Oakmont of Valencia

Allegation investigated: Resident choked another resident in care.

This is an Amendment to the original report, issued on 06/15/23, to correct the section number indicated in the deficiency box and update the typographical error made under the section number 87411(a)(2). On 6/15/2023, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an initial complaint investigation. Upon arrival, LPA was greeted by staff and the Executive Director, Myla Belson. An entrance interview was conducted, and the purpose of the visit was explained. Allegation: Resident choked another resident in care. It is alleged that on 6/6/23, resident #1 (R1) was sent to the emergency department at the hospital, because R1 was choked by another resident (R2). To investigate this allegation, LPA conducted an interview with the Executive Director at 10:30 a.m. and the Executive Director confirmed that on 6/6/23, there was an Continue on LIC9099-C Substantiated unwitnessed altercation between two residents. The incident was unwitnessed, however R1 reported to the Med-Tech (S1) on shift that they had neck pain due to the incident that had occurred. Afterwards, the Med-Tech called emergency services, and R1 was taken to the local hospital for evaluation. Executive Director stated that they believe this incident happened in the hallway, since both resident rooms were next to each other. Executive Director stated that since the incident, R1 has been moved to another unit in memory care, in service training for managing difficult behaviors was completed for staff, and R2 had a physician’s appointment on 6/7/23 where their medications were adjusted, and an updated Individualized Service Plan (ISP) was completed today, on 6/15/2023. At 1:30 p.m. an interview was conducted with R1, and R1 confirmed the incident occured. LPA conducted record review from 11:00 – 12:00 p.m. and the following was reviewed: • LIC500 • Resident Roster • Physician’s Report for R1 and R2 • ISP’s for R2 dated 1/26/23, 2/15/23, and 6/15/23 • Physician’s prescription for updated medication for R2 • Med-Tech notes regarding incident on 6/6/23 • In-Service sign in sheet – Managing Difficult Behavior done 6/7/23 • Incident Reports 6/6/23, 2/10/23 ' An incident report was submitted to CCL by the ED 6/6/23 and a SOC341 explaining the incident between both residents.LPA observed R2’s ISP to have been updated on 2/15/23, after an incident occurred on 2/10/23, where R2 was found in R1’s bedroom and R1 told staff that R2 had tried to rape them. Due to interviews conducted and records reviewed, it is determined that this was not an isolated incident, and the allegation mentioned above is substantiated. Deficiencies issued per CA Code of Regulations, Title 22. Report signed and delivered. Appeal rights issued. Deficiency cleared as of today's visit.the state’s words, verbatim · CDSS document, Jun 15, 2023 · control 31-AS-20230608081726

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 17, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on records reviewed and interviews, it was determined that R2 choked or physically grabbed R1 by the neck. Additionally, there was a previous incident report that stated on 2/10/23, R2 was caught in R1's bedroom. The behavior issues exhibited by R2 towards R1 posess an immediate health and safety risk or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 15, 2023

Plan of correction: Executive Director stated that since the incident, R1 has been moved to another unit in memory care, in service training for managing difficult behaviors was completed for staff, and R2 had a physician’s appointment on 6/7/23 where their medications were adjusted, and an updated Individualized Service Plan (ISP) was completed today, on 6/15/2023. Deficiency cleared as of today's visit.

Type of visit: Case Management - Incident

This is an Amendment to the original report, issued on 06/15/23, the Licensee has appealed the deficiency and it has been granted, therefore, the deficiency will be dismissed from LIC809-D page. On 6/15/23, LPA arrived at the facility to conduct an initial complaint investigation. This Case Management – Incident report is being done in conjunction with Complaint Control # 31-AS-20230608081726. LPA conducted record review from 11:00 a.m. – 12:00 p.m. to address allegations on complaint control number mentioned above. During records review, LPA reviewed incident report dated 2/10/23, where R1 reported to staff that R2 had tried to rape them. At approximately 11:30 a.m., the Executive Director stated this was an incident that had been alleged by R1, but they could not confirm it happened. An incident report was submitted to CCL along with a SOC341,and it was reported that overnight staff found R2 in R1’s bedroom, both in their undergarments and R2 was escorted back to their bedroom. Incident report stated that in service training was done on “staff locking resident doors overnight” and increased status checks. LPA reviewed R2's updated ISP, and no plan or notes were written for sexual behaviors. Due to the lack of information and plan to address R2's behaviors, deficiency issued per CA Code of Regulations, Title 22. Appeal rights issued. Report signed and delivered.the state’s words, verbatim · CDSS document, Jun 15, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management visit in regards to an SIR (Special Incident Report) that was submitted pertaining to resident #1 (R1) who was administered wrong medication. LPA met with Executive Director Myla Belson, who was informed the reason of the visit, and who reported to LPA, that staff # 1 (S1) accidentally administered the wrong medication to R1 because there was another resident with the same first name but different last name. S1 immediately contacted the Health Services Director, ED, and Memory Care Director. Family was also notified the same day; who was visiting R1 at the facility. R1 was sent to the hospital for evaluation, and was returned to the community, with no documentation of any medical or adverse action of the wrong medication. The ED reported the incident to Licensing with a SIR. During today's visit. ED reported that the facility and corporate implemented additional medication training, that involves licensed registered nurses that will be conducting training on April 11 and 13, 2023. Also, ED reported that additional medication training was conducted with the Regional Health Services Specialist, who is a licensed LVN (Licensed Vocational Nurse). There responsibilities is to oversee and provide additional support and resources to facility and staff. In addition, medication procedures were changed, to resident's identification are now labeled by last name and first initial,room number, and a picture of the resident. ED has recently hired a newly Wellness Nurse, that is currently in training, that would be available for additional medication and facility support. ED will continue ensure medication technicians receive adequate and complete training, that involves shadowing by Health Services Director, Wellness Nurse, or Resident Care Coordinator. ED will also continue to follow the training plan that was submitted previously for the plan of correction (POC). ED was made aware that during today's visit a citation and repeat civil penalty will be issued due to the recent incident involving medication error. Exit interview, appeal rights, citation and civil penalty issued to ED and copy of the report.the state’s words, verbatim · CDSS document, Apr 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Apr 10, 2023

87411 Personnel Requirements-General; (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following...This requirement was not met as evidence by: (4) Knowledge required to safely assist with prescribed medications... Staff #1 administered the wrong medication to resident #1. This poses as an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: ED reported to LPA that a consulting group has been hired to provide additonal medication training to staff and the facility. ED will submit the subjects of the training and staff signatures of all who attended. LPA is aware during the visit, the consulting group is scheduled for 04/11 & 04/13, 2023. ED must submit documentation of training on 04/14/2023.

Allegation investigated: Resident died due to staff administering the wrong medication

This is an Amendment to the original report issued on 03/29/2023 to correct an error (typo) in the deficiency listed on page 6. Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Executive Director and explained the reason for the visit. On 11/10/2022, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Resident died due to staff administering the wrong medication.” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Christine Ferris. Continue on LIC9099-C Substantiated On 11/14/22 LPA Panushkina initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but not limited to physician’s report 09/24/2019, progress notes, Medications Administration Record (MAR) for October 2022. Medications Management -General Policy related to the complaint. No update resident appraisal observed. LPA conducted interviews with four (4) out of four (4) staff on 11/07/2022, and Neptune Society staff, 11/08/2022. Investigator Ferris, conducted interviews with, witnesses (on 11/30/22), Primary Care Physician (on 12/19/22), nine (9) out of nine (9) staff members (on 11/30/22, 12/27/22. 12/28/22 and 12/29/22), Los Angeles County Department of Medical Examiner-Coroner-Investigator (on 01/26/23), and subpoenaed Los Angeles County Fire Department Response Repot and 911 Audio (on 12/15/22) and reviewed on 12/20/22. Allegation: Resident died due to staff administering the wrong medication The investigation findings revealed that R1 had been living at this facility since September 28, 2019. Although, R1 was able to independently ambulate throughout the facility, due to the use of full-time oxygen, R1 had a wheelchair as a backup (in case of fall or weakness). In addition, findings revealed that R1 was able to manage his/her own medications and due to R1’s changes in medical condition, R1’s responsible party requested the facility to start managing/storing R1’s medications as of October 1st, 2022. During the Case Management Visit, conducted by LPA Panushkina on 11/07/22 at 12:05pm, LPA requested R1’s Centrally Stored Medications and Destruction Record (SCMDR) and observed no document was available. When LPA asked S3 why R1’s SCMDR record was left blank, S3 was unable to give an explanation and informed LPA that he/she just recently (as of October 2022) got hired. LPA also observed R1’s Appraisal Needs and Services Plan and or resident reappraisal, last dated on 06/30/2021, was not updated. During the course of investigation, LPA was also informed by S6 that although, S1 completed all required (by Oakmont) medication training, in September 2022, S1 expressed concerns numerous times to the staff and management about not being confident to independently administer medications to the residents and was scheduled to work without being provided an additional training/re-training. Continue on LIC9099-C On 11/06/2022, S1 failed to ensure the medications were correctly dispensed and administered five (5) incorrect medications to resident (R1), which were prescribed to another resident (R2). Moreover, the facility failed to obtain timely medical attention for R1. Upon discovery that R1 was administered five (5) incorrect medications, staff was allegedly instructed to frequently check on R1 and obtain his/her "vitals", (i.e., R1’s blood pressure and oxygen saturation levels). First, no documentation was produced to show R1 was checked on at any time and no documentation was produced to show R1’s "vitals" were checked, upon Investigator Ferris’s request (on 11/30/22 and on 01/11/23). Second, S3 provided names of staff, to Investigator Ferris, whom he/she instructed to check on R1. Those staff were interviewed by the Investigator and denied being instructed to check on R1, denied checking on R1, and denied knowledge of the incident. There was no documentation or statements made to show any measures were taken to decrease the potential for a negative outcome from the medication error. Finally, neither emergency medical services (911), R1's Primary Care Physician, Poison Control, nor R1's family were contacted immediately after discovering R1 was given five (5) incorrect medications and no medical attention or intervention of any kind was obtained for R1 prior to death. In addition, LPA reviewed the facility’s Medication Management-General Policy on 11/17/2022. According to the “Policy #7: The medication error must be investigated by the Health Services Director (HSD) or designee. The HSD will identify the appropriate follow-up, including the notification of the responsible party and healthcare practitioner.” Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting R1's death. The Licensee/Executive Director were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed, and delivered.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 31-AS-20221110135757

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 31, 2023

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above by not having a staff regularly check on or document any changes as agreed upon, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: The Licensee has agreed to do the following: 1. Develop and Submit facility protocol, which details how care staff are instructed to identify and document any changes in resident condition and what follow up actions will be taken and by whom Submit to CCL by POC date 2. Schedule an in-service training with care staff ensuring that staff are trained on the facility protocol as it pertains to the observation of the resident. Submit the sign-in sheet(s) to CCL by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 31, 2023

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.... This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: The Administrator has agreed to do the following: 1. Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening again and to ensure compliance to the cited regulation

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Mar 31, 2023

87463 Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement was not met as evidence by: Based on review of documentation during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition that required the assistance with medications management, which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463(a). Proof of training should be submitted to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Mar 31, 2023

87411 Personnel Requirements-General (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (4) Knowledge required to safely assist with prescribed medications... This requirement was not met as evidence by: Based on the investigation, the licensee did not comply with the section cited above, for Staff #1 (S1), which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee agreed that all personnel (current and or future) will receive the required training. A verification of staff training will be submitted to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(b) · Plan of correction due date: Mar 31, 2023

87405 Administrator - Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as evidence by: Based on the investigation, the Administrator/Executive Director did not comply with the section cited above, failing to follow and carry out medication policy, which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee agreed that the facility Administrator/Executive Director, designee and all staff handling and/or administrering medications will be trained on the Facility's updated Medication Policy/Protocol. Proof of training will be submitted to CCLD by POC date.

