Palmcrest Grand Residence

Type of visit: Required - 1 Year

On 03/28/2022 around 10:00am Licensing Program Analysts (LPA) Jose Calderon conducted an unannounced Required 1-year inspection. LPA Calderon met with Administrator Peggy Clark and discussed the purpose for today’s visit. The facility is a 2-story building, that is licensed for a capacity of 262 in which a total of 10 can be bedridden. There is currently a total of 106 residents (38 in the Memory Care Unit). LPA Calderon toured the entire physical plant which includes: reception desk, mail box area, administrative offices business offices, recreation area, beauty salon, utility closets, storage room(cleaning solutions and toxins were locked and inaccessible to residents), linen closets, 5 television areas(2 in memory care), medication room, kitchen, dining room, lounge/pool table area, restrooms, laundry room, and inspected randomly selected 3 bedrooms on the first and 3 second floor as well as 4 rooms in the memory care unit. All bedrooms were observed, pull cords in the bathrooms and bedrooms for emergency assistance were tested. Bathrooms contain grab bars, non-skid mats and are clean and operable. The 7-day supply of perishable and 7-day non-perishable food was observed to be complying. LPA Calderon did observe expired nonperishable foods being stored. Administrator and lead cook advised that this would be taken care of today. The water temperature was tested throughout the facility and averaged between 107.1- and 112.8-degrees F. LPA Caldron reviewed 4 resident records and observed that residents in rooms 114, 119, 129 and 239 did not have any issues with their Physician's reports and Appraisal / Needs and Service plans. LPA Calderon conducted a tour of the facility randomly inspected selected bedrooms 114, 119, 129, 239, 417, 419 and 421 observed that: in rooms 114, 119, 129 the non-slip shower tape needed to be replaced. In room 239 the mattress needed to be turned over per the resident. In room 419 the shower door handle needed to be replaced. Per the administrator all issues would be repaired today. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. During today’s visit there were no deficiencies observed under California code of regulation title 22, division 6, chapter 8. Exit interview held. A copy of the report was provided to Administrator Peggy Clark.the state’s words, verbatim · CDSS document, Mar 28, 2022

Allegation investigated: Facility did not follow quarantine procedures for COVID-19

On 02/09/2022 around 01:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 01/12/2021 LPA Calderon interviewed Administrator(S1) and S2 conducted a tour of the physical plant. On 01/11/2022 LPA Calderon interviewed W1 for complaint. On 02/08/2022 LPA Calderon interviewed S2-S5 and on 02/09/2022 LPA Calderon interviewed R1- R5. On 02/07, 02/08, 02/09/2022 LPA Calderon noted the actions of facility regarding C19 process. The investigation revealed the following: Unsubstantiated Allegation: Facility did not follow quarantine procedures for COVID-19 It is alleged that the Facility did not follow quarantine procedures for COVID-19. On 01/12/2022 witness 1 who stated that the facility was not following C19 regulations and noted staff not wearing masks and other PPE while inside the facility. On 01/11/2022 and 02/08/2022 LPA Calderon interviewed S1-S6 who stated that they follow all DPH and DSS process regarding C19. On 02/09/2022 LPA Calderon interviewed R1-R5 who stated that all staff wear masks and other PPE supplies while inside the facility. On 02/07,02/08, and 02/09/2022 LPA Calderon noted that facility is on lock down, that all staff wear masks, shields and gowns and there is signage all over the facility regarding the use of PPE’s. LPA Calderon did not see any staff nor resident not use a mask while in the common arears. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided in person for records.the state’s words, verbatim · CDSS document, Feb 9, 2022 · control 11-AS-20220110154428

Allegation investigated: Facility does not properly bathe resident Facility does not meet resident's incontinence needs

On 02/09/2022 around 02:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 02/08/2022 LPA Jose Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 02/08/2022 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months, admission agreement. On 02/02/2022 LPA Calderon interviewed R1 and on 02/07/2022 and 02/08/2022 LPA Calderon interviewed S1-S6. On 02/07/2022 LPA Calderon interviewed R1-R10 The investigation revealed the following: Unsubstantiated Allegation: Facility does not properly bathe resident It is alleged Facility does not properly bathe resident. On 02/07/2022 LPA Calderon Interviewed R1 who stated that the facility staff had either missed or refused to give R1 a bathe and that R1 had gone for 9 days without someone cleaning his body. R1 states that staff are not happy with R1 and are getting R1 back due to making so many complaints. R2 stated that R2 takes a shower by R2 and does not need any help from staff. On 02/08/2022 LPA Calderon reviewed all facility paperwork for R1 to include the admission agreement, needs and service, physician report, MAR which all support that facility can help R1 bathe but that R1 is very capable of clean R1 except for hard to reach places. On 02/08/2022 LPA Calderon interviewed S1-S6 who state that R1 asked the female staff to clean and touch his private parts which they refused, staff states that they will not go into R1 room unless there is another staff member and currently only man staff helps R1 bathe. Allegation: Facility does not meet resident's incontinence needs. On 02/02/2022 LPA Calderon Interviewed R1 who stated that R1 had gone to the bathroom in R1 bed many times and that staff refuses to change R1 diaper or the sheets in his bed and that due to staffing issues and that staff is getting R1 back for making so many complaints therefore R1 needs are not being met. On 02/08/2022 LPA Calderon reviewed facility paperwork to include the admission agreement, needs and service plan, physician report all supports that R1 needs some help with R1 incontinence needs, but can go to the bathroom. On 02/07/2022 LPA Calderon interviewed S1-S6 who state that when R1 needs to have R1 diaper or sheets changed they do so as many times as needed. Staff state that they might have to take some time to get to his room on a night shift but there is no way they would go 9 days without changing is bed sheets or his diaper. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Feb 9, 2022 · control 11-AS-20220202153526

Allegation investigated: Facility falsified documents. Facility did not safeguard resident's personal belongings.

