it was flooded over 6 months ago, and staff did not ensure that facility main gate is operational. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 2, 2023 · control 15-AS-20230703094609

Allegation investigated: Facility has pests.

On 8/02/2023 at 2:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegation above. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation LPA interviewed the reporting party (RP), R1 and the facility administrator (ADM). LPA also toured Unit 115. RP reported that his sister lives in Unit 115 has had bed bugs on and off for the past several months. Most recently his sister needed medical attention for the bed bug bites. Unit 115 is on the independent living side of the facility. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** ADM stated that as soon as he was made of the situation (7/24/23) he and the facility maintenance director called Bay Area Bed Bugs, Orkin and several other companies. Orkin inspected the unit on 7/25/23 and responded with a proposal. ADM agreed to the proposal and the service was scheduled for 7/31/23. LPA received a copy of the Orkin invoice dated 7/31/23. LPA interviewed R1 who stated that she is no longer being bitten. R1 sated “they killed them all.” LPA toured Unit 115 and observed no evidence of bed bugs. This agency has investigated the complaint alleging facility has pests we have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 2, 2023 · control 15-AS-20230724111330

Type of visit: Case Management - Health Checks

On 7/13/23 at 3:10 p.m., Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 118.5 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/26/23. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 13, 2023

Type of visit: Required - 1 Year

On 7/13/23 at 12:46 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Anthony Garcia and explained the purpose of the visit. The facility’s fire clearance was approved for a total of 197 residents of which 166 can be non-ambulatory and 10 bedridden. At 1:00 p.m., LPA reviewed 5 staff records and 5 of 5 are associated to the facility. At 1:40 p.m., LPA reviewed 5 residents records. LPA will return at a later date to complete the inspection. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 13, 2023

Allegation investigated: Facility has mold Staff failed to provide a safe and comfortable environment for residents

On 5/12/23 at 12:10 p..m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation, LPA toured the facility including but not limited to the common areas, kitchen, and 1 apartment. LPA also interviewed the reporting party (RP), 3 staff (S1, S2 and S3) and 2 residents (R1 and R2). Sample size was limited as this complaint happened in 2020. Based on observations and intrviews conducted the allegation that the facility has mold and failed to provide provide a safe and comfortable environment for residents is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 12, 2023 · control 15-AS-20230502151950

Allegation investigated: -Facility is short staffed. -Facility has pests. -Facility is not conducting fire drills as required. -Facility is unsanitary.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and close the complaint.. LPA met with Executive Director Anthony Garcia, and informed the purpose of visit. During the course of investigation, the Department obtained copies of resident roster and staff schedule Interviews and inspection were conducted. Allegation Facility is short staff. It was allleged that facility is short satt. On 12/01/21. LPA interviewed Ruth Ocon, Executive Director at the time complaint was received. Ocon stated that she has to left go two staff for violation of company rules and policies and in the process of hiring. LPA also interviewed S1 and S2 on 12/01/21. S1 stated she's covering both Assisted Living and Memory Care units while facility is in the process of hiring. S2 who is on the unit not covered by the 2 staff who were let go, stated that she works 7 days a week due to short stafing as a result of people leaving. .....continued on 9099C (page 2) Substantiated Page 2 On this day, 2/24/23, Anthony Garcia stated that they are in the process of hiring Memory Care Services Coordinator. Based upon interviews, ,the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility has pests. It was alleged that rats are being found in the dining room and kitchen, and have chewed through the boxes of emergency food supply stored in the basement. On 12/01/21, LPA conducted inspection, and observed mouse droppings in the food storage, and canned food with small bites on the labels LPA interviewed staff S1 on that same day who stated that food supplies has to be moved from large to small storage due to rat infestation. Based upon interview and inspection, the Department has found the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Facility is not conducting fire drills as required. It was alleged that the facility has not conducted a fire drill in over 6 months. On this day. 2/24/23, LPA obtained copies and reviewed fire drill records in facility's file which showed dated 9/22/22, 10/27/22 and 1/27/23. LPA also interviewed Resident Services Director Joanne Nisperos who stated they only started doing fire drills when Anthony Garcia became the Executive Director. Based upon interview and record review, the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. ...continued on 9099C (page 3) Page 3 Allegation: Facility is unsanitary It was alleged that trash is overflowing in all of the buildings, in the stairwells and the trash chutes. On 12/01/21, LPA conducted inspection, and observed on the lowest level on the stairwell in Memory Care unit a shopping bag with soiled diapers. used disposable gloves and soiled pads. Based upon inspection, the Department has found the allegation as substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with Anthony Garcia. Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided. On 12/01/21, LPA interviewed Ruth Ocon, the Executive Director at that time who stated that front door lobby was not locking about 6 months ago from the day of interview. It was fixed and worked for about a month and got broken again. On that same day and on this day, 2/24/23. LPA tested the door by pushing the bar for the disabled to push to open the door, and observed was working properly. On 12/01/21, staff was interviewed who stated that it's been working and that she was told that the door is locked at night. On 2/24/23, Anthony Garcia was interviewed who stated that the door has an alarm that is automatically activated at certain hour at night. Copy of record obtained showed that the sprinkler system, kitchen hood system, and exhaust were serviced on 10/17/22. LPA inspected the kitchen vents and hood on 2/24/23 which were observed clean. Based on interviews, records review and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Allegation: Staff allow resident to smoke inside the facility. It was alleged that there's a resident (R1) in AL unit that constantly smoke inside her room. On 12/01/21, LPA interviewed R1 who stated she smoked inside her room, but when the staff discovered, she quit smoking. Allegation: Staff are not properly trained. It was alleged that staff do not have the required training such as dementia training and mandated reporter training. On 2/24/23, LPA asked for staff records and copies of staff training, ED provided copies of training that were download from the computer, however, records do not show the number of required training. Based on records review conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No citation issued. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 24, 2023 · control 15-AS-20211123105807

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 24, 2023

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed ........... -This requirenent is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above for not having sufficient staff.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: Executve Director stated they are in the process of hiring memory care coordinator. Proof that this postiion is filled-up tp be submitted by 3/24/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 3, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on inspection, observation and inteview, the licensee did not comply with the section above for having rat infestation.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: Corrected. Faciliy hired pest control company. Proof of service obtained by LPA on this same day, 2/24.23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(l)(8) · Plan of correction due date: Mar 3, 2023

87705 Care of Persons with Dementia (l):(8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above for not having completed fire drills which poses potential safety risks to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: Executive Diector (ED) to have fire drill conducted and submit proof by 3/03/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 3, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on inspection and observation, the licensee did not comply with the section above for trash in the stairwell which ppsed potential health and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: The garbage was removed on the day LPA observed. In addition, ED will in-service the staff and submit by 3/03/23.