Allegation investigated: Resident died due to staff administering the wrong medication

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Executive Director and explained the reason for the visit. On 11/10/2022, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Resident died due to staff administering the wrong medication.” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Christine Ferris. On 11/14/22 LPA Panushkina initiated the complaint. LPA conducted tour of the facility and obtained copies of pertinent information which include but not limited to physician’s report 09/24/2019, progress notes, Medications Administration Record (MAR) for October 2022. Medications Management -General Policy related to the complaint. Continue on LIC9099-C Substantiated No update resident appraisal observed. LPA conducted interviews with four (4) out of four (4) staff on 11/07/2022, and Neptune Society staff, 11/08/2022. Investigator Ferris, conducted interviews with, witnesses (on 11/30/22), Primary Care Physician (on 12/19/22), nine (9) out of nine (9) staff members (on 11/30/22, 12/27/22. 12/28/22 and 12/29/22), Los Angeles County Department of Medical Examiner-Coroner-Investigator (on 01/26/23), and subpoenaed Los Angeles County Fire Department Response Repot and 911 Audio (on 12/15/22) and reviewed on 12/20/22. Allegation: Resident died due to staff administering the wrong medication The investigation findings revealed that R1 had been living at this facility since September 28, 2019. Although, R1 was able to independently ambulate throughout the facility, due to the use of full-time oxygen, R1 had a wheelchair as a backup (in case of fall or weakness). In addition, findings revealed that R1 was able to manage his/her own medications and due to R1’s changes in medical condition, R1’s responsible party requested the facility to start managing/storing R1’s medications as of October 1st, 2022. During the Case Management Visit, conducted by LPA Panushkina on 11/07/22 at 12:05pm, LPA requested R1’s Centrally Stored Medications and Destruction Record (SCMDR) and observed no document was available. When LPA asked S3 why R1’s SCMDR record was left blank, S3 was unable to give an explanation and informed LPA that he/she just recently (as of October 2022) got hired. LPA also observed R1’s Appraisal Needs and Services Plan and or resident reappraisal, last dated on 06/30/2021, was not updated. During the course of investigation, LPA was also informed by S6 that although, S1 completed all required (by Oakmont) medication training, in September 2022, S1 expressed concerns numerous times to the staff and management about not being confident to independently administer medications to the residents and was scheduled to work without being provided an additional training/re-training. On 11/06/2022, S1 failed to ensure the medications were correctly dispensed and administered five (5) incorrect medications to resident (R1), which were prescribed to another resident (R2). Moreover, the facility failed to obtain timely medical attention for R1. Upon discovery that R1 was administered five (5) incorrect medications, staff was allegedly instructed to frequently check on R1 and obtain his/her "vitals", (i.e., R1’s blood pressure and oxygen saturation levels). First, no documentation was produced to show R1 was checked on at any time and no documentation was produced to show R1’s "vitals" were checked, upon Investigator Ferris’s request (on 11/30/22 and on 01/11/23). Continue on LIC9099-C Second, S3 provided names of staff, to Investigator Ferris, whom he/she instructed to check on R1. Those staff were interviewed by the Investigator and denied being instructed to check on R1, denied checking on R1, and denied knowledge of the incident. There was no documentation or statements made to show any measures were taken to decrease the potential for a negative outcome from the medication error. Finally, neither emergency medical services (911), R1's Primary Care Physician, Poison Control, nor R1's family were contacted immediately after discovering R1 was given five (5) incorrect medications and no medical attention or intervention of any kind was obtained for R1 prior to death. In addition, LPA reviewed the facility’s Medication Management-General Policy on 11/17/2022. According to the “Policy #7: The medication error must be investigated by the Health Services Director (HSD) or designee. The HSD will identify the appropriate follow-up, including the notification of the responsible party and healthcare practitioner.” Based on the information gathered, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting R1's death. The Licensee/Executive Director were informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed, and delivered.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 31-AS-20221110135757

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 31, 2023

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above by not having a staff regularly check on or document any changes as agreed upon, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: The Licensee has agreed to do the following: 1. Develop and Submit facility protocol, which details how care staff are instructed to identify and document any changes in resident condition and what follow up actions will be taken and by whom Submit to CCL by POC date 2. Schedule an in-service training with care staff ensuring that staff are trained on the facility protocol as it pertains to the observation of the resident. Submit the sign-in sheet(s) to CCL by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 31, 2023

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health.... This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff did not seek medical attention for R1 in a timely manner, which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: The Administrator has agreed to do the following: 1. Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening again and to ensure compliance to the cited regulation

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87462(a) · Plan of correction due date: Mar 31, 2023

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. Based on review of documentation during investigation, the licensee did not comply with the section cited above by not completing a resident appraisal due to changes in R1’s medical condition that required the assistance with medications management, which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463. Proof of training should be submitted to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Mar 31, 2023

87411 Personnel Requirements-General (d) All personnel shall be given on the job training... This training and/or related experience shall provide knowledge of and skill in the following... (4) Knowledge required to safely assist with prescribed medications... This requirement was not met as evidence by: Based on the investigation, the licensee did not comply with the section cited above, for Staff #1 (S1), which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee agreed that all personnel (current and or future) will receive the required training. A verification of staff training will be submitted to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(b) · Plan of correction due date: Mar 31, 2023

87405 Administrator - Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. Based on the investigation, the Administrator/Executive Director did not comply with the section cited above, failing to follow and carry out medication policy, which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee agreed that the facility Administrator/Executive Director, designee and all staff handling and/or administrering medications will be trained on the Facility's updated Medication Policy/Protocol. Proof of training will be submitted to CCLD by POC date.

Allegation investigated: Resident sustained an unexplained injury in care. Resident sustained multiple falls due to lack of supervision. Facility is not meeting resident's nighttime supervision needs.

An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Angela Panushkina to issue the findings of the above listed allegation. LPA met with the Executive Director and explained the reason for the visit. On 10/06/2022, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations: "Resident sustained an unexplained injury in care." "Resident sustained multiple falls due to lack of supervision." "Facility is not meeting resident's nighttime supervision needs." On 10/07/22 an initial visit was conducted by LPA Panushkina. On that day LPA conducted tour of the facility, interviewed with facility staff and obtained copies of pertinent information related to the allegation. This complaint investigation was conducted by Laarni Santiago, Investigator from Community Care Licensing Continue on LIC9099-C Substantiated Division’s Investigations Branch (IB). The investigation consisted of interviews with R1’s family members, facility Executive Director, Health Services Director, Memory Care Director, two (2) Resident Coordinators, two (2) Medical Technician's, Hospice Nurse, two (2) Facility Care Providers, two (2) Private companions (hired by R1's family), Housekeeping, R1's records review - included but not limited to physicians report (signed and dated on 01/11//2019 - 04/14/21 and 10/21/22), resident care notes (from 04/29/21 to 10/06/22), 1st Hospice care plan (dated as of 10/22/2022), 2nd Hospice care plan (dated as of 10/10/22) and other relevant documentation. Investigator, Santiago, also subpoenaed R1’s Medical Records on 10/13/22 and reviewed on 12/23/22. Allegation: "Resident sustained an unexplained injury in care." The investigation findings revealed that R1 had been living at this facility, in a Memory Care Unit, since April 2021. Interview with R1’s family revealed that R1 continued to have multiple falls from 09/12/22 that resulted in bruising and skin tear. Review of medical records confirmed that on 09/12/22, the facility initiated emergency medical services and resident was later diagnosed with a nasal tip fracture after an unwitnessed fall that staff was unable to explain. In addition, on 10/08/2022, family brought R1 for a doctor’s visit due to unexplained bruising and confirmed that R1 sustained three rib fractures. Lastly, R1 continued to have multiple falls that resulted in bruising and skin tear until R1 moved out of the facility on 10/26/2022, due to hospitalization from another fall. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. Allegation: "Resident sustained multiple falls due to lack of supervision." Although the family brought on multiple companions for R1, they were not always available and were unsuccessful in preventing falls and reducing injuries. Facility was aware of the R1’s decline, yet interviews and records verified that there were no updated reappraisals or fall plan in place to reflect on managing the resident’s change of condition. Staff revealed inconsistent information on how often they checked on resident. Throughout the course of the resident’s decline, Executive Director advised the family that they don’t have the staffing to meet R1’s needs and suggested getting a one-on-one caregiver or placing R1 in another community more suitable for his/her needs. Although the Executive Director communicated with the family about moving R1, they admitted they were willing to let the family extend their notice, knowing the facility Continue on LIC9099-C could no longer meet R1's needs. Facility neglected to produce an appropriate fall plan and retained the resident, knowing that the facility did not have adequate care and supervision to meet R1's needs. Lastly, the Regional Office received twelve (12) unwitnessed fall incident reports form 09/12/22 to 10/26/22. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. Allegation: "Facility is not meeting resident's nighttime supervision needs." Interview with R1's family revealed that they were initially told by the facility that R1's room had a motion detector that would alert staff of the fall, but later discovered that it was inoperable. In addition, the family was advised that the facility was going to place a bed alarm that would notify staff when R1 got up, but the facility failed to supply that. Finally, interview with the Executive Director revealed that the family was informed that the facility did not have enough staff to supervise R1 at night and requested the family to provide R1 with one-on-one caregiver or move R1 to another home. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed and delivered. Allegation: Facility is not meeting resident's personal hygiene needs. It was alleged that R1 did not shower/shave nor had their teeth brushed due to facility being understaffed. During the subsequent visit made on 02/07/23, LPA conducted a physical inspection in a Memory Care Unit and observed twelve (12) residents in a dining and TV area wearing clean clothes, well groomed and appeared well taken care of. In addition, interviews with the Executive Director and three (3) staff members revealed that the facility provides basic services (grooming, bathing, dressing, etc.) to all residents. Moreover, LPA observation, record reviews and interviews revealed that all hygiene needs are being met and that residents are scheduled to have showers at least two (2) to three (3) times a week or as needed and the facility caregivers are on standby for those who need assistance. Based on interviews, document reviews and LPA observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 31-AS-20221006103434