On 02/09/2022 around 02:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 02/08/2022 LPA Jose Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 02/08/2022 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months, admission agreement. On 02/02/2022 LPA Calderon interviewed R1 and on 02/07/2022 and 02/08/2022 LPA Calderon interviewed S1-S6. On 02/07/2022 LPA Calderon interviewed R1-R2 The investigation revealed the following: Unsubstantiated Allegation: Facility falsified documents. It is alleged Facility falsified documents. On 02/07/2022 LPA Calderon Interviewed R1 who stated that the facility had altered or changed many of his paperwork, but R1 did not have proof. R2 stated that R2 had reviewed R2 medical paperwork and there was no been changed and R2 did not have any issues with the facility or R2 medical paperwork. On 02/08/2022 LPA Calderon reviewed all facility paperwork for R1 to include the admission agreement, needs and service, physician report, MAR which all state that there were no changes to resident 1 facility paperwork. On 05/31/2022 LPA Calderon interviewed R3 - R10 all state staff had never changed or falsified their medical or facility records. Allegation: Facility did not safeguard resident's personal belongings. party. On 02/02/2022 LPA Calderon Interviewed R1 who stated that personal items had been lost or stolen and R1 believes that the cleaning staff had taken R1 items, but R1 did not have any proof. R2 who states that a few months ago R2 had lost $100.00 dollars, or a staff took the money, R2 states that the facility paid her back, and no one has taken or stolen any of R2 personal items. 02/08/2022 LPA Calderon Interviewed S1-S6 all state that the facility does safe guard the personal items of the resident and no staff member would steal or take any resident personal items. On 05/31/2022 LPA Calderon interviewed R3 - R10 all states that no staff member has ever taken or used their personal items and no other resident has ever taken their personal items from their room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Feb 9, 2022 · control 11-AS-20220131135256

Allegation investigated: Facility is not following COVID-19 guidelines Residents are not being showered timely due to lack of staff Residents are not being changed timely due to lack of staff

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 02/09/2022 at 01:00 PM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 02/09/2022 approximately 01:00 PM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1) on 01/11/2022. On 01/11/2022 LPA Calderon requested copies of the following: staff and residents’ roster, SIR reports (for current complaint), physician’s report, appraisal/needs and service plan, and all medical records to include any hospital records for Resident #1 and MAR for R2 – R5. On 02/08/2022 LPA Calderon interviewed S2 – S6 for complaint and on 02/09/2022 LPA Calderon interviewed R1 – R5 for complaint for complaint. On 01/11/2022 LPA Calderon interviewed W1 for complaint. The investigation revealed the following: Unsubstantiated Allegation: Facility did not follow quarantine procedures for COVID-19 It is alleged that the Facility did not follow quarantine procedures for COVID-19. On 01/12/2022 witness 1 who stated that the facility was not following Covid-19 regulations and noted staff not wearing masks and other PPE while inside the facility. On 01/11/2022 and 02/08/2022 LPA Calderon interviewed S1-S6 who stated that they follow all DPH and DSS process regarding Covid-19. On 02/09/2022 LPA Calderon interviewed R1-R5 who stated that all staff wear masks and other PPE supplies while inside the facility. On 02/07/2022,02/08/2022, and 02/09/2022 LPA Calderon noted that facility was closed to guests per Long Beach Department of Health directive, that all staff wear masks, shields and gowns and there is signs all over the facility regarding the use of PPE’s. LPA Calderon did note that all guest have to sign in at the front desk, answer Covid-19 questions and have their temperature taken. LPA Calderon also noted staff and residents wear mask while inside the facility and LPA Calderon had my temperature taken and was asked Covid-19 questions. Allegation: Residents are not being showered timely due to lack of staff. It is alleged that the Residents are not being showered timely due to lack of staff. On 01/12/2022 witness 1 who stated that the facility staff due to Covid-19 was not showering residents on a regular basis, but witness did not have any names of other residents this was happening too. On 01/11/2022 and 02/08/2022 LPA Calderon interviewed S1-S6 who stated that they follow all DPH and DSS process regarding Covid-19 and that due to Covid-19 staff are busy and somewhat backed up giving showers, but staff does have a showering schedule per floor and help resident that need showering needs based on needs and service plan. On 02/09/2022 LPA Calderon interviewed R1-R5 who stated that staff do help residents that need help showering on a weekly basis and that Covid-19 has backed up staff, but residents have no issues with the service provided. Residents state that staff are busy, but there are no staffing issues. Allegation: Residents are not being changed timely due to lack of staff. It is alleged that the Residents are not being changed timely due to lack of staff. On 01/12/2022 witness 1 who stated that the facility due to Covid-19 was not changing residents’ diapers on time, but witness did not have any names of residents this was happening too. On 01/11/2022 and 02/08/2022 LPA Calderon interviewed S1-S6 who stated that they follow all DPH and DSS process regarding Covid-19 and that due to Covid-19 staff are working harder for all residents, but residents that need diaper change or help changing their diaper are given help every day and staff does keep records of changing of diapers for residents based on the resident needs and service plan. On 02/09/2022 LPA Calderon interviewed R1-R5 that they do not need to wear diapers, but that they do have residents/friends that have their diaper changed daily and have not heard of any issues with service from staff. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of Facility did not follow quarantine procedures for COVID-19, Residents are not being showered timely due to lack of staff, Residents are not being changed timely due to lack of staff is found to be UNSUBSTANTIATED. A telephonic exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided in person for records.the state’s words, verbatim · CDSS document, Feb 9, 2022 · control 11-AS-20220111114958

Allegation investigated: Resident's showering needs are not being met.