Allegation investigated: Staff does not respond to resident's call in a timely manner.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Executive Director Anthony Garcia, and informed the purpose of visit. During the course of investigation, the Department obtained copies of resident roster, staff schedule and call button/pendant records. Interviews were conducted and call button/pendant records were reviewed. On 3/25/21, LPA interviewed family member (FM1) who stated they (family) visited resident (R1) on 3/22/21, and they pressed the call button for assistance, staff only came after 25 to 30 minutes. LPA was not able to obtain information from R1. On 12/01/21, LPA interviewed R2 and R3. R2 stated when she pressed her pendant staff responds within 10 to 15 minutes while R3 said staff responds at most 30 minutes. Review of call button records for the said incidents showed several response times ranging from 16 minutes 57 seconds to 65 minutes to 59 seconds. .....continued on 9099C Substantiated Based on records review and interviews, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Anthony Garcia. Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided. Page 2 Allegation: Staff left resident on the floor for expended period of time. It was alleged that R1 fell off from bed, and was left on the floor for extended period of time. Family member (FM1) was interviewed on 3/25/21 who stated they saw on the camera they placed on R1’s room that R1 was on the floor on 3/13/21 and 3/14/21, and R1 was left unattended for 2 to 3 hours. LPA tried to obtained video footage from FM1 but was unsuccessful. LPA was not able to obtain information from R1 of what had happened on the alleged incident dates. Another family member (FM2) was interviewed on 12/01/21 who stated there were some issues but indicated caregivers are good in providing good care to the resident. Based upon interviews conducted, and FM1 unable to provide video footage of the alleged incident, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff do not follow the admission agreement in accordance with the service plan. It was alleged that per Admission Agreement R1 is to be checked every hour. FM1 was interviewed on 3/25/21 who stated that R1 is on an hourly check per Admission Agreement. They were verbally told R1 is on level 5 care needs; however, they do not know what is level 5. Copies of Admission Agreement and Needs and Services Plan were obtained and reviewed by LPA. Although Admission Agreement showed R1 is on level 5 based on the rate fee charge, this document and the Needs and Services Plan didn’t indicate R1 is on hourly check. Review of Appendix B-1 of Admission Agreement showed the rate charge for R1 falls under level 5. On 2/24/23. Resident Services Director was interviewed who stated that the status checks for level 5 resident is every two hours or 4 times per 8 hours shift. Based upon interviews conducted, and records review, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. ,,,,continued next on 9099C (page 3) Page 3 Allegation: Resident's room does not have adequate heater. It was alleged that the heater in R1’s room does not work, and staff brought in a temporary heater which is not adequate. FM1 was interviewed on 3/25/21 who stated that R1 told FM1 that wall heater on R1’s room was not working on 3/14/21 and the staff only brought in the floor heater that day and it was not working either. LPA verified and FM1 said the wall heater was still not working but the floor heater was already working, On 3/26/21 and 12/01/21, LPA conducted inspection. LPA observed on 3/26/21 that R1’s room was vacated as R1 moved to Memory Care Unit on the night of 3/25/21. LPA observed the heater working. LPA was not able to obtain information from R1. On 3/26/21, LPA interviewed Ruth Ocon, the Executive Director during that time who stated she never received any complaint about heater not working. On 12/01/21, LPA interviewed R2 who at that time was on the room vacated by R1 stated the temperature in the room is okay and the heater is working. R3 stated the heater in R3's room is working, Based upon interviews and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff denied resident the right to reasonable visitations. It was alleged that staff denied the family member visits to R1 under any condition, even though everyone in the facility is already vaccinated for Covid-19. On 3/25/21, LPA interviewed FM1 who stated that they were allowed to get inside R1's room when they were moving-in R1's furniture on 3/12/21. They were told the facility has 2 positive cases, and that they cannot visit. However, when R1's other family members went to the facility on 3/14/21, they were allowed to get in. FM1 stated there's a lot of confusion in regards to visitation, and that were not told about window and/or virtual visitations. They were only allowed to visit Tuesday, 3/16/21. LPA reviewed facility history of Covid-19 positive cases which showed a case was reported on 3/09/21, 2 days before R1 moved-in. LPA interviewed Ruth Ocon on 3/26/21 who stated when the facility has Covid case, they are not allowing visitation until Public Health clears the facility. However, when there's new admission, they are allowing the family to come inside on the day of move-in, so they can set-up the room, and move-in some stuff the resident will need. ....continued pon 9099C (page 4) Page 4 The facility's side door is open, and the family members' temperatures are check Ocon also stated that R1’s niece (name she does not remember) came to visit but they asked her to leave, and explained about the facility not allowing indoor visitation. Copy of email blast dated 3/08/21 showed Ocon provided information to staff which includes visitation will be outside only. Ocon also stated an email blast was sent to residents' family members. On 12/01/21, LPA interviewed another family member (FM2) and resident R2. FM2 stated when she visits, she test for Covid. FM2 also stated she does not have any problem with visitation. R2 stated R2’s family members come and visit, and were allowed to come in. R2 also stated that staff checks the family members’ temperatures first before they are let in. LPA conducted inspection on 12/01/21, and observed a tent in the facility courtyard for outdoor visitation. Based upon interviews and inspection conducted, the Department has investigated the above allegation and found as unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted. and copy of this report provided.the state’s words, verbatim · CDSS document, Feb 24, 2023 · control 15-AS-20210317082415

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Feb 25, 2023

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. -This requirement is not met as evidenced by: -Based on records review and interviews. the licensee did not comply with the section above for staff not responding to residents' calls in timely manner which poses immediate health, safety and personal right risks to persons in care.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: Executive Director (ED) stated he and/or Care Service Directors will review the call button records periodically to ensure timely response. In additiionm, ED will conduct in-service training, and submit copy of training topic with attendees signatures by 2/25/23.

Type of visit: Case Management - Deficiencies

While conducting investigation of a complaint (15-AS-20211123105807) and upon request for staff file, LPA learned that files were not available. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Anthony Garcia. Exit interview conducted. Copy of this report, Appeal Rights and LIC9098 Proof of Correction form provided.the state’s words, verbatim · CDSS document, Feb 24, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f) · Plan of correction due date: Mar 3, 2023

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. -This requierment is not met as evodenced by: -Based on interview, the licensee did not comply with the above for not having staff file available for review.the state’s words, verbatim · CDSS document, Feb 24, 2023

Plan of correction: Executive Director to read the Regulation, and self-certify that records wiill be made reacily available for inspection. Self-certification to be submitted by 3/03/23..

Allegation investigated: Staff have not repaired a washing machine for the residents

On 2/15/23 at 3:00 p.m., Licensing Program Analyst (LPA) G. Clark conducted an unannounced visit to deliver the findings for the above allegation. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation, LPA interviewed the complainant (RP) and the facility's administrator (ADM). LPA toured the independent living side of the facility and observed 1 washing machine (GE manufacturer) with an out of order sign taped to it. ADM was not able to produce records of repairs attempts for the washing machine. Based on LPA’s observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) and are being cited on the attached LIC 9099D. Exit interview conducted, a copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Feb 15, 2023 · control 15-AS-20230130110824

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 15, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: based on interviews and inspection. the licensee did not comply with the section above. LPA observed a clothes washer in the Salem Building with an out or order sign on it which poses a potential safety risk to person in care.the state’s words, verbatim · CDSS document, Feb 15, 2023

Plan of correction: Administrator to do the following: Have the necessary repairs completed or replace the washer with an operational unit by the POC date.