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5)(A) · Plan of correction due date: Mar 31, 2023

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made... This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, licensee did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls, which poses/posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee/Administrator agreed to schedule vendorized training for all staff regarding Regulation 87705(c0(5)(A) Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 03/31/2023 and completion of training by 03/31/2023. Licenee/Administrator also agreed to Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(c)(5)A) by POC date to LPA Because this violation resulted in resident sustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(4) · Plan of correction due date: Mar 31, 2023

Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, Licensee/Administrator did not comply with the section cited above by knowing that R1 needed 1:1 staffing and did not put into current appraisal as the appraisal was never updated, which poses/posed an immediate health and safety risk to residents is care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee/Administrator agreed to conduct by-weekly meetings with all staff regarding residents changes (if any). Licensee/Administrator will complete an appraisal of needs for specific client/residents to identify individual needs and develop a service plan for meeting those needs. If the client/resident is accepted for placement the staff person responsible for admission shall jointly develop a needs and services plan with the client/resident’s authorized representative referral agency/person, physician, social worker or other appropriate consultant. Licenee will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(4) by POC date to LPA

Allegation investigated: Resident sustained multiple falls while in care

An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Angela Panushkina to issue the findings of the above listed allegation. LPA met with the Executive Director and explained the reason for the visit. On 11/22/22 LPAs Panushkina and Cava conducted an initial visit and during that visit LPAs interviewed with the Regional Operations Specialist, five (5) out of five (5) staff members, three (3) MedTechs, Chef, one (1) cook, ten (10) out of ten (10) residents and reviewed facility records from 12:00pm to 4:00pm. LPAs also obtained copies of pertinent documents relevant to the investigation. A similar complaint (#31-AS-20221006103434), regarding the same Resident #1 (R1), was received by the Regional Office (RO) on 10/06/22 and referred to Community Care Licensing Division’s Investigations Branch (IB) on 10/07/22. Continue on LIC9099-C Substantiated Assigned Investigator, Laarni Santiago, subpoenaed R1’s Medical Records on 10/13/22 and reviewed on 12/23/22. The Investigator's final report was received by RO on 01/13/23. Allegation: Resident sustained multiple falls while in care The investigation findings, conducted by the Investigator, Laarni Santiago, revealed that R1 had been living at this facility, in a Memory Care Unit, since April 2021. Interview with R1’s family revealed that R1 continued to have multiple falls from 09/12/22 to 10/26/22 that resulted in bruising and skin tear. Review of medical records confirmed that on 09/12/22, the facility initiated emergency medical services and resident was later diagnosed with a nasal tip fracture after an unwitnessed fall that staff was unable to explain. In addition, on 10/08/2022, family brought R1 for a doctor’s visit due to unexplained bruising and confirmed that R1 sustained three rib fractures. Lastly, R1 continued to have multiple falls that resulted in bruising and skin tear until R1 moved out from Oakmont of Valencia on 10/26/2022, due to hospitalization from another fall. Although, the facility was aware of the R1's decline, yet records verified that there were no updated reappraisals or fall plans in place to reflect on managing the R1’s change of condition. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed and delivered.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 31-AS-20221118155410

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(4) · Plan of correction due date: Mar 31, 2023

Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Basen on the information obtained, by the Investigator, Licensee/Administrator did not comply with the section cited above by knowing R1 needed 1:1 staffing and did not put into current appraisal as the appraisal was never updated, which poses an immediate health and safety risk to residents is care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee/Administrator will conduct by-weekly meetings with all staff regarding residents changes (if any). Licenee will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87705(4) by POC date to LPA

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5)(A) · Plan of correction due date: Mar 31, 2023

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia... (5) Each resident with dementia... A) When any medical assessment... ...corresponding changes shall be made... This requirement is not met as evidenced by: Based on the information obtained, by the Investigator, licensee did not comply with the section cited above by failing to provide an updated care plan to address R1's chronic falls, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2023

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87705(c0(5)(A) Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 03/31/2023 and completion of training by 03/31//2023.

Allegation investigated: Facility staff are not providing resident with their records

Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director (ED) Myla Belson and informed her the reason of the visit. On March 01, 2023, LPA contacted the complainant pertaining to the allegation mentioned above. It was revealed to LPA, that the records requested were no longer needed, and to retract the complaint. During today's visit, LPA interviewed the ED, who reported, that the records being requested were from an attorney's office, and there protocols and procedures, that if any attorney office requests, must be handled by the facility's corporate legal team, and they would communicate to the party that is requesting the documents. ED informed LPA, that she received an email from the attorney's office, that the documents requested are no longer needed. Therefore, based on interviews and documentation, the allegation is Unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 3, 2023 · control 31-AS-20230227163839

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: Staff are not assisting resident in a timely manner Staff do not answer the phone when residents call for assistance

At approximately, 10:00am Licensing Program Analyst (LPA), Angela Panushkina arrived to Oakmont of Valencia in response to the above mentioned allegations. LPA met with the Executive Director and explained the reason for the visit. LPA conducted a physical plant walk through, at approximately 10:45am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit. LPA conducted interview with the Executive Director, four (4) staff members, one (1) MedTech, eight (8) out of thirteen (13) residents between 10:15am to 1:30pm and reviewed facility records from 1:35pm to 2:00pm. LPA also obtained copies of pertinent documents relevant to the investigation. Continue on LIC9099-C Unsubstantiated In addition, during todays visit, while interviewing a sample of eight (8) out of thirteen (13) residents, LPA randomly tested resident’s pendant and emergency pull cords in the bathrooms. Allegation: Staff are not assisting resident in a timely manner To investigate this allegation, LPA conducted a random inspection of seven (7) pendants and four (4) emergency pull cords in the bathrooms and staff responded within a reasonable time. The facility’s expectation for response time is 10 minutes. Interview with the Executive Director revealed that during each shift (morning, afternoon and night) the facility has enough staff members scheduled to take care of the resident's needs. Interviews with eight (8) out of thirteen (13) residents, who were able to communicate, revealed that they are satisfied with the staff response time when they need assistance. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Allegation: Staff do not answer the phone when residents call for assistance Interviews with the Executive Director, one (1) concierge, one (1) MedTech revealed that at 8:00pm all facility phone calls are being forwarded to another phone that is being answered by the facility MedTech and all missed calls and voicemail are being checked and returned, immediately. Interviews with eight (8) out of thirteen (13) residents, who were able to communicate, revealed that they always use their pendants for an immediate assistance. In addition, LPA was informed by 4 residents that when they contacted the front desk (during the business hours), an immediate assistance was provided by the facility staff. Lastly, interviews with seven (7) residents revealed that they had no reason and or never had to contact the facility phone line after the business hours. No deficiencies issued during todays visit. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Jan 6, 2023 · control 31-AS-20221230145902

Allegation investigated: Staff are not meeting resident's showering needs.

At 10:00am, Licensing Program Analysts (LPA) Angela Pnaushkina conducted an unannounced complaint visit to investigate the above noted allegation. LPA met with the Executive Director and discussed the reason for the visit. LPA conducted a physical plant walk though and interviewed the Executive Director, Resident Care Coordinator, two (2) staff members, two (2) MedTechs and five (5) residents. LPA also obtained copies of pertinent documents relevant to the investigation. --- Staff are not meeting resident's showering needs. It was alleged that R1 did not shower for weeks. To investigate this allegation, LPA conducted a physical inspection of randomly selected rooms and interviewed staff between 10:30am-1:15pm. LPA observation, Continue on 9099-C Unsubstantiated record reviews and interviews revealed that all hygiene needs are being met and that residents are scheduled to have showers at least two (2) to three (3) times a week or as needed. In addition, facility caregivers are on standby for those who need assistance. Based on interviews, document reviews and LPA observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Dec 14, 2022 · control 31-AS-20221208085425

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

Allegation investigated: Facility does not have adequate staffing Staff administered medications to residents without physician's orders Resident sustained an injury from being over medicated

At approximately, 9:00am Licensing Program Analysts (LPAs), Angela Panushkina and Michael Cava arrived to Oakmont of Valencia in response to the above mentioned allegations. LPAs met with the Regional Operations Specialist and explained the reason for the visit. LPAs conducted a physical plant walk through, at approximately 10:30am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPAs did not observe any immediate health and safety issues during the visit. LPAs conducted interview with the Regional Operations Specialist, five (5) out of five (5) staff members, three (3) MedTechs, Chef, one (1) cook, ten (10) out of ten (10) residents and reviewed facility records from 12:00pm to 4:00pm. LPA also obtained copies of pertinent documents relevant to the investigation. Continue on LIC9099-C Unsubstantiated Allegation: Facility does not have adequate staffing Interviews with five (5) out of ten (10) residents, who were able to communicate, three (3) out of five (5) staff members, three (3) out of three (3) MedTechs revealed that the facility has enough staff members during all three shifts to meet residents needs. Interview with the Regional Operations Specialist revealed that even though the facility has enough staff to cover all shifts, they are on ongoing process to hire extra people for back up purposes. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Allegation: Staff administered medications to residents without physician's orders Interviews with five (5) out of ten (10) residents, who were able to communicate, revealed that they never take medications without their doctor's prescription order. Interviews with three (3) out of three (3) MedTechs revealed that they would never give a medication to a resident without the Doctor's order. Interviews also revealed that when a change of order is prescribed the MedTech will not start a new medication until the new prescription order is received from the doctors office. LPAs reviewed three (3) out of three (3) random resident files and observed that doctor's orders of new or changed medications were attached. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Allegation: Resident sustained an injury from being over medicated In relation to allegation staff administered medications to residents without physician's orders, it was also reported that R1 sustained an injury from being over medicated. Interviews with five (5) out of five (5) staff and two (2) out of three (3) MedTechs do not corroborate with the allegation that R1 sustained injuries that they were over medicated. Therefore, Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Exit interview conducted and copy of report was provided to the Regional Operations Specialist.the state’s words, verbatim · CDSS document, Nov 22, 2022 · control 31-AS-20221118155410