On 02/09/2022 around 02:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 02/08/2022 LPA Jose Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 02/08/2022 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months, admission agreement. On 02/02/2022 LPA Calderon interviewed R1 and on 02/07/2022 and 02/08/2022 LPA Calderon interviewed S1-S6. On 02/07/2022 LPA Calderon interviewed R1-R2 The investigation revealed the following: Unsubstantiated Allegation: Resident's showering needs are not being met. It is alleged Resident's showering needs are not being met.. On 02/07/2022 LPA Calderon Interviewed W1 who stated that the facility staff had either missed or refused to give him a bathe and that he had gone for 9 days without someone cleaning his body. W1 states that staff are not happy with him and are getting him back due to making so many complaints. R2 stated that R2 takes a shower by R2 self and does not need any help from staff. On 02/08/2022 LPA Calderon reviewed all facility paperwork for R1 to include the admission agreement, needs and service, physician report, MAR which all support that facility can help R1 bathe but that R1 is very capable of clean himself except for hard to reach places. On 02/08/2022 LPA Calderon interviewed S1-S6 who state that R1 asked the female staff to clean and touch his private parts which they refused, staff states that they will not go into R1 room unless there is another staff member and currently only man staff helps R1 bathe. On 04/21/2022 LPA interviewed R3-R10 for complaint and most state that they take their own bath or shower with no help from staff. Some residents state that staff does help them from time to time and have no issues with services. Allegation: Facility does not meet resident's incontinence needs It is alleged Facility does not meet residents incontinence needs. On 02/07/2022 LPA Calderon Interviewed W1 who stated that the facility staff had either missed or refused to help him go to the bathroom and W1 had to take care of his own needs. W1 states that staff are not happy with him and are getting him back due to making so many complaints. R2 stated that R2 goes to the bathroom with no issues and does not need any help. On 02/08/2022 LPA Calderon reviewed all facility paperwork for R1 to include the admission agreement, needs and service, physician report, MAR which all support that facility can help R1 go to the bathroom as needed but that R1 is very capable of clean himself except for hard to reach places. On 02/08/2022 LPA Calderon interviewed S1-S6 who state that R1 asked the female staff to help him in the bathroom and touch his private parts which they refused, staff states that they will not go into R1 room unless there is another staff member and currently only man staff helps R1 in the bathroom. On 04/21/2022 LPA interviewed R3-R10 for complaint and most state that they take their own bathroom needs with no help from staff. Some residents state that staff does help them from time to time and have no issues with services. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Feb 9, 2022 · control 11-AS-20220207111944

Allegation investigated: Staff neglect resulting in resident developing pressure injuries while in care

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at above facility. LPA arrived at the facility and was greeted by receptionist. LPA explained purpose of visit was to deliver findings for the allegation listed above and was allowed entry to the facility to meet with Administrator Veronica Gomez The investigation consisted of the following: On 11/5/2020 LPA spoke with administrator and was given a tour of the facility grounds. LPA saw dining room, kitchen, activity area and resident bedrooms. LPA requested the following documents: Physician’s report and other documents in association with the allegations were requested. On 2/2/2021 LPA interviewed residents 1-resident 11 (R1-R11) and staff 1-Staff 8 (S1-S8). Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff neglect resulting in resident developing pressure injuries while in care. It is alleged that resident developed pressure injuries while in facilities care due to staff neglect. According to facility records R1 was on home health and there was a wound care order from doctor as well as a wound care plan given by the home health agency to treat the pressure injuries R1 gained while in skilled nursing care. R1 was sent to the hospital on 8/24/2020 and was admitted from the hospital to a skilled nursing facility from 8/30/2020 until 10/20/2020. In case notes from skilled nursing facility it was noted that resident had a pressure injury, but it was not the same one for which they were previously receiving home health. Upon return to facility on 10/20/2020 facility conducted a body check and contacted R1’s doctor regarding pressure injury. On 10/21/2020 Home health services ordered by physician, on the same day home health received the order and treated pressure injury. A few days later, on 10/24/2020 R1 was sent to the hospital. They were released on 10/30/2020 to skilled nursing care and did not return to facility before they were hospitalized again on 11/17/2020 which is when five pressure injuries were noted by hospital staff. LPA Cifuentes interviewed residents 2 - Residents 12 (R2-R12). R1 was not available for interview by LPA but it was noted that they did not feel there was any neglect on the facilities behalf. All residents interviewed stated they did not have any pressure injuries. When asked if they felt staff took good care of them, 10 out of the 11 interviewed stated they felt staff took good care of them, with one stating they needed no assistance. Based on information gathered and service records reviewed, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted, and a copy of the report was given to Assistant Administrator Veronica Gomez.the state’s words, verbatim · CDSS document, Jan 11, 2022 · control 11-AS-20201124161136

Allegation investigated: Staff did not take resident to be seen by a physician Resident's dietary needs were not met Staff did not properly assist resident with their medication Staff did not attend to resident's call light in a timely manner Staff allowed resident to sleep on her own vomit Resident's responsible person was not informed of incident Facility staff prevent resident from video calling their responsible person Staff did not provide documentation to responsible person prior to increasing care fees to resident.