Allegation investigated: Facility has pests

On 01/19/23 at 12:20 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to deliver complaint findings. A Facetime video conference was conducted by LPA D. Panlilio on 12/09/2020 in order to meet the initial 10-day complaint notification for the above allegation(s). LPA explained the purpose of the visit and met with Anthony Garcia, Executive Director. During course of the investigation, the Department conducted interviews and record reviews. Three similar complaints was addressed. Complaint #15-AS-20200923100527 received 09/23/2020, #15-AS-20210416154529 received 04/16/21, and #15-AS-20210507092956 received 05/07/21. The noted complaints were received before and after the above allegations. The complaints were substantiated. Allegation: Facility has pests According to S2, vermin (roaches) were observed in the kitchen elevator and bathrooms. Records revealed that the facility had a documented history of pests over the course of 9 months. The facility was cited with a plan of correction. Based on interviews conducted, records received, and observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, Jan 19, 2023 · control 15-AS-20201201091707

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Jan 20, 2023

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects... All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Licensee failed to keep the facility clean and free of pests which posed a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 19, 2023

Plan of correction: The facility covered part of the kitchen wall where the vermin/rodents had access to the facility, sticky traps for rodents were set up and checked weekly. Previous LPA requested a permanent plan on how to prevent rodents/vermin entering the facility. POC was cleared on 04/07/2021

Allegation investigated: Facility is not addressing issue with rodents in the kitchen Staff does not ensure the kitchen is kept in clean, safe, sanitary conditions

On 1/17/23 at 2:05 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to open a 10 day complaint visit or the above allegations. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation, LPA interviewed Administrator, 3 staff (S1, S2 and S3) and the complainant (RP). LPA also reviewed work orders from the pest control company. Adminstrator reported that the facility has a monthly contract with Orkin Pest control. Okin monitors for rodaent activity anbd sets traps throughout the kitchen outside areas. ***report continues on LIC9099C*** Unsubstantiated **report continues from LIC9099*** S1 stated that she has not seen any rodents in the kitchen. S1 also stated that she is in the process of developing a cleaning schedule for the kitchen . Currently staff clean as they work. S2 and S3 also stated that thetyhave not seen any rodents in the kitchen. S3 demonstrated to LPA how the floor drains in the kitchen are cleaned. All drains were observed to be clean at the time of the inspection. This agency has investigated the above allegations. Based on records reviewed, and interviews conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 15-AS-20230111142713

Allegation investigated: Questionable Death. Facility administered medications to resident without physicians order. Facility mismanaged medication resulting in overmedicating resident in care Personal rights- resident spoken to inappropriate manner Personal rights- facility staff handled resident in a rough manner Responsible party not notified about resident's change in condition Staff unable to communicate with residents due to language barrier Lack of supervision- resident sustained several unwitnessed falls with injury.

On 1/17/23 at 1:35 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation, LPA interviewed S1 and S2, reviewed facility hospice roster for May and June 2022. LPA also reviewed R2’s records including physician's report, Medication Administration Records (MARs), needs and services plan, Physician Orders for Life-Sustaining Treatment (POLST), Death Report (LIC624A), SIR’s and Hospice nurse notes. On July 13, 2022 LPA was able to speak with R2’s daughter(W1). W1 stated that R2 was admitted to the facility on 5/31/22 and died on 6/27/22, W1 was present in R2’s room when he passed. ***Report continues on LIC9099*** Unsubstantiated Questionable Death. On 6/27/22 W1 decided to move R2 back to her home so she could monitor his care more closely. While moving R2 from his bed to a wheelchair he collapsed. The hospice nurse told S1 to call 911. S1 did so and then left R2’s room to retrieve his POLST from her office. When S1 returned to R2’s room the paramedics had pronounced R2 deceased. Facility administered medications to resident without physicians order. Facility mismanaged medication resulting in overmedicating resident in care. S1 stated that all medications for R2 were handled by either W1 or the hospice nurse. LPA reviewed R2 medication orders on file and MARs from 5/31/2022-6/27/2022. No medications were administered by facility staff. All medications listed on the MARs were initialed by staff as “given to family to give later” and matched physician orders on file. W1 could not recall which medications were administered without the proper order nor which date said medications were taken by R2. Personal rights- resident spoken to inappropriate manner. Personal rights- facility staff handled resident in a rough manner. Both S1 and S2 stated that they never saw any staff members at the facility speak to R2 in an inappropriate manner or handle R2 roughly. Responsible party not notified about resident's change in condition. Both S1 and S2 stated that they were in constant contact W1 regarding her father’s condition. Both S1 and S2 showed LPA numerous text messages on their phones to and from W1. Staff unable to communicate with residents due to language barrier. S2 stated that some of the housekeeping staff speak very little English but that they are not responsible for resident care. Care staff all speak English. ***Report continues on LIC9099C** ***Report continues from LIC9099C*** Lack of supervision- resident sustained several unwitnessed falls with injury. LPA reviewed R2’s SIR’s and there was no documentation of any falls. S1 stated she never was told by staff that R2 had fallen. This agency has investigated the above allegations. Based on records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 17, 2023 · control 15-AS-20220629154045

Allegation investigated: Staff did not seek emergency medical services for resident