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

Allegation investigated: Staff do not assist residents with incontinence needs Staff are not following resident admission agreement Staff not trained before caring for residents Staff do not ensure resident is wearing hearing aide support Staff are not showering residents Staff are feeding residents meals late Facility does not have a full time employee for food service Facility is not following menu plan Facility does not purchase enough food

At approximately, 9:00am Licensing Program Analysts (LPAs), Angela Panushkina and Michael Cava arrived to Oakmont of Valencia in response to the above mentioned allegations. LPAs met with the Regional Operations Specialist and explained the reason for the visit. LPAs conducted a physical plant walk through, at approximately 10:30am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPAs did not observe any immediate health and safety issues during the visit. LPAs conducted interview with the Regional Operations Specialist, five (5) out of five (5) staff members, three (3) MedTechs, Chef, one (1) cook, ten (10) out of ten (10) residents and reviewed facility records from 12:00pm to 4:00pm. LPA also obtained copies of pertinent documents relevant to the investigation. Continue on LIC9099-C Unsubstantiated Allegation: Staff do not assist residents with incontinence needs Interviews with five (5) out of five (5) staff members revealed that all incontinent residents are being changed every 2 hours or as needed. During the interview LPAs observed all Memory Care Unit residents were appropriately dressed and well taken care of. LPAs did not smell any odor while interviews were taking place. Based on information obtained through interviews and LPAs observation this allegation is deemed Unsubstantiated. Allegation: Staff are not following resident admission agreement Although, the Reporting party made an identification, the person they identified was not a resident in a Memory Care Unit. Therefore, LPAs were not able to interview the resident nor had enough evidence to prove that the facility staff was not following the Admission Agreement. Based on information obtained through document review this allegation is deemed Unsubstantiated. Allegation: Staff not trained before caring for residents Interviews with five (5) out of five (5) staff members and three (3) out of three (3) MedTechs revealed that prior to an actual schedule being released the employees take forty (40) hours of online training and five (5) days of shadowing. Interviews also revealed that if the staff member is not ready to start work on their own, they can request for an additional training. Interview with the Regional Operations Specialist revealed that all staff members have to feel comfortable working independently. In addition, five (5) out of ten (10) residents, who were able to communicate, also informed LPAs that the facility staff members provide a good care and know what they are doing. Based on information obtained through interviews this allegation is deemed Unsubstantiated. Allegation: Staff do not ensure resident is wearing hearing aide support Although, the Reporting party made an identification, the person they identified was not a resident in a Memory Care Unit. Therefore, LPAs were not able to interview the resident nor had enough evidence to prove that the staff do not ensure resident is wearing hearing aid support. LPAs interviewed five (5) out of five (5) staff members, who denied this allegation stating that they do assist residents with their hearing aid. One (1) out of five (5) staff members stated: “When a resident refuses to wear a hearing aid in the morning, we try to approach them to wear it later in the day.” Based on information obtained through interviews this allegation is deemed Unsubstantiated. Continue on LIC9099-C Allegation: Staff are not showering residents Interviews with five (5) out of ten (10) residents, who were able to communicate, revealed that they receive showers twice weekly or as needed. LPAs reviewed shower schedule for a Memory care unit and observed that when a resident refuses to shower, it is documented and a second attempt to encourage the resident to take a shower is made later on that day. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Allegation: Staff are feeding residents meals late Interviews with the kitchen Chef, one (1) cook, five (5) out of five (5) staff members and five (5) out of ten (10) residents, who were able to communicate, revealed that usually the facility meals are ready on time. However, due to COVID there was a slight delay of 5-10 minutes, but the residents did not complain. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Allegation: Facility does not have a full time employee for food service Interviews with a Chef and a cook revealed that the facility is working on hiring more employees, but whoever gets hired, immediately resigns on a following day or on that same week. Interview with an Regional Operations Specialist revealed that the facility is actively looking to hire more people and provided LPAs with a list of an employment from Indeed.com, Facebook, etc. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Allegation: Facility is not following menu plan Interviews with five (5) out of ten (10) residents, who were able to communicate, revealed that the facility always follows the daily menu. Interview with the Chef and a cook revealed that very rarely that they do a menu change. But, when they do, it is for the reasons of shortage of ingredients or shortage of staff due to some meal preparations can be time consuming. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Continue on LIC9099-C Allegation: Facility does not purchase enough food At 11:00am, LPA made a visit to the kitchen and observed it is fully stocked with perishable and non-perishable foods. Interview with the Chef and a cook revealed that the food is restocked regularly at least 2 times a week, on Wednesday and Saturday. LPAs also observed the residents with special dietary needs are posted in the kitchen prep area with pictures of the resident and their food choices or required preparation. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Exit interview conducted and copy of report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Nov 22, 2022 · control 31-AS-20221118124324

Allegation investigated: Resident sustained severe fracture while in care

An unannounced subsequent complaint visit was conducted on this day by licensing program analyst (LPA) Angela Panushkina to issue the findings of the above listed allegation. On 06/28/22, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation: Resident sustained severe fracture while in care. On 06/29/22 an initial visit was conducted by LPA W. Smith. On that day LPA Smith conducted tour of the facility, interviewed with facility staff and obtained copies of pertinent information related to the allegation. This complaint investigation was conducted by Dennis Sang, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews with R1’s family member, facility staff, facility Administrator, facility former residents and R1’s Medical Records. Continue on LIC9099-C Substantiated The investigation findings revealed that R1 had been living at this facility, in a Memory Care Unit, for approximately six (6) months and required an assistance with showers. Interview with R1’s family revealed that prior to the fall, which occurred on 05/31/22, R1 was able to ambulate without a walker and or wheelchair. Interviews with six (6) out of six (6) staff members revealed that on a day of an incident S1 was assigned to watch R1 and other residents in a movie theater. Interviews also revealed that an assigned Staff #1 (S1) took a break before they were relieved by another staff member and between five (5) to eight (8) Memory Care Unit residents were left in the movie theater unsupervised which led R1 to fall and sustain serious bodily injury. Moreover, during the interviews conducted by the Investigator, (S1) admitted leaving for a break before another staff member could replace them and take over the supervising duties. Lastly, review of R1’s Medical Records revealed that R1 was admitted to ER on 05/31/22 and was diagnosed with Right Femur Intertrochanteric FX (fractured/broken hip) that resulted in a surgery. Based on interviews and document review, during the course of the investigation, there is sufficient evidence to conclude that the above allegation is Substantiated. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Civil penalties assessed and appeal rights explained. Report reviewed, signed and delivered.the state’s words, verbatim · CDSS document, Nov 15, 2022 · control 31-AS-20220628085847

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(c)(3)(F) · Plan of correction due date: Nov 17, 2022

Basic Services: (3) "Care and Supervision" means those activities which if provided shall require the facility… It involves assistance as needed with activities of daily living… (F) Supervision of resident schedules and activities; This requirement was not met as evidenced by: Based on information obtained during the course of the investigation S1 did not comply with the cited section by neglecting and leaving demetia residents unsupervised which led R1 to fall and sustain severe hip fracture that resulted in surgery.the state’s words, verbatim · CDSS document, Nov 15, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87101... Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 11/17/2022 and completion of training by 12/01/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87101... Because this violation resulted in resident sustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

Allegation investigated: Lack of supervision resulted in resident getting assaulted by another resident while in care.

At approximately 9:00am, Licensing Program Analyst (LPA) Angela Panushkina arrived at Oakmont of Valencia in response to the above mentioned allegation. LPA met with the Regional Operations Specialist and explained the reason for the visit. At 10:30am, LPA conducted a physical plant tour of the facility including the Memory Care Unit. LPA interviewed the Regional Operations Specialitst, Memory Care Director, five (5) out of five (5) staff members, one (1) MedTech and five (5) residents between 10:45am to 3:00pm. LPA also obtained copies of pertinent documents relevant to the investigation. Allegation: Lack of supervision resulted in resident getting assaulted by another resident while in care. Interviews with five (5) out of five (5) staff members revealed that R1 became more aggressive about one (1) month ago. LPA was informed that R1 wanders around the facility and tries to enter random rooms Continue on LIC9099-C Substantiated and a staff member has a hard time redirecting R1. All staff members informed LPA that they were aware of R1 having the propensity to assault other residents in the facility. LPA was informed by all staff members that on 11/6/22 without any warning R1 assaulted and punch R2 in the face and no staff was around to stop the incident. Moreover, interviews with one (1) out of five (5) residents revealed that about three weeks ago R1 attempted to enter R3's room in a very aggressive way and caused R3 to be frightened of R1 ever since. In addition, interview with a MedTech revealed that R1's medical condition/mood changes around 2:30-3:00pm, and R1 becomes more combative. MedTech informed LPA that R1's medications have been changed, but the aggressive behavior towards the staff members and other residents' is still there. Interview with a Memory Care Director confirmed that R1 punched R2 in the face without provocation and caused bleeding on R2's face and 911 was called immediately. Memory Care Director informed LPA that the family took R1 to ER on 11/06/22 and once R1's medications are changed and or adjusted R1 will return to the community. Lastly, LPA reviewed one (1) incident report submitted on 10/12/22 and two (2) incident reports submitted on 10/16/22 where it was indicated that R1 assaulted a resident and two (2) staff members without any warnings. Based on interviews and document review, during the course of the investigation the facility failed to protect residents from being assaulted by R1. Therefore, there is sufficient evidence to conclude that the above allegation is Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D): Exit interview conducted, copy of report, citations and appeal rights issued.the state’s words, verbatim · CDSS document, Nov 15, 2022 · control 31-AS-20221110143440

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(b)(2) · Plan of correction due date: Nov 16, 2022