On 10/19/2021 around 1:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 06/21/2021 LPA Calderon interviewed Reporting Party (RP) for complaint. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint and on 07/01/2021 LPA Calderon interviewed R1-R11 for complaint. On 07/02/2021 LPA Calderon received and reviewed facility paperwork to included needs and service plan, physician report, MAR, hospital reports for complaint. LPA Calderon and Administrator (S1) and conducted a tour of the physical plant. Unsubstantiated Allegation: Staff did not take resident to be seen by a physician. It is alleged that staff refused to take resident to doctor’s appointment. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that staff did not provide transportation for R1 to be seen by his doctor. On 07/02/2021 LPA Calderon received and reviewed paperwork for R1 the medical records stated that R1 was taken to the doctors office when needed or if R1 had an appointment On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that they take residents to the doctor’s office when needed and there is no way they would deny a resident right to see their doctors. On 07/02/2021 LPA Calderon interviewed R1-R11 for complaint all stated that medical services are fine, that staff takes them to the doctor’s office when needed. Allegation: Resident's dietary needs were not met. It is alleged that Resident's 1 was not being feed properly by staff. On 06/21/2021 LPA Calderon interviewed witness) for complaint who states that staff were not following his doctors dietary plan and he was not eating. On 07/02/2021 LPA Calderon received and reviewed meal plan for facility and facility staff are following R1 dietary plan. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that staff does follow dietary plans for all residents if there are any issues with a resident meal plan staff contacts doctors for any updates. On 07/02/2021 LPA Calderon interviewed R1-R11 for complaint all stated that they receive meal plans from the facility and if they have a doctor’s meal plan, the facility works with them to make sure they get the correct food every day. Allegation: Staff did not properly assist resident with their medication. It is alleged that Staff did not properly assist resident with their medication. On 07/02/2021 LPA Calderon received and reviewed MAR paperwork for R1 the medical records dated 04/18/2021. Per medical paperwork R1 was given higher level of care and was given 5 medications per day. Based on medical paperwork there was no missing medication given to R1. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that the med-Tec have the MAR from the doctor’s office and give the correct medication every day and the medication is given to all residents on time. On 07/02/2021 LPA Calderon interviewed R2-R11 for complaint all stated that medical services are fine, that staff gives them their medication every day and on time. Residents have no concerns with staff taking care of their medication needs. Allegation: Staff did not attend to resident's call light in a timely manner. It is alleged that Staff took 25 minutes to respond to resident's call light. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that staff did not respond to R1 pushing the call light bottom and that witnessed from a video camera that it took staff 25 minutes to arrive at residents’ room. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that depending on the situation at hand it may take 5 to 10 minutes for staff to arrive at a resident room or when the call light is pushed, but that it does not take 25 minutes as reporting party suggest. On 07/02/2021 LPA Calderon interviewed R2-R11 for complaint all stated staff does take 5 to 10 minutes to respond to a call light bottom, but that staff for the most part is very quick and arrives in time to take care of resident’s needs. On 10/19/2021 LPA Calderon tested the call light system for R1 and by the time the light was pushed it took staff 5 minutes to respond and arrive at room. Allegation: Staff allowed resident to sleep on her own vomit. It is alleged that R1 was sleeping and vomit on resident. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that witness mother vomited all over R1 and R1 pushed the call button. Witness states that staff did not clean up the vomit and it took some time for staff to take care of resident. On 07/02/2021 LPA Calderon received and reviewed paperwork for R1 and there was no incident report that resident had vomit on R1. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that if a resident need to be cleaning they take care of any issue and write up a report to support what they have done. On 07/02/2021 LPA Calderon interviewed R2-R11 for complaint all stated that staff takes care of their needs and if there is a major issue like vomit, they clean the resident very fast. Allegation: Resident's responsible person was not informed of incident. It is alleged that resident’s family was not informed of incident. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that R1 had vomit on R1 and staff had not responded and the facility did not inform witness of R1 status until he reviewed the video. On 07/02/2021 LPA Calderon received and reviewed paperwork for R1 and there was no incident report that resident had vomit on R1. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that if a resident need to be cleaning they take care of any issue and write up a report to support what they have done, and this would have generated a call to the responsible party. On 07/02/2021 LPA Calderon interviewed R2-R6 for complaint all stated that staff takes care of their needs and if there is a major issue like vomit, they clean the resident very fast. Residents stated that staff does inform their family members of any major situation. Allegation: Facility staff prevent resident from video calling their responsible person. It is alleged that facility staff prevent resident from video calling family. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that witness 1 stated that R1 is not allowed to use the phone or video calls to her family and that he had to purchase a phone for his mother’s communication needs. On 07/02/2021 LPA Calderon received and reviewed call logs for R1 and there was no indication that staff stopped or kept R1 from communicating with family. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that if a resident need to communicate with their family they do what they can to make sure this is done. On 07/02/2021 LPA Calderon interviewed R2-R11 for complaint all stated that staff takes care of their communication needs, but most residents have their own cell phones to call family members. Allegation: Staff did not provide documentation to responsible person prior to increasing care fees to resident. It is alleged that Staff did not provide 60- day notice prior to increasing fees. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that the facility increased fees for services and did not give 60-day notice as the admission agreements supports. On 07/02/2021 LPA Calderon received and reviewed admission agreement and notice that supports that the resident never returned from the hospital and was not a resident long enough for any increase in facility fees. On 06/22/2021 LPA Calderon interviewed S1 who stated R1 facility fees had not been increased prior to R1 leaving the facility. On 06/22/2021 LPA Calderon interviewed S2-S7 for complaint all stated that the administrator deals with increases for services and they have no knowledge of facility fee increases. On 07/02/2021 LPA Calderon interviewed R2-R11 for complaint all stated that over the years the facility has increased fees and they have received notice for same in a timely matter. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A face to face exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 11-AS-20210617090804

Allegation investigated: Staff did not respond to communications by resident’s responsible person

On 10/19/2021 around 1:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 06/21/2021 LPA Calderon interviewed witness for complaint. On 06/21/2021 LPA Calderon received and reviewed email paperwork from witness. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint and on 07/01/2021 LPA Calderon interviewed R2-R10 for complaint. On 07/02/2021 LPA Calderon received and reviewed needs and service plan, physician report for R1. LPA Calderon and Administrator (S1) and conducted a tour of the physical plant. The investigation revealed the following: Unsubstantiated Allegation: Staff did not respond to communications by resident’s responsible person. It is alleged that Staff did not respond to communications by resident’s responsible person. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that W1 had called and emailed the administrator regarding R1 care with no response. On 07/02/2021 LPA Calderon received and reviewed emails from W1 regarding emails sent to S1 for more information on R1. There was proof via email’s that S1 had attempted to communicate with W1 regarding R1 care while in the facility. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated that if there is any issue with a resident the staff calls, emails the family of resident, and if they receive any communication from family they pass along the message to the administrator for a response. On 07/02/2021 LPA Calderon interviewed R2-R10 for complaint all stated that staff did respond to their family phone calls or emails and they do not have any issues with staff. Residents stated that their family normally calls them via personal cell phone and any issues communications with family they advise staff who makes contact. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A face to face exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 11-AS-20210617100756

Allegation investigated: Resident engaged in a physical altercation with another resident resulting in bruising. Resident’s personal belongings are stolen.