On 12/28/2022 at 1:50PM, Licensing Program Analysts (LPAs), L. Hall and L. Holmes conducted an unannounced visit to deliver complaint findings for the above allegation. LPA met with Anthony Garcia, Executive Director (ED) and explained purpose of the visit. During the course of the investigation, the Department conducted interviews with staff, witnesses, residents, obtained and reviewed records. On the allegation staff did not seek emergency medical services for resident, during interviews and record reviews it indicated R1 fell at approximately 03:20AM. Based on review of hospice records Resident 1 (R1) had an unwitnessed fall on 6/27/2020 and was found on the floor outside of her room by staff. Interview with the Hospice nurse indicated the nurse was not there at the time of the fall but was only informed by R1’s family. The hospice nurse stated that Continued on LIC9099C. Substantiated Continued from LIC9099. the facility never reported the fall. The Reporting Party (RP) stated during interview that the facility never called 9-1-1 after the fall. The RP also stated that RP called R1’s doctor and had a Mobil x-ray conducted. The x-ray showed that R1 had a broken femur, and the facility did not call 9-1-1 until 08:30PM. During record review of Alta Bates Summit-Merritt discharge summary notes dated 07/02/2020, notes indicate that R1 was x-rayed on 6/27/2020 at 11:03PM and was seen/examined on 06/28/2020. Even though medical attention was given to R1 it was not done in a timely manner, therefore, based on the investigation the allegation is deemed Substantiated. Based on LPA interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided. Continued from LIC9099. R1 on the floor. Documentation for R1 also indicates, R1 sustained approximately five additional falls despite having various one-to-one private caregivers. Staff stated during interviews that memory care clients are checked every two hours. Staff that were interviewed all stated R1 was a wanderer and would often forget to use her walker or would leave it in multiple places. Staff also stated during interviews that memory care clients are checked every two hours. Reporting Party (RP) stated that on 6/27/2020 R1 was found on the floor by staff at approximately 3:20AM. (RP) contacted the on-call doctor prior to R1 being transported to the Emergency Department (ED) and x-rays showed R1 sustained a left femur fracture. During the course of the investigation, including file review, the Department observed that after R1 transitioned to the memory care unit on 5/30/2020, R1 continued to sustain injuries from multiple falls. Record review indicated that it was documented in Hospice Care’s initial assessment of R1 that R1 was never to be left unsupervised. Records also indicated that the family provided a one-to-one caregiver. The caregiver along with facility staff indicates R1 was not left unsupervised. Review of R1’s unusual incident reports that occurred between 5/24/2020 to 6/15/2020, it was documented and noted that medical treatment was not necessary as R1 sustained bruising and did not complain of any pain. Review of the facility’s unusual incident reports and staff charting indicates that R1 had a history of falls. Continued on LIC9099C. Continued from LIC9099C. Staff that were interviewed all stated R1 was a wanderer. Record review and interviews indicated that on 6/17/2020 R1 wandered into another resident’s room where she was found on the floor by the RP. R1’s one-on-one private companion was cancelled on 6/7/2020 and restarted on 6/22/2020, thus R1 did not have a one-on-one companion at the time of the incident. Record review indicated that staff responded when they heard Resident 2 (RP 2) screaming loudly once, therefore staff was in the general area and was able to respond in a timely manner at the time of the incident. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Dec 28, 2022 · control 15-AS-20200629162751

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jan 16, 2023

87465 (g) The licensee shall immediately telephone 9-1-1 if an injury... has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidence by: Based on investigation the Licensee did not comply with the section cited above in telephoning 9-1-1 immediately for an injury, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: Administrator agrees to have an authorized vendor conduct in-service staff retraining on timely addressing residents’ medical needs. Administrator agrees to submit completed staff retraining certifications to CCLD by POC date.

Type of visit: Case Management - Other

On 12/28/2022 at 2:45PM, Licensing Program Analysts (LPAs) L. Hall and L. Holmes arrived unannounced to conduct a Case Management visit. LPA met with Anthony Garcia Executive Director (ED) and explained the reason for the visit. When the Department was conducting a complaint investigation (15-AS-20200629162751) on 7/7/2020, facility documents were requested. The requested documents were not received as of 11/9/2020. The regulation states the licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand. The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 28, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(c) · Plan of correction due date: Jan 16, 2023

87755 Inspection Authority of the Licensing Agency (c)The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand... Records may be removed if necessary for copying... This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing records requested by the department which poses a potential health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Dec 28, 2022

Plan of correction: Administrator agreed to provide documents to the department when requested and provide and in-service training explaining regulation 87555 and submit a verification of training with signatures to CCLD by POC date.

Type of visit: Case Management - Other

On 12/13/22 approximately at 3:55PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Wellness Director and explained the purpose of the visit. A total of 1 resident from GLG is currently living in Pacifica. During visit, LPA met with this resident. the resident stated that the transition was smooth and she feels safe and comfortable living in facility. Supplies were adequate and staffing is stable. There was no imminent health/safety concerns on today's date. Exit interview conducted with Wellness Director and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 13, 2022

Allegation investigated: Facility staff was not aware of resident DNR status

On 11/29/22.at 2:00 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegation. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation LPA interviewed the complainant (RP) and S1. RP’s interview confirmed that she was present in R1’s room when the facility nurse (S1) called paramedics for assistance with R1. RP further confirmed that S1 left R1’s room after calling the paramedics to go to her office to obtain R1’s POLST document. ***report continues LIC9099C*** Unfounded ***Report continue from LIC9099*** During S1’s interview she stated that R1 was admitted just weeks prior (5/31/22) as a hospice resident with a DNR in place. S1 was not in R1’s room when the paramedics allegedly performed CPR on R1. When S1 returned to R1’s room the paramedics had pronounced R1 deceased. This agency has investigated the complaint alleging that facility staff was not aware of resident DNR status. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 15-AS-20220705092744

Allegation investigated: Facility has bed bugs. Resident did not receive showers as agreed to. Staff stored another resident's belongings in a resident's room. Bathroom showers are dirty. Staff do not wear gloves when caring for residents. Resident pendant was not answered by staff. Staff did not assist the resident with incontinence.

On 11/29/22.at 1:30 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver the findings for the above allegations. LPA met with Anthony Garcia, Administrator and explained the purpose of the visit. During the course of investigation, LPAs A. O’Hollaren and L. Francisco interviewed the complainant (RP) and 5 staff. LPAs obtained bed bug treatment logs, shower skin check assessment documents, end of shift reporting documents, med tech communication logs and toured the facility. Based on documents received the facility had a proactive treatment plan for bed bugs in place and was activity treating rooms identified as having bed bugs. **report continues on LIC9099C*** Unsubstantiated ***Report continues from LIC9099*** Skin check shower logs documented that the RP was receiving showers regularly, on occasion the RP would refuse showers. The Executive Director (ED) reported that some resident’s belongings had to be temporarily moved to accommodate the bed bug treatment activities. During the LPAs tour of the facility it was observed that the shower rooms were clean with the exception of one room that had a faint smell of urine. Staff were observed to be wearing gloves. S3 reported that staff have 15 minutes to answer pendent calls in their assigned area. If staff cannot answer the pendent, they radio in for assistance. Facility keeps a pendent log to see who cleared the pendent and when. End of shift reporting documents chart that RP received incontinence care on a regular basis. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 29, 2022 · control 15-AS-20210526120635

Allegation investigated: Financial abuse Facility would not allow resident to have phone calls from immediate family Facility would not communicate with resident's POA

On 10/13/22 at 2:15 p.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation in regards to the allegations above. LPA met with Administrator, Anthony Garcia and informed him the reason for the visit. During the course of investigation, LPA interviewed staff, reviewed R1's records including facility file, Power of Attorney document dated 9/04/21, Residence and Care Agreement and Resident Ledger. LPA found the resident's ledger to be in order with checks documented and marked as payment to the facility. The POA during R1's time at the facility was R1's sister as documented on the Power of Attorney document dated 9/4/21. The facility communicated with the POA as needed throughout R1's time at the facility. *** report continues on LIC9099C*** Unfounded ***report continues from LIC9099*** During the review of R1's POA agreement it is stated "Care and Control of Person. My agent is authorized, in my Agent's sole and absolute discretion from time to time and at any time, with respect to the control and management of my person." In order to met this directive the POA instructed the facility to block all communication with R1's family in New Jersey. The POA stated that talking to his family in New Jersey upsets R1 and she didn't want that for R1. This agency has investigated the complaint alleging financial abuse, facility would not allow resident to have phone calls from immediate family and facility would not communicate with resident's POA. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted, a copy of this reported provided.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 15-AS-20221005120903

Allegation investigated: Facility staff member lacked qualifications.