Basic Services: (b)(2) "Basic Services," as defined in Health and Safety Code section 1569.312, means those services required to be provided by the facility in order to obtain and maintain a license and in such combinations as may meet the needs... This requirement was not met as evidenced by: Based on information obtained during the course of the investigation licensee failed to protect R2 from being assaulted by R1 which poses an immediate health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87101... Licensee/Administrator will submit the credentials of the trainer with the scheduled training dates by 11/18/2022 and completion of training by 12/01/2022.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Angela Panushkina, conducted a CASE MANAGEMENT visit at this facility to issue deficiency in conjunction with complaint control no.: 31-AS-20221110143440 and met with a Regional Operations Specialist. LPA explained the reason for the visit. Although, the LPA received an email notification from the Executive Director on 11/06/22 regarding the incident between R1 and R2, the actual Incident Report (LIC624) was never submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. At the time a civil penalty of $1,000.00. was issued (repeated violation) and a citation was recorded on LIC809D. Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 15, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Nov 17, 2022

87211(a)(1) A,B & D Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA the licensee did not comply with the section cited above by failing to notify CCLD regarding the incident that occured on 11/06/22 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 15, 2022

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced case management visit due to an incident that was reported to licensing. LPA met with Health Service Director and explained the reason for the visit. LPA conducted a physical plant walk through, at approximately 11:00am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA conducted interview with the Health Service Director, two (2) out of two (2) MedTechs and reviewed Resident #1 (R1's) facility records from 11:45am to 2:00pm. LPA also obtained copies of pertinent documents relevant to the investigation. Upon review of documents LPA observed the following: R1's Medications were not documented on Centrally Stored Medication and Destruction Records (CSMDR) At the time a civil penalty of $1,000.00. was issued (repeated violation) and a citation was recorded on LIC809D. LPA also has determined further investigation is needed and will return at a later date to continue the investigation. Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Nov 7, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6)A-F · Plan of correction due date: Nov 8, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: Licensee / Administrator will schedule vendorized training for all staff by 11/09/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 11/09/22

Allegation investigated: Resident sustained injuries from falls while in care

At 10:10am, Licensing Program Analyst (LPA) Angela Panushkina made an unannounced subsequent visit to finish investigation into the allegation above. LPA met with an Executive Director and explained the reason for the visit. LPA made the initial complaint visit on 10/22/22 and conducted interviews with Memory Care Director, five (5) out of five (5) staff, one (MedTech) and reviewed facility records. LPA also obtained copies of pertinent documents relevant to the investigation. During today’s visit, LPA interviewed Executive Director. Regarding the allegation that Resident sustained injuries from falls while in care, it was alleged that on 10/18/22, at 1:30pm, R1 was left in a Memory Care Unit (TV room) and sustained more injuries due to fall. Review of Unusual Incident/Injury Report (incident occurred at 1:15pm) submitted by the facility on 10/18/22 indicated that R1 had an unwitnessed fall and no injuries were noted. Second (unwitnessed) incident that Continue on LIC9099-C Unsubstantiated occurred on the same day, at approximately, 3:00pm indicated that R1 was found with 3 skin tears and an immediate action was taken. Also, during the investigation, LPA was provided with an eyewitness contact information. Interview with the witness, who confirmed they were at the facility on 10/18/22 around 1:30pm, revealed that R1 did not fall. An eyewitness stated: "R1 didn't actually fall. He/she folded in half and one of the caretakers caught him/her. R1 didn't fall on the floor." Although, there was an information that R1 experienced the fall, there was insufficient evidence to collaborate the allegation that R1 sustained injuries from the fall. Furthermore, interviews with three (3) out of five (5) staff members revealed that R1 has a tendency to injure self. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Exit interview conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 26, 2022 · control 31-AS-20221019110538

Allegation investigated: Staff are inappropriately administering medication to resident

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with the Executive Director and explained the purpose of the visit. LPA conducted physical plant tour at 11:00 AM, requested facility records relevant to the investigation at 11:20 AM and conducted interviews with staff between 11:00 AM to 12:30 PM. To investigate this allegation: Staff are inappropriately administering medication to resident, LPA conducted interviews with Executive Director and three (3) out of five (5) MedTechs. Interview with an Executive Director revealed that MedTech’s are the only authorized people to dispense and administer medications. Interviews with three (3) out out of five (5) MedTechs revealed that every time they receive a new medication it has to be recorded in Centrally Stored Medications and Destruction Record (CSMDR). LPA was also informed by all Continue on LIC9099-C Unsubstantiated three (3) MedTech's that they always follow residents doctor's orders and when a new medication order is received, the facility has a copy available in resident's file. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Exit interview conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 26, 2022 · control 31-AS-20221024135652

Allegation investigated: Staff are retaliating against resident.

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegation. LPA met with the Executive Director and explained the purpose of the visit. LPA conducted physical plant tour at 11:00 AM, requested facility records relevant to the investigation at 11:20 AM and conducted interview with staff between 11:00 AM to 12:30 PM. To investigate this allegation: Staff are retaliating against resident, LPA interviewed with an Executive Director at around 11:00am and was informed that the facility did not issue an Eviction Letter nor retaliated against the resident. Interview also revealed that R1’s needs and level of service have changed and the facility was responsible to bring it up to residents/familys attention. In addition, during the random visits conducted by LPA Panushkina on 10/07/22 and 10/22/22, LPA attempted to interview Resident #1 (R1) but was unable due Continue on LIC9099-C Unsubstantiated to R1’s medical condition. Thus, R1 was not aware that the source of complaint and/or complainant against any facility under Community Care Licensing (CCL) is strictly confidential and was never divulged to the facility and/or staff so that the facility could not retaliate nor take action against the complainant (be it resident/staff or any person who has an association with staff/resident of the facility). Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Exit interview conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Oct 26, 2022 · control 31-AS-20221024094536

Allegation investigated: Facility is malodorous

This is an amended report which excludes confidential names of residents and staff. Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegations. LPA met with Memory Care Director and explained the purpose of the visit. LPA conducted physical plant tour at 10:00 AM, requested facility records relevant to the investigation at 11:00 AM and conducted interview with staff and residents between 11:00 AM to 2:00 PM. To investigate this allegation: Facility is malodorous, LPA conducted interviews with Memory Care Director, five (5) out of five (5) staff and one (MedTech). Interviews revealed that the facility had not have recent sewer issues and no one smelled nor received any complaints regarding a bad smell. During today’s visit LPA did not observe any bad smell at the facility. Continue on LIC9099-C Unsubstantiated Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and copy of this report provided to the Executive Director.the state’s words, verbatim · CDSS document, Oct 22, 2022 · control 31-AS-20221019110538

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

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility. LPA met with the Executive Director and explained that this visit was conducted to address the incorrect deficiency report that was issued on 09/28/22 (Complaint Control # 31-AS-20220805133307) due to a technical/computer glitch issue. On 09/28/22, LPA issued a civil penalty of $23,100.00 due to a repeated deficiency violation in error (LIC809 and LIC809-D) During today's visit LPA issued a new Case Management Deficiency report to this facility with a correct civil penalty in the amount of $1000.00 Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 7, 2022

Allegation investigated: Facility not following Covid-19 protocol

At 10:00am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to investigate the allegations above. LPA met with an Executive Director and explained a reason for the visit. Upon arrival, LPA observed all facility staff members and some of the residents wearing masks. LPA conducted a physical plant tour of the facility, to ensure no immediate health and safety issues were present. Interview with the Executive Director confirmed that on 09/19/22 an unannounced visit was made by a credible witness and the facility was no longer taking the temperatures of visitors to the facility as part of the facility's routine COVID screening. Executive Director informed LPA that the facility was following a new Provider Continue on LIC9099-C Unsubstantiated Information Notice (PIN) that they received on September 15th, 2022. Executive Director provided a copy of PIN 22-28-ASC to LPA. Review of document revealed that "in August, the Center for Disease Control and Prevention (CDCP), along with California Department of Public Health (CDPH) in updated testing guidance, indicated screening testing is no longer recommended..." Although, effective September 17th, 2022 visitors are no longer required to be tested or show proof of vaccination, the facility still continues to encourage residents, staff members and visitors to wear masks. Based on the interview conducted with an Executive Director and document review this allegation is Unsubstantiated at this time. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Sep 28, 2022 · control 31-AS-20220927140356

Allegation investigated: Residents pull cords are in disrepair Staff do not respond to residents call buttons timely

Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with Executive Director, Cyntia Drachenberg, and explained the reason for the visit. Entrance interview conducted. During the initial 10-day complaint visit conducted on 07/27/22, LPA Panushkina interviewed Executive Director, Activity Coordinator, MedTech, 4 out of 4 staff, 10 out of 10 residents and reviewed facility records. LPA also obtained copies of pertinent documents relevant to the investigation. Also, during the initial visit, while interviewing a sample of 10 residents, LPA randomly tested resident’s pendant and emergency pull cords in the bathrooms. Continue on LIC9099-C Substantiated During the initial visit made on 07/27/22, LPA conducted a random inspection of one (1) pendant and three (3) emergency pull cords in the bathrooms, at Assisted Living (AL) Unit, and staff responded within a reasonable time. The facility’s expectation for response time is 10 minutes. However, a random inspection of one (1) resident’s pendant and four (4) emergency pull cords, in the bathroom, at the Memory Care Unit (Traditions 1 and Traditions 2) discovered that none of the five (5) emergency call buttons were operational. Interview with the Executive Director confirmed that the facility was aware of residents pull cords being in disrepair (in Memory Care Unit) as of July 5th, 2022 and that the facility’s Maintenance Director placed an order for new batteries as of 07/21/22. Based on LPA's observation and review of the information received, allegations Residents pull cords are in disrepair AND Staff do not respond to residents call buttons timely, are substantiated at this time. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director. the visits made by LPA on 08/10/22, 09/01/22, 09/14/22, 09/17/22/, 09/28/22,to this facility, LPA observed all staff members always wore masks. Therefore, based on interviews and LPA observation this allegation is deemed Unsubstantiated at this time. Allegation: Residents are not being showered timely Interviews with 7 out of 10 residents, who were able to communicate, Executive Director, Activity Coordinator, MedTech and 4 out of 4 staff, indicated that all of the Oakmont of Valencia residents are scheduled to have showers at least two (2) to three (3) times a week or as needed. LPA also was informed that the facility keeps a shower log for each resident. Based on interviews and document reviews, this allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 28, 2022 · control 31-AS-20220721103906

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(2) · Plan of correction due date: Oct 5, 2022

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on LPAs observation during the visit made on 07/27/22 the licensee did not comply with the section cited above. Resident’s pendant and/or emergency cord devices in both Memory Care Units were in poor repair and non-operational, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2022

Plan of correction: Licensee/Administrator placed an order for repairs on 07/22/22. During 09/01/22 visit LPA tested three emergency cord devices in rooms #135, #144 and #147 and observed all three emergency cord devices were in good condition during visit. POC cleared during visit.