On 08/19/2021 around 11:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 08/05/2021 LPA Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 8/05/2021 LPA Calderon obtained copies of Staff and Resident rosters, physicians report, needs and service plan for R1-R2. On 8/11/2021 LPA Calderon interviewed witness(W1). On 8/05/2021 LPA Calderon interviewed S2-S4 and interviewed R2- R3. On 08/11/2021 LPA Calderon called R1 who hung up on LPA. On 8/11/2021 received and reviewed R1 and R2 facility paperwork. The investigation revealed the following: Unsubstantiated Allegation: Resident engaged in a physical altercation with another resident resulting in bruising. It is alleged on Resident engaged in a physical altercation with another resident resulting in bruising. On 08/05/2021 interviewed S1 who confirmed the photo of R1 with a black eye was from March 2021 and was a old picture. S1 states that R1-R2 did not advise her of any altercation and that no SIR report was filed. S1 confirms the police did not come to the facility and investigate any assault. On. 8/05/2021 LPA Calderon interviewed S2-S4 who all confirmed to issues between the two residents. On 08/05/2021 LPA Calderon interviewed R2-R3 both suggest R1 made up this story and no one ever assaulted R2. On 08/11/2021 LPA Calderon tried to interview R1, but R1 who failed to give statement and hung up on LPA Caldron. On 08/11/2021 LPA Calderon received and reviewed medical records for R1-R2, but records suggest easily signs of dementia and could not or would not give a statement Allegation: Resident’s personal belongings are stolen. It is alleged on Resident’s personal belongings are stolen... On 08/05/2021 interviewed S1 who confirmed that no report was made by R1 to the administrator, staff or the police on stolen items. S1 confirms that R1-R2 are good friends and there has been no issues between to 2 men. On 08/08/2021 LPA Calderon interviewed R2-R3 both confirm no one has ever stolen items in their room. On 08/11/2021 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided via email for records.the state’s words, verbatim · CDSS document, Aug 19, 2021 · control 11-AS-20210729083924

Allegation investigated: Facility staff mismanage medications. Facility does not have adequate staffing.

On 08/19/2021 around 10:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 05/25/2021 LPA Jose Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 5/25/2021 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months records for R1. On 6/07/2021 LPA Calderon interviewed S2-S6 and attempted to interview R1-R10 in the (MC) memory care unit but was unable to obtain any interviews. On 06/07/2021 received and reviewed R1 facility paperwork. Unsubstantiated The investigation revealed the following: Allegation: Facility staff mismanage medications. It is alleged Facility staff mismanage medications. On 05/25/2021 LPA Jose Calderon interviewed Administrator (S1) who stated S1 staff did not mismanage medications for R1. On 5/25/2021 LPA Calderon requested copies of the following: Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months records for R1. LPA Calderon reviewed MAR and did not observe medication discrepancy at this time of visit. On 6/07/2021 LPA Calderon interviewed S2-S6 who stated that the Med-Techs keep records of what they give to residents daily. On 05/31/2022 LPA Calderon interviewed R2 - R9 and residents did not state that staff was mismanaging their medication and they were happy with the service given. Allegation: Facility does not have adequate staffing. It is alleged Facility does not have adequate staffing. On 05/25/2021 LPA Jose Calderon interviewed Administrator (S1) who stated there are enough employees, but some staff take vacation, but this does not effect service of the residents. On 5/25/2021 LPA Calderon requested copies of the following: Staff personal records, time sheets. Record received did not note any staffing issue or a mismanagement of staff. On 6/07/2021 LPA Calderon interviewed S2-S6 who stated that they were not short staffed. On 05/26/2021 LPA Calderon interviewed R1 who stated there were no staffing issues.. On 05/31/2022 LPA Calderon interviewed R2 - R9 all residents states there is enough staff to provide services to all residents in their care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided via email for records.the state’s words, verbatim · CDSS document, Aug 19, 2021 · control 11-AS-20210519090545

Allegation investigated: Facility did not ensure facility was free from pests Staff did not meet resident's hygiene needs

On 08/19/2021 around 02:00pm Licensing Program Analyst (LPA) Jose Calderon, initiated a complaint investigation to deliver the investigation findings for the allegation listed above. today’s complaint investigation was conducted in person via face to face meeting with Peggy Clark. The Investigation consisted of the following: On 06/10/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 6/10/2021 LPA Caldron obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), medical records, Physicians Report and Medication list) and pest control records for 3 months. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8. On 6/10/2021 LPA Calderon interviewed R2 – R13. LPA Calderon could not interview R1 due to communication barriers. On LPA Calderon received and reviewed 2 videos taken from Witnesses on 6/5/2021 and 6/7/2021. Substantiated Allegation: Staff did not meet resident's hygiene needs It is alleged Staff did not meet resident's hygiene needs. On 06/10/2021 LPA Calderon and LPM Hammond interviewed the Administrator S1, S1 stated Hospice was responsible for providing baths to the resident, but this was not being done. Administrator stated S1 reached out to Hospice to remind them of that responsibility. Staff states hospice was responsible for bathing R1. The Administrator stated the facility staff are responsible for providing bed baths to R1, but it was not being done which contributed to ants crawling on the R1 face. LPA Calderon reviewed R1 file and observed the hospice Care Plan does include bathing. LPA Calderon could not interview R1 due to communication problems. LPA Calderon interviewed R2 -R13 most but not all stated that they took their own baths and did not need staff help. Allegation: Facility did not ensure facility was free from pests: It is alleged that the Facility did not ensure facility was free from pests. It is alleged that R1 had ants on R1 face, mouth, ears and body while sleeping. On 6/09/2021 LPA Calderon interviewed R1 family member who stated W1 visited R1 on 6/5/2021 and noted ants on R1 face and body and then W2 visited R1 on 6/7/2021 and took video of large number of ants on R1 face. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8 who all stated ant problems in the facility and stated ants in room 103, 105, 130, 130 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents stated ant problems in the facility. LPA Calderon could not interview R1 due to communication problems. On LPA Calderon received and reviewed 2 videos taken from W1 members on 6/5/2021 and 6/7/2021 which shows ants on R1 who was sleeping in the bed. Based on LPM and LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. A exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for recordsthe state’s words, verbatim · CDSS document, Aug 19, 2021 · control 11-AS-20210609104746

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(C)(3)(A) · Plan of correction due date: Aug 27, 2021

87705 Care of Persons with Dementia :(c) Licensees who accept and retain residents with dementia..(3) In addition to...(A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; Based on observation, interviews facility faciled to clean R1 face after drinking cocnut water and failed to notice ants in R1 bed which poses an immediate health, safety risk to residentsthe state’s words, verbatim · CDSS document, Aug 19, 2021

Plan of correction: Administrator to develop a training plan for staff that work with residents that have dementia and submit plan to LPA no later than 8/27/2021 Administrator to develop a training plan for staff to work with residents that have dementia and need to be bathe or washed and submit plan to LPA no later than 06/10/2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 85072(b)(2) · Plan of correction due date: Jun 10, 2022