On 8/30/2022 at 11:45 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and respect to deliver investigation findings. LPA explained the purpose of the visit with Executive Director (ED). Allegation: Facility staff member lacked qualifications - Substantiated The Department has investigated this allegation and per records review and interviews, and found that former administrator (S1) certificate was expired on 6/30/2021 but was approved for extension to 12/31/2021. S1 admitted that her Administrator certificate was not renewed. New Administrator S3 was assigned and performed Administrator responsibilities effective on 3/1/2022, No record of an active certified Administrator associated with facility was found in January and February in 2022. Continue on LIC9099-C Substantiated Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with ED. Appeal Rights and a copy of this report provided. Allegation: Facility is in disrepair (broken refrigerators) – Unsubstantiated The Department has investigated this allegation and per interviews and observation found that 1 broken freezer and 2 broken small refrigerators in the main kitchen did not affect facility operation. 1 big freezer and 2 big refrigerators located in lower level of the kitchen were observed well functional and have amble space to store food. Per reviewing the equipment order form, it's in the process of replacing broken equipment. Kitchen director S2 stated the broken freezer and refrigerators were used for keeping daily meals supplies such as prepared salad and ice cream for the day, and it would be efficient and convenience to have them repair or replace in the main level of kitchen instead of having staff walk back and forth. Based on observation, records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with ED and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2022 · control 15-AS-20220324123422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 6, 2022

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed facility does not have an active certified Administrator associated in the month of January and February 2022 which poses a potential health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2022

Plan of correction: Executive Director agreed to review the regulation and submit a self-certification of understanding regulation to CCL by the POC due date.

Allegation investigated: Facility doesn't have an Administrator. Residents key fobs are in disrepair.

On 8/30/2022 at 8:50 a.m., Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and respect to deliver investigation findings. LPA explained the purpose of the visit with Executive Director (ED). Allegation - Facility doesn't have an Administrator-Substantiated The Department has investigated this allegation and per records review and interviews, and found that former administrator (S1) certificate was expired on 6/30/2021 but was approved for extension to 12/31/2021. S1 admitted that her Administrator certificate was not renewed. New Administrator S3 was assigned and performed Administrator responsibilities effective on 3/1/2022, No record of an active certified Administrator associated with facility was found in January and February in 2022. Continue on LIC9099-C Substantiated Allegation - Residents key fobs are in disrepair-Substantiated The Department has investigated this allegation and per records review and interviews, and found that disfunctional key fobs was an on-going issue and has not been repaired in timely manner. On 3/30/22, LPA toured the Salem Woods building with Administrator S3 to inspect the key fobs. LPA observed S3 tried to use FOB keys to open the doors which did not operate the door open. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with ED. Appeal Rights and a copy of this report provided. Allegation - Facility fire alarms are in disrepair- Unsubstantiated The Department has investigated this allegation and per records review and interviews, and found that Annual Fire Inspection on Salam Woods Building was passed on 11/29/2021. No record for incident of fire alarm went off was found. Allegation - Facility is not properly maintaining trash disposal-Unsubstantiated The Department has investigated this allegation and per records review and interviews, and found that bulk pickup has been arranged by maintenance department and scheduled date was confirmed. On 3/30/22, LPA toured the areas where trash bins and dumpsters were, and observed that trash bins and dumpsters were empty, which were picked up on the trash date 3/29/2022 (every Tuesday and Thursday), A few items of chairs, tables and sofa were observed next to the dumpsters. Administrator S3 stated that management team was aware and has scheduled pulk pickup tomorrow. On 3/31/22, S3 provided a picture of showing the dumpsters area was clean to CCL. Based on observation, records reviewed, and interview conducted, the above allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with ED and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2022 · control 15-AS-20220324151334

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 6, 2022

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed facility does not have an active certified Administrator associated in the month of January and February 2022 which poses a potential health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2022

Plan of correction: Executive Director agreed to review the regulation and submit a self-certification of understanding regulation to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 6, 2022

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times.... This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed key fobs on Salam Woods Building did not operate to open the door which poses a potential health and safety concern to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2022

Plan of correction: Defeciency Cleared. ED has awarded the contract of repairing key fobs system on 8/23/22, the project starting date is pending, and also, ED proactively keeps CCL updated.

Allegation investigated: Staff did not respond to resident's call button in a timely manner.

On 7/25/2022, Licensing Program Analyst (LPA) L.Ibo conducted an unannounced complaint visit, met with Resident Service Director (RSD) Joann Nisperos and Executive Director Anthony Garcia and explained the purpose of the visit. Allegation: Staff did not respond to resident's call button in a timely manner. During the course of investigation, records review revealed that residents call button response time dated 6/26/2022- 7/3/2022 is ranging from 1 minute up to 51 minutes. ...continue to LIC9099C... Substantiated Allegation: Resident's call button is in disrepair. Based on interview and records review, staff admitted that the alert system that is showing on the computer is in disrepair due to down wifi signal, although the wifi is down the pager system is active all the time, staff still receiving alerts from the residents pendants. Allegation: Facility has inadequate staffing. Based on interview and records review, based on staff roster and work schedules it was revealed that there are 3-4 staff for morning shift, PM shift have 3-4 staff were scheduled at 2 staff at night time. Residents stated when they needed assistance, staff were always there to help. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Anthony Garcia. A copy of this report provided. Pendant summary reports indicated that about 22 cases (6/26/2022-7/3/2022) where response times were 30 minutes long. LPA reviewed a few of those cases and most cases were residents activating pendant. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted , report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 25, 2022 · control 15-AS-20220721084640

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(4) · Plan of correction due date: Aug 1, 2022

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, facility staff failed to respond to residents pendant call for assistance in a timely manner which poses a potential risk to the health and safety of resident under care.the state’s words, verbatim · CDSS document, Jul 25, 2022

Plan of correction: Executive director agrees to conduct staff training will be conducted about the facility’s protocol on pendant call response and submit proof of training to CCL by POC date,

Type of visit: Case Management - Health Checks

On 7/01/22 at 2:15 p.m., Licensing Program Analyst (LPA) Greg Clark conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Anthony Garcia, Executive Director and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, dining room and outdoor area. 7-day of non-perishable and 2-day of perishable food supplies were observed. Resident's medications were kept locked in the med cart. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observed. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/11/22. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 1, 2022

Allegation investigated: Facility is not assisting resident with ADLs.