Allegation investigated: Staff dispensed wrong medications not prescribed to resident Staff falsified resident medication logs

At 10:00am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Administrator and explained the reason for the visit. During the visit made on 09/14/22, LPA Panushkina spoke with the Administrator and three (3) out of three (3) MedTech’s. LPA also reviewed the facility Centrally Stored Medication and Destruction Records (CSMDR) of random residents receiving medication assistance by the facility staff. Upon review of the medications LPA observed that three (3) out of three (3) randomly chosen prescribed medications were centrally stored by the facility. LPA also observed that each resident has an individual, labeled basket for their medications. Interviews with three (3) MedTech’s revealed that they dispense medications for one resident at a time. All MedTech’s informed LPA that once resident takes the medication, MedTech initials the Medication Administration Record (MAR) log. LPA was also informed that when the resident refuses to take the Continue on LIC9099-C Unsubstantiated medication the staff member writes a comment/reason in MAR log as to why the medication was not taken. Based on review of the facility medication records for the months of July, August and September 2022, for three (3) out of three (3) residents, all documents appeared to be completed to its entirety including medication name, strength, instruction control, date filled, etc. Based on the interviews conducted and documentation reviewed, there is not enough substantial evidence or witnesses to concur with the allegations. Therefore, both allegations are deemed to be Unsubstantiated at this time. Exit interview conducted and copy of this report provided to the Executive Director.the state’s words, verbatim · CDSS document, Sep 28, 2022 · control 31-AS-20220805133307

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced Case management visit to the facility. LPA met with the Executive Director and explained that this visit was conducted to address the issues previously noted during complaint investigation visit conducted on 09/14/2022. On 09/14/22 LPA obtained documents relevant to the investigation of the complaint alleging “Staff dispensed wrong medications not prescribed to resident”; (Complaint Control # 31-AS-20220805133307). Upon review of documents LPA observed the following: · Medication was not properly documented on Centrally Stored Medication and Destruction Records (CSMDR) At the time a civil penalty of $23,100.00 was issued (repeated violation) and a citation was recorded on LIC809D. Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 28, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)A-F · Plan of correction due date: Oct 5, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.the state’s words, verbatim · CDSS document, Sep 28, 2022

Plan of correction: LPA was informed that the facility completed a medication training for all staff on 09/19/22. Documents obtained and POC cleared during today's visit

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Panushkina conducted an Annual Required visit and inspection of the facility. LPA met with an Executive Director and explained the reason for the visit. Infection Control: Upon arrival, LPA observed staff were wearing proper face masks. At 11:20am, LPA toured the facility and observed the following: The facility is a large 2 story building with two (2) Memory Care Units (Tradition 1 and Tradition 2). In the main entrance of the building there is a cafe that is a self-serving refreshment and snack area with seating. The main living room has seating and a grand piano for entertainment. There is a reading room and private dining area for family or visitors to use. Food Inspection: Kitchen and dining area are located on the ground floor of the facility. LPA observed there was sufficient stock of one week non-perishable foods and two days perishable food. Kitchen was observed to be sanitary and free of pests. Smoke detectors/carbon monoxide are hardwired and located throughout the facility. Fire alarms are program to dispatch the Fire Department. Therefore, LPA obtained paperwork for the last fire alarm inspection which was conducted on 09/28/2022. Fire extinguishers were observed to be charged with a service date of 07/11/2022. Common Areas: Common areas consists of front lobby sitting area, activity rooms, in Assistance Living, and Memory Care Units. All areas were properly furnished and sanitary with sufficient room for residents to lounge. Facility also has a beauty salon, gym and a theater for residents. Laundry area is located on a second floor of the facility. Facility has three (3) MedTech rooms, two (2) are located inside the Memory Care Unit and one (1) room is on an Assisted Living side. LPA observed all rooms were kept locked and inaccessible to residents in care. Continue on LIC809-C Resident Rooms: Facility consists of 86 rooms. Rooms consists of single or shared occupancy. A random selection of bedrooms was toured both in Memory Care and Assisted Living. All bedrooms were properly furnished and had appropriate bed linens. Rooms were observed to be sanitary. Bathrooms: Bathrooms were toured and observed to be clean and properly stocked with towels and soap. Nonskid mats and grab bars were observed in all bathrooms. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records were reviewed for proper documentation. Outside: LPA toured the outside area of the facility. LPA observed two private patios with appropriate outside furniture and shaded area for residents. No deficiencies cited. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Sep 28, 2022

Allegation investigated: Resident's room has fecal smears. Resident's 240 room is odoriferous.

At 9:00am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Executive Director and explained the reason for the visit. LPA conducted physical plant tour around 9:20am and requested facility documents relevant to the investigation. LPA interviewed staff between 10:30am – 1:00pm and reviewed facility records 1:00pm to 2:30pm. LPA also visited rooms for five randomly chosen residents in a Memory Care Unit. During LPA’s tour, the facility and randomly chosen 5 resident’s room appeared clean and smelled fresh. Interviews with four (4) staff members revealed that the facility housekeeper is scheduled to clean four to five rooms per day, including the hallway, on Monday and Saturday from (6:00am-3:00pm). All staff members informed LPA that cleaning is done - daily and they had not received any complaint regarding the above mentioned allegations. Continue on LIC9099-C Unsubstantiated Based on the information obtained through interviews, record reviews and LPA’s observation both allegations are deemed Unsubstantiated at this time. Exit inter interview conducted and copy of this report provided to the Executive Director.the state’s words, verbatim · CDSS document, Sep 17, 2022 · control 31-AS-20220103144127

Allegation investigated: Staff did not prevent a resident from physically abusing another residents

At 10:35am, Licensing Program Analyst (LPA) Angela Panushkina made an unannounced subsequent visit to finish investigation into the allegation above. LPA met with an Executive Director and explained the reason for the visit. It is alleged that Staff did not prevent a resident from physically abusing another resident. LPA made the initial complaint visit on 09/01/2022. On that day LPA conducted interviews with the Executive Director, Memory Care Director, MedTech, Activity Coordinator, Activity Assistant, 3 out of 3 staff, 2 out of 2 residents and reviewed facility records. LPA also obtained copies of pertinent documents relevant to the investigation. During the initial visit to Oakmont of Valencia Memory Care Unit (Traditions 2), LPA was unable to identify any resident witnesses. Interviews with an Executive Director, Memory Care Director, MedTech, Activity Coordinator, Activity Assistant and three (3) staff members revealed that there was no abuse between Continue on LIC 9099-C Unsubstantiated resident to resident. It was resident #1 (R1) being aggressive and abusive towards the staff members. Based on information obtained through interviews and document review this allegation is deemed Unsubstantiated. Exit interview conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Sep 14, 2022 · control 31-AS-20220823163149

Allegation investigated: Staff did not inform responsible party of an unusual incident Staff did not prevent resident from wandering away from facility

At 12:00pm LPA, Angela Panushkina, conducted an unannounced complaint visit to the above facility. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. LPA met with the Executive Director, Cyntia Drachenberg and explained the reason for the visit. In conjunction with a Complaint visit made on 09/01/2022, LPA conducted a physical plant tour of the entire facility including the Memory Care Unit. During that time LPA tested five (5) out of five (5) facility egress system in a Memory Units. LPA observed the egress system to be properly working and fully operational. During the initial 10-day visit, made by LPA Avetisyan, on 08/10/22 interview with an Executive Director revealed that on 08/04/2022, at approximately, 4:05pm R1 eloped from the Memory Care Unit (Traditions 2) and was found by two staff members minutes later, in the same area as community, standing by a parked car. R1 was returned safely and the assessment showed no injuries. Executive Director also confirmed that due to Continue on LIC9099-C Substantiated miscommunication among the staff members, the family was not notified regarding this incident until 08/05/2022. Although, R1's family was verbally informed about the incident, no written report was send to the responsible party, timely. Moreover, on 08/26/22, the Department received another incident regarding R1's elopement which was, again, undetermined how R1 got out from the community. Therefore, based on this information, both allegations: Staff did not inform responsible party of an unusual incident and Staff did not prevent resident from wandering away from facility are Substantiated. An exit interview was conducted, appeal rights explained and a copy of this report given to Cynthia Drachenberg, Executive Director.the state’s words, verbatim · CDSS document, Sep 14, 2022 · control 31-AS-20220805133307

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(6) · Plan of correction due date: Sep 16, 2022

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2022

Plan of correction: Licensee shall provide written plan of action to show the steps they will take to prevent this issue from happening again. All staff trainig must be complete by POC date and copies of training materials along with sign-in sheet must be emailed to LPA

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 21, 2022

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify residents responsible party (in writing) about the incident within seven (7) days of the occurence, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2022

Plan of correction: Licensee shall ensure a written report is submitted to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Licensee shall provide in-service training with all staff members andCopy of the training materials, along with the a sign-in sheet shall be submitted to LPA by POC date.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Angela Panushkina, conducted a CASE MANAGEMENT visit and met with an Executive Director. LPA explained the reason for the visit. During the visit, made on 09/01/22, LPA was informed that several incidents took place between 08/03/2022 to 08/22/2022 and were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed Executive Director that all staff members are mandated reporters and they are all responsible for reporting. On 09/02/22, LPA received twelve (12) incidents that occurred on following dates: 08/03/22 (one incident) 08/04/22 (one incident) 08/10/22 (one incident) 08/17/22 (two incidents) 08/18/22 (two incident) 08/19/22 (one incident) 08/20/22 (one incident) 08/22/22 (three incidents) Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report given emailed to the Executive Director.the state’s words, verbatim · CDSS document, Sep 14, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Sep 21, 2022

87211(a)(1) A,B & D Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA during the visit made on 09/01/22, the licensee did not comply with the section cited above by failing to notify CCLD regarding the twelve incidents that occured between 08/03/22 -08/22/22, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 14, 2022

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copy of the training materials and certificates, for all staff members, shall be submitted to LPA by POC date.