85072 Personal Rights:(B)The licensee shall insure that each client is accorded the following personal rights.(2)To have the facility inform his/her relatives and authorized representative.... Based on observation, interviews, video, facility failed did meet resident's hygiene needs which posed an immediate health, safety risk to residentsthe state’s words, verbatim · CDSS document, Aug 19, 2021

Allegation investigated: Staff did not provide timely medical assistance. Staff did not check on the resident for several hours during the day. Staff did not contact resident representative in a timely manner. Resident assaulted another resident

On 10/08/2021 around 1:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 06/21/2021 LPA Calderon interviewed witness for complaint. On 06/21/2021 LPA Calderon received and reviewed needs and service plan, physician report for R1. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint and on 07/01/2021 LPA Calderon interviewed R1-R10 for complaint. LPA Calderon and Administrator (S1) and conducted a tour of the physical plant. Unsubstantiated The investigation revealed the following: Allegation 1: Staff did not provide timely medical assistance. It is alleged on Staff did not provide timely medical assistance. On 06/21/2021 LPA Calderon interviewed W1 for complaint who states that staff did not provide medical assistance to R1 when R1 fell out of R1 bed. On 06/21/2021 LPA Calderon received and reviewed needs and service plan and physician report for R1 the facility records stated no errors were made with R1 medical care and R1 did not sustain any injuries, but R1 did get a black eye when R1 head contacted the floor. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all state R1 had fallen, but once they found out they took care of R1 medical needs. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state that medical services are fine, can be improved but their medical needs are taken care of. Residents state that they have no concerns with staff services and like living in the facility. LPA Calderon went to R1 room, R1 was sleeping and could not give a statement. Allegation 2: Staff did not check on the resident for several hours during the day. It is alleged on Staff did not check on the resident for several hours during the day. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that staff did not provide medical assistance to R1 when R1 fell out of her bed and that it took some time for staff to become aware of R1 fall out of R1 bed. On 06/21/2021 LPA Calderon received and reviewed needs and service plan and physician report for R1 the facility records state that R1 medical needs are being taken care of by staff and that the facility does check in on resident at least 2 times per day and this is how they found out that R1 had fallen out of bed. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all stated R1 had fallen, but once they found out they took care of R1 medical needs and responded to the fall in a timely manner. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state that medical services are fine, and they deny any issues but, can be improved but their medical needs are taken care of. LPA Calderon went to R1 room, R1 was sleeping and could not give a statement. Allegation 3: Staff did not contact resident representative in a timely manner. It is alleged on Staff did not contact resident representative in a timely manner. On 06/21/2021 LPA Calderon interviewed W1 for complaint who states that staff did not provide medical assistance to R1 when R1 fell out of R1 bed and W1 was made aware of the injury to R1 when the hospital called W1. Witness states that no one from the facility called W1 regarding the injury to R1 head. On 06/21/2021 LPA Calderon received and reviewed needs and services plan and physician report for R1 the facility records state that staff did contact resident family regarding the resident falling out of bed, state no major injuries, but R1 did get a black eye when R1 head contacted the floor. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all state R1 had an fall, and they contacted the POA who is the W2 of W1 but had no obligation to advised witness that R1 had fallen. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state that medical services are fine, can be improved and staff does contact their families and make them aware of their medical status. Allegation 4: Resident assaulted another resident It is alleged Resident assaulted another resident. On 06/21/2021 LPA Calderon interviewed witness for complaint who states that R2 had assaulted R1, but R1 did not call the police or report the assault to staff. On 06/21/2021 LPA Calderon received and reviewed all SIR reports associated to R1 and R2 and there is no report made regarding any assault. On 06/22/2021 LPA Calderon interviewed S1-S7 for complaint all state they had no knowledge of any assault and had never spoke to R1 regarding the complaint. On 07/01/2021 LPA Calderon interviewed R2-R10 for complaint all state they had no knowledge of any issue for R1 and had not seen the police at the building on the date of complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with S1, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Aug 18, 2021 · control 11-AS-20210614134751

Allegation investigated: Facility staff did not administer resident's medication as prescribed. Facility staff did not ensure resident was using medical device as prescribed. Facility staff did not launder resident's clothing in a timely manner.