On 6/16/2022 at 10:45AM, Licensing Program Analyst (LPA), L. Hall and C. Fowler arrived unannounced to conduct a complaint investigation and deliver complaint findings for the allegation above. LPA met with Yadira Valdiva, Business Manager and explained the reason for the visit During the course of the investigation LPA. G. Luk interviewed staff, Resident 1 (R1), and Witness 1 (W1). LPAs L. Hall and C. Fowler interviewed S3, S4, obtained the following documents: Admission agreement, advantage resident assessment, facility roster, invoice statement, outside agency/services documentation, physician's reports dated 2/9/2021 and 7/26/2021, hospice assessments, needs and services plan dated 2/10/2021, narrative charting, and resident assessment dated 2/10/21. Continued on LIC9099C. Unsubstantiated Continued from LIC9099. Based on LPAs record review and interviews R1's condition had declined and R1 needed a higher level of care. R1 refused puree foods per hospice assessment and S4. Facility would finely chop food for R1, but R1 had little to no appetite. S1 stated that R1's family would speak to her personally regarding any changes relating to R1. R1 moved out of the facility on 8/3/2021 to a skilled nursing facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 15-AS-20210727162312

Allegation investigated: Facility doors are not being properly maintained.

On 6/02/22 at 1:45 p.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to complete a 10 day visit to open the investigation for the above allegation. LPA met with Anthony Garcia, Executive Director. During the course of investigation, LPA interviewed Anthony Garcia and observed the doors to the independent living buildings. The keypads on both doors do not read the key fob. A code must be entered and the doors must be manually opened. This is difficult for residents using walkers or in wheelchairs. During the interview Mr. Garcia told the LPA that he is waiting on a third bid to replace the doors. In the meantime doors are sometimes propped open and staff are available to assist residents if needed. This usually occurs during mealtime as many of the independent living residents come over to the main building for their meals. *** cont'd on 9099 c*** Substantiated Due to this being a repeat violation Civil Penalties are being assessed. See LIC421FC. Based on LPA observations and interview which were conducted on 6/02/22, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted and a copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jun 2, 2022 · control 15-AS-20220523120235

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 30, 2022

87303 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation is not being meet by observation of the doors to the independent living building. The doors must be manually opened manually which posed a potential threat to the safety of the residents in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Executive Director has agreed to provide LPA with bi-weekly updates on the progress of the door repair.

Type of visit: Required - 1 Year

On 5/12/22 at 1:39 p.m., Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct Infection Control Inspection. LPA met with Executive Director, Anthony Garcia and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to: front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility has a 30 day supply of medications. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPE maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 12, 2022

Allegation investigated: Facility is not following COVID-19 protocols

On 04/27/22 at 2:41PM, Licensing Program Analysts (LPAs) D Panlilio and G Clark conducted an unannounced complaint investigation, met with Resident Services Director (RSD) who is the manager on duty for the day and delivered the investigation finding to RSD. LPAs explained the purpose of the visit with RSD. During investigation, LPAs observed the front entrance had COVID signages in place and 4 staff wearing face masks while on duty. Routine symptom checks (temperature checks, COVID questionnaire) were done. LPAs observed hand sanitizers available as well as additional COVID signages posted in common areas as reminders to practice cough/sneeze etiquette, social distancing, wearing face masks, visitation policies. RSD stated that faciity staff continue to follow COVID protocols and have housekeeping conduct daily cleaning and disinfection of commonly touched surfaces. Continued on next page, LIC 9099-C Unsubstantiated RSD stated she tried to administer the COVID antigen tests yesterday to R1 & R2. However, R1 was out of the facility running errands and R2 told RSD that she already got tested 3 times earlier in the week and the test results were all negative. LPAs requested RSD to administer the antigen tests on R1 & R2 while at the facility. LPAs observed both antigen test results on R1 and R2 came back negative. During the visit, R1 & R2 confirmed with LPAs that RSD tried to administer the COVID antigen tests on 04/26/22. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit Interview conducted and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 27, 2022 · control 15-AS-20220426163958

Allegation investigated: Facility does not provide a safe environment for resident

On 04/26/22 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator. Allegation: Facility does not provide a safe environment for residents Investigation Finding: SUBSTANTIATED Based on interviews and observations, facility does not provide a safe environment for residents. On 1/06/22 at 2:50PM, LPA toured the Salem Woods building with administrator (ADM) to inspect the exterior doors. LPA observed both exterior doors were not opening automatically. LPA observed ADM tried to use FOB keys to open the doors which did not work along with broken handicap plates that do not open the doors from the inside automatically located on the other side of the building. Continued on next page, LIC 9099-C Substantiated ADM stated she has been working with 2 specialty door companies since March 2021 with exterior doors still not functioning properly. On 03/16/22, another LPA observed the FOB key and button to activate the elevator in the garage did not work. LPA interviewed 2 residents at Salem Woods who stated they were not able to use the elevator from the garage to the upper levels in the last several months. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 15-AS-20220107152901

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: May 26, 2022

Personal Accommodations & Services: The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by non functioning building elevator, exterior doors & FOB keys which posed a potential Health & Safety risk to residents in carethe state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD proof of repairs to permanently fix broken building elevator, exterior doors & FOB keys for residents in care.

Allegation investigated: Resident sustained multiple infected pressure injuries while in care Staff fail to change resident's diaper frequently and when wet Staff fail to reposition resident several times a day using proper technique

On 04/26/22 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator. Allegation: Resident sustained multiple infected pressure injuries while in care Investigation Finding: SUBSTANTIATED Based on interviews and records review, R1 was being treated for wound care by a home health nurse at the facility from 5/18/20 to 8/7/20. On 6/15/20 HHN observed that the wound was not healing as expected and by 7/11/20, HHN observed that a red wound was developing. On 8/5/20, HHN observed that R1’s wound was not healing due to contamination with urine. The facility staff were instructed to check for incontinence care need every hour; upon review of the care plan, there was no update made to the care plan with this direction. The preponderance of evidence has been met. Therefore, the allegation is substantiated. Continued on next page, LIC 9099-C Substantiated Allegation: Staff fail to change resident’s diaper frequently and when wet Investigation Finding: SUBSTANTIATED Based on interviews and records reviews, R1 was being treated for wound care by a home health nurse at the facility from 5/18/20 to 8/7/20. On 7/11/20, HHN observed a new red wound at the left buttock and on 7/24/20 instructed staff to change R1 promptly after each episode of incontinence to prevent deterioration of the wounds. On 8/5/20, HHN observed that R1s wound was not progressing due to continuing urine contamination. The preponderance of evidence has been met. Therefore, the allegation is substantiated. Allegation: Staff fail to reposition resident several times a day using proper technique Investigation Finding: SUBSTANTIATED Based on interviews and record reviews, HHN notified staff to reposition R1 every 2 hours while in bed and keep R1 clean and dry at all times for wound to heal on 06/24/20 and 07/06/20. On 06/26/2020 HHN brought in Occupational Therapist (OT) to train staff on proper resident repositioning techniques. On HHN’s routine wound care visit dated 07/11/20, a new wound on the left buttock which was observed to be red and reported this to staff. HHN again instructed staff to reposition R1 every 2 hours in bed and encourage R1 to hydrate and eat food. Upon review, it was found that this direction was not added to the care plan. The preponderance of evidence has been met. Therefore, this allegation is substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.the state’s words, verbatim · CDSS document, Apr 26, 2022 · control 15-AS-20200807153407