Allegation investigated: Questionable Death

An unannounced initial 10 day complaint visitr was condcuted on this dat by licensing progra analys (LPA) Yelena Avetisyan. Upon arrival LPA met with Executive Director, Cyntia Drachenberg and explained the reason for the visit. On 10/18/2021, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding an allegation of a questionable death. It was alleged that facility Resident #1 (R1) died due to medical conditions developing from the severe facial injuries sustained at the facility. On 10/19/2021 an initial 10-day visit was conducted by LPA A. Panushkina to initiate the investigation. On that day LPA Panushkina conducted tour of the facility reviewed records and obtained copies of pertinent records. On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022. Hospice records reviewed revealed that after 10/9/2021 hospitalization R1 was discharged to Option One Congregate Living Facility. Unsubstantiated On 5/11/2022 LPA Avetisyan requested copy of R1’s death Certificate from Option One Congregate living and Tri Valley Hospice. Copies of the Death certificate were received on 5/12/2022 and 5/11/2022. Upon review, both copies of the death certificate documented R1’s cause of death to be Advanced Parkinson’s without any other contributing diagnosis. Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation of Question death is deemed Unsubstantiated at this time. Exit interview conducted, copy of report and appeal rights issued. On 10/19/2021 an initial 10-day visit was conducted by LPA A. Panushkina to initiate the investigation. On that day LPA Panushkina conducted tour of the facility reviewed records and obtained copies of pertinent records. Medical records were requested by the office of Investigations. The records were received and reviewed on 11-29-2021 by Investigator Kujuwa. Additionally, on various days 2/14/2022, 3/9/2022 and 3/11/2022 Investigator Kujuwa conducted interviews with, facility staff and on 3/18/2022 conducted interview with the complainant. On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022. On 5/11/2022 a subsequent complaint visit was conducted by Licensing Program Analyst (LPA) Yelena Avetisyan. On that day LPA Avetisyan conducted re-review of R1’s facility records and interviewed staff who were working at the facility when the 9/11/2021 and 10/9/2021 injuries occurred. In regard to the allegation of: Due to staff neglect Resident 1 (R1) sustained severe facial injuries it was reported that on 10/9/2021 R1 was transported to Henry Mayo Newhall ER and diagnosed with Facial injuries (laceration of lip, fracture of nasal bones). When interviewed R1’s family stated that the facility staff called them and reported that staff were pushing R1 in a wheelchair, R1 put her feet down on the floor, launched forward and fell on her face. R1’s family reported that resident was very weak, and they do not believe R1 would be able to launch herself forward. Review of Tri Valley hospice POC/IDG, review dated 10/9/2021 documents records prior to the incident for R1’s mobility as Bed-Bound/Chair-bed transfer, dependent on 6/6 ADL’s, requires repositioning ever 2 hours. 10/5/2021 Home Aid (HA) visit documents R1 carefully transferred to the shower. While conducting review of Resident Care Notes LPA did not observe documentation regarding the incidents. 5/11/2022 Staff interviews revealed R1 was being pushed to the dining room by Staff 1 (S1). Staff did not observe the incident however reported being called for assistance, hearing R1 loudly screaming for help and observing R1 bleeding severely. According to staff interviewed they did not observe footrests on the wheelchair. Staff interviewed also reported questioning S1’s explanation of how the accident occurred and questioned the speed of the wheelchair. According to Staff R1 had a tendency to put her foot down from wheelchair and would be able to walk with 2 staff holding onto her but not sure if R1 could stand on her own. Continue on LIC9099-C Investigator Kujuwa and LPA Avetisyan attempted to conduct interview with S1 but were unable to do so. Staff # 4 also informed the LPA that incident details were documented on the Crossover report. On 5/11/2022 administrator Cyntia Drachenberg informed the LPA that Crossover reports are only kept for a month. LPA was also informed that information regarding both of the incidents were documented in the company's internal reports which would not be released to the Department. Based on the information obtained there is sufficient evidence to support the allegations, therefore the allegations of Neglect/Lack of Care and Supervisor Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care and Due to staff neglect Resident 1 (R1) sustained severe facial injuries are deemed Substantiated. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Aug 10, 2022 · control 31-AS-20211018141211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Aug 12, 2022

Specifically for a terminally ill resident that is receiving hospice services… For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met as evidenced by: Based on the information obtained during the course of the investigation the licensee/Administrator did not comply with the section cited by failing to call 911 when R1 was experiencing severe pain resulting from an unexplained injury which posed an immediate health and safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87469.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87469.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Aug 12, 2022

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457....... This requirement was not met as evidenced by: Based on information obtained during the course of the investigation the staff did not comply with the cited section by neglecting to put the footrests on R1’s wheelchair causing R1 to reportedly put foot down, fall forward and sustain severe facial injuries which posed an immediate health and safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87464.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464. Because this violation resulted in resident beingsustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

Allegation investigated: Questionable Death

An unannounced initial 10 day complaint visitr was condcuted on this dat by licensing progra analys (LPA) Yelena Avetisyan. Upon arrival LPA met with Executive Director, Cyntia Drachenberg and explained the reason for the visit. On 10/18/2021, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding an allegation of a questionable death. It was alleged that facility Resident #1 (R1) died due to medical conditions developing from the severe facial injuries sustained at the facility. On 10/19/2021 an initial 10-day visit was conducted by LPA A. Panushkina to initiate the investigation. On that day LPA Panushkina conducted tour of the facility reviewed records and obtained copies of pertinent records. On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022. Hospice records reviewed revealed that after 10/9/2021 hospitalization R1 was discharged to Option One Congregate Living Facility. Unsubstantiated On 5/11/2022 LPA Avetisyan requested copy of R1’s death Certificate from Option One Congregate living and Tri Valley Hospice. Copies of the Death certificate were received on 5/12/2022 and 5/11/2022. Upon review, both copies of the death certificate documented R1’s cause of death to be Advanced Parkinson’s without any other contributing diagnosis. Based on the information obtained, there is insufficient evidence to support the allegation, therefore the allegation of Question death is deemed Unsubstantiated at this time. Exit interview conducted, copy of report and appeal rights issued. On 4/13/2022 Licensing Program Analyst (LPA) Yelena Avetisyan emailed subpoena for records to Tri Valley Hospice Care, Inc. Records were received on 4/22/2022. On 5/11/2022 a subsequent complaint visit was conducted by Licensing Program Analyst (LPA) Yelena Avetisyan. On that day LPA Avetisyan conducted re-review of R1’s facility records and interviewed staff who were working at the facility when the 9/11/2021 and 10/9/2021 injuries occurred. Records reviewed and interviews conducted revealed the following: In regard to the allegation of: Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care: It was reported that on 9/11/2021 R1 was taken to Henry Mayo Newhall emergency room with a dislocated left shoulder and staff were not aware how R1 sustained the injury. On 10/19/2021 LPA Panushkina communicated with R1’s family who reported that upon their return from the emergency room staff reported to them that R1 started feeling pain after dinner, and hospice was called the next morning because of the pain worsening. While conducting review of facility records LPA Avetisyan observed the following documented on the licensees Resident Care Notes: 9/10/2021 at 22:15 pm staff requested assistance from the med-tech because R1 was “grimacing when touching left shoulder”. Upon med-tech documented slight swelling on L side. Staff noted “informed the health director, also to contact hospice and monitor shoulder and pain” On 9/11/2021 at 23:50 am Med-tech documented R1 “in a lot of pain L shoulder hurting to slightest touch. Called Hospice will send a nurse in the morning” per staff notes the hospice instructed to administer morphine as PRN. However, the hospice communication log documented the hospice agency receiving a call to see R1 due to severe pain and swelling to the left shoulder. Caregiver reported R1 “is crying, grimacing, pulling back” Hospice communication log also documents caregiver reported giving R1 2 doses of morphine for severe pain. The call was documented on the communication log on 9/11/2021 at 09:30 am. Hospice staff arrived at the facility approximately 9:15 am on 9/11/2021 and transported to the hospital by Power of Attorney at approximately 10:00 am. However, hospital records document resident being admitted to the Emergency room 14:38 pm. Additional information obtained during the course of the investigation revealed that facility and hospice records documented R1 being a fall risk however licensee did not have a fall risk plan in place. Staff are asked to call Hospice agency first for any incident that occurs with residents regardless if the reason for the call is related to the terminal diagnosis. The licensee/administrator failed to follow reporting requirements related to this incident. In regard to the allegation of: Due to staff neglect Resident 1 (R1) sustained severe facial injuries it was reported that on 10/9/2021 R1 was transported to Henry Mayo Newhall ER and diagnosed with Facial injuries (laceration of lip, fracture of nasal bones). When interviewed R1’s family stated that the facility staff called them and reported that staff were pushing R1 in a wheelchair, R1 put her feet down on the floor, launched forward and fell on her face. R1’s family reported that resident was very weak, and they do not believe R1 would be able to launch herself forward. Review of Tri Valley hospice POC/IDG, review dated 10/9/2021 documents records prior to the incident for R1’s mobility as Bed-Bound/Chair-bed transfer, dependent on 6/6 ADL’s, requires repositioning ever 2 hours. 10/5/2021 Home Aid (HA) visit documents R1 carefully transferred to the shower. While conducting review of Resident Care Notes LPA did not observe documentation regarding the incidents. 5/11/2022 Staff interviews revealed R1 was being pushed to the dining room by Staff 1 (S1). Staff did not observe the incident however reported being called for assistance, hearing R1 loudly screaming for help and observing R1 bleeding severely. According to staff interviewed they did not observe footrests on the wheelchair. Staff interviewed also reported questioning S1’s explanation of how the accident occurred and questioned the speed of the wheelchair. According to Staff R1 had a tendency to put her foot down from wheelchair and would be able to walk with 2 staff holding onto her but not sure if R1 could stand on her own. Investigator Kujuwa and LPA Avetisyan attempted to conduct interview with S1 but were unable to do so. Staff # 4 also informed the LPA that incident details were documented on the Crossover report. On 5/11/2022 administrator Cyntia Drachenberg informed the LPA that Crossover reports are only kept for a month. LPA was also informed that information regarding both of the incidents were documented in the company's internal reports which would not be released to the Department. Based on the information obtained there is sufficient evidence to support the allegations, therefore the allegations of Neglect/Lack of Care and Supervisor Resident 1 (R1) sustained an unexplained injury for which the staff failed to obtain timely medical care and Due to staff neglect Resident 1 (R1) sustained severe facial injuries are deemed Substantiated. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569,49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Aug 10, 2022 · control 31-AS-20211018141211

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Aug 12, 2022

Specifically for a terminally ill resident that is receiving hospice services… For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement was not met as evidenced by: Based on the information obtained during the course of the investigation the licensee/Administrator did not comply with the section cited by failing to call 911 when R1 was experiencing severe pain resulting from an unexplained injury which posed an immediate health and safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87469.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87469.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Aug 12, 2022

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457....... This requirement was not met as evidenced by: Based on information obtained during the course of the investigation the staff did not comply with the cited section by neglecting to put the footrests on R1’s wheelchair causing R1 to reportedly put foot down, fall forward and sustain severe facial injuries which posed an immediate health and safety and personal rights risk to R1.the state’s words, verbatim · CDSS document, Aug 10, 2022

Plan of correction: Licensee/Administrator will schedule vendorized training for all staff regarding Regulation 87464.. Licensee/administrator will submit the credentials of the trainer with the scheduled training dates by 8/12/2022 and completion of training by 9/2/2022. Licenee/Administrator will also Submit Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87464. Because this violation resulted in resident beingsustaining a serous bodily injury immediate civil penalty in the amount of $500 is issued.