Licensing Program Analysts (LPAs) Nicol Wesley and Nune Margaryan conducted a subequent complaint visit and met with Assistant Program Manager Peggy Clark to discuss the purpose for todays visit. Investigation consisted of the following: During todays visit, LPAs requested to review resident #1's file and to review the medication log and records. On 02/21/2020 LPA requested a copy of the resident and staff roster and interviewed Program Manager Peggy Clark, Assistant Administrator Erin Fiore and Administrator Russell Amparano. LPA Wesley also interview other parties. Regarding allegation: Facility staff did not administer resident's medication as prescribed and Facility staff did not ensure resident was using medical device as prescribed. During the interviews with the Administrator and the Assistant Administrator they advised that resident #1 was receiving their medication as prescribed since they Continued on LIC 9099C. Unsubstantiated moved into the facility in December of 2019. Administrator advised that the Medication Technicians issue the residents medication in a timely manner and according to the doctors orders. It was also communicated that there was a discrepancy with resident #1's medical insurance and due to their age of resident #1, there were issues with the type of medical coverage they qualify for and resident #1's family had to incur out of pocket expenses for some of resident 1#'s medication and this was a result of the resident previously residing out of State. The Assistant Administrator also said that when resident #1 arrived to the facility, the family provided them with some of resident #1's medication but there was no listed medi cation for seizures, and there was no medical equipment for sleep apnea in which the family was supposed to provide per their discussion during the virtual pre placement interview. LPA interviewed staff #2 and they did not recall resident #1 as they were out of leave during that time, but did say they distribute all medication on time and according to the doctors. During the interview with staff #3 they said they give resident medication on time according to the doctors orders. Staff #3 recalled having conversations with resident #1's family and having to constantly contact them in regards to getting resident #1's prescriptions refilled. Staff #3 advised that they informed resident #1s family that they could get the refills set up through the facility pharmacy but the family declined and said the resident had their own doctor and they had a pharmacy that they used because the medical insurance did not coverage all the residents medication so they had to pay for some of the medication out of pocket. Staff #3 informed the LPA that they never received any medication for seizures and said the family never provided the a facility with a CPAP machine for resident #1 to use at night, although it was previously discussed that the resident used one prior to coming to California. LPA reviewed the MAR log and did not see any prescriptions for seizure medication or a CPAP device. During the file review, LPA Wesley did not observe any current literature/prescriptions/doctors order that listed any current use of seizure medication or a CPAP device. During the investigation it was observed that when resident #1 resided out of staff, the medication was issued once in August 2019 as a preventative measure, there was no records/prescription/doctor orders for a CPAP machine in California, however there was indication that resident #1 did utilize a CPAP machine prior to residing at Palmcrest Grand back in October 2019. During the interviews with residents, they informed the LPA that they never had a problem with their prescribed medication being issued in a timely manner and said that the medication was given to them as prescribe at specific times of the day. LPA Wesley attempted to contact resident #1 and their responsible party and was informed that resident #1 had passed away. LPA attempted to interview other parties and was informed that they did not wish to speak to me or discuss or the matter any further. There is no evidence to support the allegations: Facility staff did not administer resident's medication as prescribed and Facility staff did not ensure resident was using medical device as prescribed. Continued on LIC 9099 Page 3. Regarding allegation: Facility staff did not launder resident's clothing in a timely manner. During the interviews with the assistant Administrator Fiore, LPA Wesley was informed that resident #1 soiled their garments more frequent that usual and the resident had limited underclothes and garments. The Assistant Administrator said when they called the family to bring the resident additional clothes, they agreed, but never bought them to the facility. Staff #1 was interviewed and said that each resident has an assigned laundry day and that resident #1 did not have a variety of garments to wear and denied that garment were in a hamper soiled with urine as the resident #1 clothing was so limited, they had to wash the residents clothes daily as they were incontinent. Staff #4 also who also said resident #1 was incontinent would also have to assist with the frequent washing of resident #1's clothes as they only had a few articles of clothing and when they requested additional clothing from the family, they never received any. Staff #4 denied that there was soiled garments in a hamper filled urine and also said they had to provide the resident with additional showers. LPA Wesley attempted to contact resident #1 and their responsible party and was informed that resident #1 had passed away. LPA attempted to interview other parties and was informed that they did not wish to speak to me or discuss or the matter any further. LPA interviewed a random selection of residents who said they do not have any problems with staff washing their clothing, and they have never had soiled clothing especially saturated with urine There is no evidence to support the allegation Facility staff did not launder resident's clothing in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. There are no deficiencies cited and a copy of this report was given during the exit interview.the state’s words, verbatim · CDSS document, Aug 3, 2021 · control 28-AS-20200220130538

Allegation investigated: Bathroom leak came through the floor into a resident's room.

On 07/08/2021 around 11:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 4/21/2021 LPA obtained copies of Staff and Resident rosters, physicians report. On 4/13/2021 LPA Calderon interviewed reporting party (RP). On 4/15/2021 LPA Calderon interviewed S2-S7 and on 4/15/2021, 04/20/2021 LPA Calderon interviewed R1- R10 for complaint. On 07/01/2021 LPA Calderon interviewed S8 for complaint Substantiated Allegation: Bathroom leak came through the floor into a resident's room. It is alleged Bathroom leak came through the floor into a resident's room. On 04/13/2021 Reporting Party (RP) stated that R1 room was flooded by a water leak from the room above her floor. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who could confirm that there was water leak in the room above R1 room, but that the leak had been repaired. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 all confirm the water leak in the room above R1 room, but no one was injured. On 04/20/2021 LPA Calderon interviewed R2-R10 all state there are water leaks all over the facility, but no one had any knowledge of the leak in R1 room. Based on LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (8) and Chapter (6) are being cited on the attached LIC9099D. A exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records. Allegation: Resident was pushed causing injury. It is alleged Resident was pushed causing injury. On 04/13/2021 Reporting Party (RP) stated that R1 was pushed off her bed by another employee. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who could not confirm that any staff member pushed or attacked R1 while she was sitting on her bed. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 no employee had knowledge of any staff pushing a resident off their bed onto the floor. On 04/20/2021 LPA Calderon interviewed R2-R10 all did not have any proof that staff pushed R1 off her bed. On 04/20/2021 interviewed R1 who confirmed staff did not push off the bed, but she rolled off the bed when staff turned her on her side to clean her and she kept going and fell to the floor. On 04/21/2021 received and reviewed all facility paperwork for R1, there is no medical record of R1 falling or being injured from a fall from her bed. On 07/01/2021 LPA Calderon interviewed S8 who confirmed she rolled R1 onto her side to start cleaning her body and R1 kept going and R1 fell to the floor. Allegation: Bathroom leak flooded the kitchen. It is alleged Bathroom leak flooded the kitchen. On 04/13/2021 Reporting Party (RP) stated that R1 room was flooded by a water leak from the room above her floor and that this water flooded the kitchen area. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who could confirm that there was water leak in the room above R1 room, but that the leak had been repaired and never touched the kitchen. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 all confirm the water leak in the room above R1 room, but no information on a flood in the kitchen area. On 04/20/2021 LPA Calderon interviewed R2-R10 all state there are water leaks all over the facility, but no one had any knowledge of the leak in the kitchen. On 04/22/2021 LPA Calderon inspected the kitchen area and could find no signs of any water damage. Allegation: Hygiene care of residents It is alleged Hygiene care of residents. On 04/13/2021 Reporting Party (RP) stated that staff missed helping clean himself. On 04/15/2021 LPA Calderon interviewed Administrator Lesly Figueroa who confirmed R1 was capable of cleaning himself. On 04/15/2021 and 4/20/2021 LPA Calderon interviewed S2-S7 all confirm staff takes care of residents that need help taking a shower. On 04/20/2021 LPA Calderon interviewed R2-R10 all state that they do not need help from staff cleaning or showering. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 8, 2021 · control 11-AS-20210412091544

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(A) · Plan of correction due date: Jul 8, 2021

87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews and observations LPA confirmed that there was a water leak which came from another bathroom on the floor above. Staff confirmed a water leak and damage to resident room which poses a potential health, safety or personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jul 8, 2021