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 26, 2022

Personal Rights (a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by resident sustaining pressure injuries while in care which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper incontinence care and will submit to CCLD copy of completed staff retraining.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: May 26, 2022

Basic Services Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications… This requirement was not met as evidenced by staff failing to reposition resident in bed which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper repositioning techniques and will submit to CCLD copy of completed staff retraining.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(3)(B) · Plan of correction due date: May 26, 2022

Personnel requirements - General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following: (B) Importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control… This requirement was not met as evidenced by staff failing to reposition resident which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Apr 26, 2022

Plan of correction: By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper repositioning techniques and will submit to CCLD copy of completed staff retraining

Allegation investigated: Personal Rights - Resident sustained multiple pressure injuries while in care.

On 04/14/22 at 11:50 a.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings for the above allegation. LPA met with Anthony Garcia, Executive Director and explained the purpose of the visit. During the course of the investigation, the Department conducted interviews with facility staff, residents, witnesses and complainant. Documents including but not limited to: R1’s Physician’s Report, home health records, Care Plan, discharge notes were obtained. REPORT CONTINUES ON 9099C Unsubstantiated On 4/30/2021, R1 was admitted to memory care unit from assisted living. An initial health assessment was completed on 5/26/2021 and no indication of any rashes during skin assessment. On 8/6/2021, S2 observed a wound on bottom of right foot, and notified R1’s responsible party and primary care physician. Wound care was initiated by Pine Park Health (PPH) and ProHealth Home Health (PHHH) on 8/19/2022 and 8/20/22; respectively. Staff were instructed to reposition R1 every 2 to 3 hours and offload pressure. Based on interviews with staff, staff reported that R1 was being repositioned as they were instructed. The Department was unable to provide or disprove there was neglect by the facility. Although, R1 sustained multiple wounds while at the facility, R1 was receiving wound care by PPH and PHHH. W1 stated home health was aware R1 sustained multiple pressure injury due to R1’s bed bound status and there were no concerns of staff being neglectful. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 14, 2022 · control 15-AS-20211007162353

Allegation investigated: Facility has vermin

On 3/22/2022, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced visit with to deliver the findings of above allegation. LPA met with Vildivia Yadira, Business office manager explained the purpose of the visit, interim Administrator Cynthia Morris is not available during the visit. During course of the investigation, the Department conducted interviews and record review. According to S1 facility observed vermin at the stock room in the kitchen area. Facility then hired third party company to eliminate vermin and closed an open portion of kitchen wall where the vermin have an access to the kitchen area. …Continued on LIC9099C… Substantiated Based on interviewed conducts, records received, and observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Yadira V., Business office manager. Copy of report and appeals rights provided.the state’s words, verbatim · CDSS document, Mar 22, 2022 · control 15-AS-20210507092956

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(27) · Plan of correction due date: Apr 1, 2022

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Licensee failed to keep the facility clean and free of rodents which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2022

Plan of correction: S2 states facility covered part of the kitchen wall where the vermin/rodents have access to the facility, sticky trap for rodents are set up which is being check weekly. LPA requested for a permanent plan on how to prevent rodents/vermin entering the facility. LPA discussed with S2 and Yidara about starting weekly monitoring documentation when staff check sticky trap. Staff will indicate the following information but not limited to; check date, if there is/are rodents captured, the action that was taken. This document and plan need to be submitted to CCL by POC date.

Allegation investigated: Facility is in disrepair.

On 03/16/22 at 11:20AM, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced complaint visit, met with Resident Service Director (RSD) Joann Nisperos and explained the purpose of the visit. LPA toured the Salem Woods building with RSD to inspect the elevator. LPA observed RSD tried to press the button and use FOB key to activate elevator in the garage which did not work. LPA interviewed 2 residents at Salem Woods, they both stated that they were not able to use elevator from garage to upper levels in the last several months. The maintenance director stated that he started getting quotations from different companies lately. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be SUBSTANTIATED. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Substantiatedthe state’s words, verbatim · CDSS document, Mar 16, 2022 · control 15-AS-20220314095000

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 31, 2022

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by inaccessible elevator from garage to residential levels which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2022

Plan of correction: Facility will submit a plan of maintenance service which needs to be approved by CCL by the POC due day.

Allegation investigated: Facility does not have a certified administrator.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Yadira Valdivia (Business Office Manager), and informed the purpose of visit. LPA conducted interviews. Staff (S1 and S2) stated that Executive Director Ruth Ocon is no longer the facility's administrator. S1 and S2 indicated that Cynthia Morris took over and now overseeing the facility operation. LPA spoke with Cynthia Morris who confirmed S1 and S2's statements. Cynthia stated she is the interim administrator while the facility is in the process of hiring an administrator. Cynthia stated she is a certified administrator. LPA obtained copy of certificate (# 6055404740; expiration: 1/31/20224). Based on information obtained, the allegation is unfounded. An unfounded findings means that the allegation is false and is without reasonable basis. ...........continued next page (9099C) Unfounded No citation issued for this visit. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 15-AS-20220304131546

Allegation investigated: Facility is not following COVID-19 protocols. Facility is in disrepair.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with Ruth Ocon/Executive Directorand informed the purpose of visit. LPA conducted inteviews.and obtained copies of resident roster and staff schedule/ . Allegation:Facility is not followiing COVID-19 protocols It was alleged that faclity is not protecting residents or staff from COVID in an acceptable manner. It was further alleged that resident (R1) who was tested positive was seen walking around without mask and talking to other residents on the day this resident was tested positive. Unsubstantiated Ruth Ocon stated R1 is an independent living (IL) resident who came to the dining room one time, She talked to R1 and since then R1 didn't come to the dining room. Staff (S1) indicated R1 is an IL resident and confirmed R1 no longer comes to the dining room. Review of resident roster confirmed R1 is an IL resident. LPA observed the front desk person screening essential visitors. LPA further observed visitors wearing masks and the staff whom LPA interviewed were wearing N95 mask. LPA also observed residents in the front lobby wearing mask and 6 feet away from each other. LPA interviewed S1 and maintenance director (S2) who both indicated they don full PPEs before entering the apartments of residents positive of COVID and doff off when leaving the apartments. Allegation: Facility is in disrepair. It was alleged that the front gate does not close due to electrical issue. When LPA arrived, LPA observed the front gate closed. LPA has to use the dial pad to speak to the front desk person who opened the gate. Ruth Ocon stated the front gate was not operational about a week or 2 weeks ago because of power outage and the front gate was open. Interview of maintenance staff (S2 and S3) confirmed the gate was open for 1 day and they observed PG&E personnel working about 2 blocks away from the facility. S2 said that he and S3 checked and that upon checking his (S2) determination was that there was loss of power. They turned on the gate and it rebooted and the gate came back up and operational. Based on observation and interviews, there's is not enough preponderance of evidence that violations occurred, therefore the allegations are closed as unsubstantiated. No deficiencies cited. Exit interview conducted and copy of this report provided to Ruth Ocon.the state’s words, verbatim · CDSS document, Feb 2, 2022 · control 15-AS-20220126125900