Allegation investigated: Insufficient staffing Facility failed to provide activities for the residents Facility staff failed to meet residents’ hygiene needs Facility staff failed to provide adequate food service Facility staff failed to provide a safe and comfortable environment Facility staff are not taking any precautions for COVID-19

At 9:15am Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the allegations mentioned above. LPA was greeted by a staff member and screened for COVID-19. LPA was later greeted by the Executive Director, Tom Park. The purpose of this visit was explained. At 9:40am LPA requested LIC500 and room roster, weekly menue and an activity calendar. Allegation: Insufficient staffing. LPA conducted a tour and interviewed a sample of 11 residents from 10:45am to 1:00pm . During tour LPA randomly tested a resident’s pendant. LPA conducted sample interviews of (3) caregivers, Regional Memory Care Specialist, LVN, Activity Coordinator and Executive Director. Continue on LIC 9099-C Unsubstantiated After review of the information received the allegation, Insufficient staffing is unsubstantiated at this time. Interviews with 9 out of 11 residents, who are able to communicate, indicated that staff are meeting their needs within a timely manner and are happy with service. LPA conducted a random inspection of the pendant at 11:51 am, staff responded within a reasonable time at 11:59 am. The facilities expectation for response time is 15 min. Interviews with 2 out of 3 staff indicate that there is sufficient staffing to meet the needs of the resident’s timely due to their communication with each other. Two (2) out of three (3) staff indicate that there is a staffing issue when someone calls in sick, however a manager will step in the position of caregiver to assist and help staff. Interview also indicated that the MedTech will step to assist caregivers as needed. Allegation: Facility failed to provide activities for the residents. It is alleged that there are no activities offered by the facility. LPA conducted interviews with 9 out of 11 residents, who are able to communicate, and 3 staff members. Information from interviews revealed that since the onset of Covid-19 the facility does not offer as many activities due to wanting to social distance and keep residents safe. Interviews with residents did show that the facility still conducts bingo, exercise, coloring, music, ect. During todays visit, facility hired a pianist and at 12:40pm LPA observed 25 residents from Memory Care Unit were engaged in singing, dancing and listening to a music. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Allegation: Facility staff failed to meet residents’ hygiene needs. LPA interviewed 9 out of 11 residents, who are able to communicate, and was informed that facility staff always takes good care of them (pull-ups being changed every 2 hours or as needed, showers are being provided twice weekly or as needed). LPA observed all residents wearing clean clothes, smelled good and being well groomed. LPA also observed the entire facility being clean and free from odor. Based on the information obtained through interviews and observation this allegation is deemed Unsubstantiated at this time. Allegation: Facility staff failed to provide adequate food service Regarding the allegation that staff are not providing residents with food of good quality, LPA interview with nine (9) residents, who were able to communicate, and revealed that nine (9) residents believe that the quality of the food being served at the facility is okay or good. Continue on LIC9099-C LPA record review and observation also revealed that the facility provides complete meal with fruit and vegetable servings on every meal and staff interview reveals that kitchen staff also customize food being served upon resident's request. Moreover, LPA was informed that the weekly menu may vary and daily menu provides options and alternate option for the residents to choose. Based on the information gathered during this visit, this allegations is deemed unsubstantiated at this time. Allegation: Facility staff failed to provide a safe and comfortable environment LPA interviewed three (3) staff members, Regional Memory Care Specialist, LVN, Activity Coordinator and Executive Director. LPA was informed that Memory Care Unit residents were wondering out of their room during the COVID outbreak and the facility staff followed COVID protocols and re-directed them back into their rooms. Based on the information obtained, the allegation is deemed unsubstantiated at this time. Allegation: Facility staff are not taking any precautions for COVID-19 It was alleged that the facility staff are not taking any precautions for COVID-19 and are not practicing social distancing. LPA conducted a physical plant tour on this 02/02/22 and observed signs throughout the facility promoting mask wearing and social distancing. LPA also observed staff wearing masks throughout the facility. Based on LPA observations, the facility takes adequate precautions for COVID-19. Based on information obtained, the allegation is deemed unsubstantiated at this time.the state’s words, verbatim · CDSS document, Feb 2, 2022 · control 31-AS-20220124163550

Allegation investigated: Facility staff did not give residents their medications correctly. Facility staff are not adequately trained. Facility's signage is not properly posted.

At 4:40pm Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with the Administraot, Tom Park, and explained the reason for the visit. Allegation: Facility staff did not give residents their medications correctly. On 01/11/22, LPA spoke with the Administrator and a MedTech. LPA also reviewed the facility CSMDR records of the random residents receiving medication assistance by the facility staff. Upon review of the medications LPA observed that three (3) out of three (3) randomly chosen prescribed medications were centrally stored by the facility, however, they were not properly documented on CSMDR. LPA observed R1’s two (2) medications were given as prescribed, however, both medications were not documented on CSMDR. Moreover, LPA observed R2’s prescribed blood pressure medication that was filled on 12/07/21 had only 6 tablets left in a bottle. However, CSMDR records for “Date Started” column was left blank. Continue on LIC9099-C Substantiated LPA observed R3’s prescribed, narcotic medication was filled on 11/24/21 (in bubble pack) for AM, Noon and PM and was not documented on CSMDR. The Administrator and staff stated that they were not aware of as to why some medications were not documented. When LPA requested to see PRN medication records for the same residents, LPA was informed that PRN records were kept in a main resident’s file, per previous MedTech’s request. LPA informed the Administrator that all medication related documents shall be kept in one file to ensure an accuracy of a proper documentation and requested that all staff handling medication shall take/re-take medication training. Based on interviews and observations made by LPA on 1/11/22 at 11:28am this allegation is deemed Substantiated. Allegation: Facility staff are not adequately trained. S1 stated that their training on passing medications consisted of a brief explanation from the outgoing staff member about when to give AM vs PM medications. At 11:50am LPA asked the administrator for proof of S1's training and was given a one page paper that listed hours for various topics, including 6hrs for medications, but did not specify the day the training was given or by whom. Based on interviews and LPA observations this allegation is deemed Substantiated. Allegation: Facility's signage is not properly posted On an initial visit, made on 1/11/22, LPA was able to tour the facility at 11:09am and interview the Administrator. While conducting a tour of the common areas, Administrator stated that the Ombudsman’s poster is placed on a second floor, in an activity room. LPA was able to observe the Ombudsman's poster, along with all licensing posters, posted in a frame. LPA requested that all posters that contain information on the appropriate reporting agency in case of a complaint or emergency shall be posted in the main entryway of the facility. Based on the information obtained through interviews and observation this allegation is deemed Substantiated. Exit interview conducted, copy of report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 2, 2022 · control 31-AS-20220103144127

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)A-F · Plan of correction due date: Feb 9, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed and PRN medications on CSMDR, which poses a potential health and safety rist to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: Administrator agreed to schedule vendorized training for all staff by 02/9/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 02/09/22

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: Feb 9, 2022

§1569.69 Employees assisting residents with self-administration of medication; training requirements (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training.... This requirement is not met as evidenced by: Based on record review and interviews, licensee failed to ensure staff were provided the required 24 hours of initial training, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: Administrator agreed to schedule vendorized training for all staff by 02/3/22 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion by 02/03/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.33 · Plan of correction due date: Feb 9, 2022

Posting requirements 1569.33(h)(2) (2) Each residential care facility for the elderly shall post this poster in the main entryway of its facility. This requirement was not met as evidenced by Based on observations made by LPA on 1/11/22 at 11:09am, the licensee did not comply with the section cited above, in posting the Ombudsman’s poster in the main entryway, which posed a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2022

Plan of correction: Administrator agreed to remove the Ombudsman’s poster from the activity room (on a second floor) and post it in the main entryway (on a first floor).

Allegation investigated: Resident was allowed to leave the facility without staff supervision

At 09:40am LPA, Angela Panushkina, conducted an unannounced complaint visit to the above facility. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. At approximately, 09:50am the Administrator arrived and LPA explained the reason for the visit. LPA conducted a physical plant tour of the entire facility including the Memory Care Unit. LPA tested four (4) out of four (4) facility egress system in a Memory Unit. LPA observed the egress system to be fully operational this day. LPA interviewed the Administrator, at approximately 10:20am, and the Administrator stated that on 10/20/21 R1 pushed the egress door and care staff responded within 30 seconds. However, another resident was found near the alarming door and was escorted back to his/her room. Meanwhile, R1 exited the side door Continue on LIC9099-C Substantiated without staff supervision and walked down the street, where he was seen and recognized by a family member of another resident and escorted back to the facility. Therefore, based on this information, the allegation is Substantiated. An exit interview was conducted, appeal rights explained and a copy of this report given to Stephanie Funderburg, Administratorthe state’s words, verbatim · CDSS document, Nov 3, 2021 · control 31-AS-20211026133955

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(6) · Plan of correction due date: Nov 5, 2021

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued safety of residents... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure the safety of resident who wondered away from the facility, which poses an immediate health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Licensee shall provide written plan of action to show the steps they will take to prevent this issue from happening again. POC must be submitted to CCL by POC due date.