Allegation investigated: Facility is in disrepair

On 01/06/22 at 2:50PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint visit, met with administrator/executive director (ADM) and explained the purpose of the visit. LPA toured the Salem Woods building with ADM to inspect the exterior doors. LPA observed both exterior doors were not opening automatically. LPA observed ADM tried to use FOB keys to open the doors which did not work along with broken handicap plates that do not open the doors from the inside automatically located on the other side of the building. ADM stated she has been working with 2 specialty door companies since March 2021 with exterior doors still not functioning properly. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email. Substantiatedthe state’s words, verbatim · CDSS document, Jan 6, 2022 · control 15-AS-20220105082452

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 4, 2022

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by inoperable exterior doors which posed a potential health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 6, 2022

Plan of correction: Administrator/Executive Director agreed to elevate the broken exterior doors with corporate to get the doors permanently fixed for the safety of all residents, visitors and staff. By POC due date, Administrator/Executive Director will submit to CCLD a copy of repaired exterior doors invoice certifying that the exterior doors are safely operable for residents, visitors & staff to use.

Allegation investigated: Facility does not have heat

On 01/04/2022 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct complaint investigation for the allegation above. LPA met with Administrator Ruth Ocon and nurse Joan Nisperos. LPA toured the facility to check random bedrooms and common areas, LPA observed facility thermostat was set up for 80 degrees Fahrenheit. LPA observed that residents was provided with small heaters and extra blankets. LPA conducted interview with staff and residents, based on the interview, on 12/29/2021 staff noticed 3 bedrooms that do not have electricity and the circuit breaker was turning on and off, Administrator then called electricians to assess the situation, on the same day there was a planned power shut off for atleast 2-3hrs to fix electrical circuit . Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted with Joan Nisperos. A copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 4, 2022 · control 15-AS-20220103102247

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility not assessing residents prior to admission. Facility has bed bugs. Facility has pests.

On 12/6/2021 starting at 1:15 PM, Licensing Program Analysts (LPAs) L. Francisco and G. Clark arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Resident Care Director, Joann Nisperos and explained the purpose of the visit. LPAs later met with Executive Director, Ruth Ocon at 2:40 PM. During the complaint investigation, LPA toured memory care, obtained information, collected documents and interviewed 5 staff and 1 resident. Based on information obtained, facility is not assessing residents prior to admission. LPA was not provided additional information. However, LPA reviewed a sample of a new admission and observed a Preplacement, Physician Report and Care Plan completed by facility prior to resident's admission. REPORT CONTINUES ON 9099C Unsubstantiated ***THIS IS AN AMENDED REPORT FROM VISIT ON 12/6/2021*** However, during an interview with staff 5 (S5), it was revealed since the elevator is 50 years old, and grand-fathered into a building code where a sump pump can be used in the elevator shaft. S5 confirmed the sound of water can be heard, but it does not affect the operation of the elevator. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided via email. Based on information obtained, facility has pests and bed bugs. LPA reviewed records and observed a invoice for monthly maintenance from Clark Pest Control and a heat treatment schedule by Bay Area Bed Bugs. During LPAs tour of memory care, LPAs did not observe pests. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. Due to technical difficulties, a copy of this report provided via email.the state’s words, verbatim · CDSS document, Dec 6, 2021 · control 15-AS-20211129121021

Type of visit: Required - 1 Year

On 11/04/2021 starting at 8:43 AM, Licensing Program Analyst (LPA) Catherine Lin and Licensing Program Manager (LPM) Jeremy Fong arrived unannounced to conduct Infection Control Inspection. LPA and LPM met with Administrator Ruth Ocon and explained the purpose of the visit. Upon entry, LPA and LPM's temperature were checked at the front desk and asked to sign-in. LPA and LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 4, 2021

The state marks this report as 6 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 10/11/21 starting at 3:25 pm Licensing Program Analysts (LPAs) L. Francisco and G. Clark conducted a health and safety check as a result of department receiving a priority 1 complaint. LPAs toured facility including but not limited to the apartments, bathrooms, common areas, kitchen, and outdoor area. Hot water temperature was measured at 117, 123 and 96 degrees F in 3 bathrooms. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/20/21. There are no accessible bodies of water observed. The following deficiencies were observed: at 3:35 pm the hot water temperature was maintained at 123 degrees F. at 3:50 pm the hot water temperature in common bathroom was maintained at 96 degrees F. at 3:55 pm LPAs observed a dresser blocking the exit door in the memory care building The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 Failure to correct deficiencies by POC date may result in additional Civil Penalties. . Exit interview conducted Resident Care Director, Joann Nisperos. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 11, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Oct 12, 2021

Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents...Hot water temperature controls shall be maintained ... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed hot water temperature maintained at 123 and 96 degrees F which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2021

Plan of correction: Administrator will maintain hot water temperature between 105 to 120 degrees F and submit a self-certification letter to CCL by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(d)(6) · Plan of correction due date: Oct 12, 2021

Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed a dresser blocking the exit in the memory care building which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 11, 2021

Plan of correction: Administrator will remove dresser and submit a photo to CCL by POC date. In addition, Administrator will review regulation and conduct training with staff and submit a copy of training to CCL by 10/29/2021

Allegation investigated: Facility does not provide a safe and healthful environment for the resident.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct investigation of the above allegation. LPA met with Exectuive Director Ruth Ocon and explained the purpose of the visit. LPA also met with Resident Services Director-LVN Joann Nisperos and Memory Care Director Ebony Foi. LPA conducted inspection with Joann Nisperos. LPA inspected rooms in assisted living section of the facility and checked the generator in the store room. LPA observed protruding cables in the hallway outside residents rooms, and pails of paint and Pennzoil close to the running generator. Therefore, the allegation is substantiated. .....continued on 9099C Substantiated Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with Ruth Ocon. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 18, 2021 · control 15-AS-20210813150529

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 19, 2021

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: -Based on inspection and observation, the licensee did not comply with the section cited above. LPA observed cables in the hallway and pails of paint and Pennzoil close to the running generator. These pose immediate safety risks to persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2021

Plan of correction: Executive Director called and left message to facility's maintenance director to address/clear the issues while LPA is still at the facility. Pictures to be submitted by 8/19/2021.

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