Plan of correction: Licensee to have bathroom water pipes checked on a monthly basis and will provide infrormation to DSS

Allegation investigated: Staff did not provide timely medical assistance. Resident developed an infection on hand

On 07/08/2021 around 12:00 PM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Peggy Clark. The Investigation consisted of the following: On 06/15/2021 LPA Jose Calderon interviewed Administrator Peggy Clark(S1) and conducted a tour of the physical plant. On 06/15/2021 and 07/01/2021 LPA Calderon interviewed S2-S6 for complaint. On 06/14/2021 and 06/16/2021 LPA Calderon interviewed witness for complaint. On 06/15/2021 LPA Calderon interviewed R1 for complaint. On 06/15/2021 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months and Kaiser Hospital records for R1. On 07/02/2021 received and reviewed medical paperwork for R1. Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide timely medical assistance. On 06/15/2021 LPA Jose Calderon interviewed Administrator (S1) who stated R1 injured R1 right index finger while using R1 wheel chair. S1 states that R1 was assessed by RN when they became aware of the injury and then transported to the hospital for evaluation. On 06/15/2021 and 07/01/2021 LPA Calderon interviewed S2-S6 for complaint, all state they were aware of R1 injury to the finger, but also state that they took care of R1 needs, but R1 finger was not getting better, and R1 was moved to the hospital for more care. On 06/14/2021 and 06/16/2021 LPA Calderon interviewed Witness (W1) and W1 stated that when W1 visited R1, W1 noticed gangrene on the right index finger. W1 took R1 to Kaiser hospital. On 06/15/2021 LPA Calderon interviewed R1 for complaint, he states an unknown person pushed R1 down a ramp inside the facility and R1 injured his finger on his wheel chair. On 06/15/2021 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months and Kaiser Hospital records for R1. On 07/02/2021 received and reviewed Kaiser Medical Records for R1. The review of the medical records revealed that R1 did not have gangrene or an infection. Based on interviews conducted and records the facility provided basic first aid for an injury and R1 was taken to the hospital when the injury worsened. Allegation: Resident developed an infection on hand On 06/15/2021 LPA Jose Calderon interviewed Administrator (S1) who stated R1 injured R1 right index finger while using R1 wheel chair. S1 states that R1 was assessed by RN and then transported to the hospital for evaluation. On 06/15/2021 and 07/01/2021 LPA Calderon interviewed S2-S6 for complaint, all state they were aware of R1 injury to the finger, but also state that they took care of R1 needs, but R1 finger was not getting better, and R1 was moved to the hospital for more care. On 06/14/2021 and 06/16/2021 LPA Calderon interviewed Witness (W1) and W1 stated that when W1 visited R1, W1 noticed gangrene on the right index finger. W1 took R1 to Kaiser hospital. On 06/15/2021 LPA Calderon interviewed R1 for complaint, he states an unknown person pushed R1 down a ramp inside the facility and R1 injured his finger on his wheel chair. On 06/15/2021 LPA Calderon requested copies of the following: Staff and Resident Roster, Needs and Service plan, Physician Report, medical reports for past 3 months, Medication list, SIR reports for 3 months and Kaiser Hospital records for R1. On 07/02/2021 received and reviewed Kaiser Medical Records for R1. The review of the medical records revealed that R1 did not have gangrene or an infection. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Administrator Peggy Clark, and a hard copy was provided for records.the state’s words, verbatim · CDSS document, Jul 8, 2021 · control 11-AS-20210614154902

Allegation investigated: Facility did not ensure facility was free from pests Personal Rights

On 06/10/2021 around 3pm Licensing Program Manger Janae Hammond and Licensing Program Analyst (LPA) Jose Calderon, LPA Jones, LPA Cifuentes, LPA Coronel and long-term ombudsman Medrano initiated a complaint investigation to deliver the investigation findings for the allegation listed above. today’s complaint investigation was conducted in person via face to face with Administrator Lesly Figueroa. The Investigation consisted of the following: On 06/10/2021 LPA Calderon interviewed Administrator Lesly Figueroa(S1) and conducted a tour of the physical plant. On 6/10/2021 LPA Caldron obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), medical records, Physicians Report and Medication list) and pest control records for 3 months. On 6/09/2021 LPA Calderon interviewed reporting party (R1) who confirmed she visited her mother R1 on 6/5/2021 and noted ants on R1 face and body and then granddaughter visited R1 on 6/7/2021 and took video of large number of ants on R1 face. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8 who all confirmed ant problems in the facility and confirmed ants in room 103, 105, 130, 133 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents confirmed ant problems in the facility. LPA Calderon could not interview R1 because R1 family moved resident to another facility and R1 has dementia and could not be interviewed. shows ants on R1 who was sleeping in the bed Substantiated On LPA Calderon received and reviewed 2 videos taken from family members on 6/5/2021 and 6/7/2021 which The investigation revealed the following: Allegation: Facility did not ensure facility was free from pests. It is alleged on facility did not ensure facility was free from pests. LPA Calderon received a video of R1 with ants crawling all over R1’s face, ears, mouth, nose and bed. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8 who all confirmed ant problems in the facility and confirmed ants in room 103, 105, 130, 133 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents confirmed ant problems in the facility. LPA Calderon could not interview R1 because R1 family moved resident to another facility and R1 has dementia and could not be interviewed. On LPA Calderon received and reviewed 2 videos taken from family members on 6/5/2021 and 6/7/2021 which shows ants on R1 who was sleeping in the bed Allegation: Personal Rights: It is alleged that the facility violated the Personal Rights of R1. It is alleged that R1 had ants on her face, mouth, ears and body while sleeping. On 6/09/2021 LPA Calderon interviewed R1 family member who confirmed she visited R1 on 6/5/2021 and noted ants on R1 face and body and then granddaughter visited R1 on 6/7/2021 and took video of large number of ants on R1 face. On 6/10/2021 LPA Calderon interviewed S1 and on 6/10/2021 LPA Calderon interviewed S2-S8 who all confirmed ant problems in the facility and confirmed ants in room 103, 105, 130, 130 and 143. On 6/10/2021 LPA Calderon interviewed R2 – R13 and 5 out of 13 residents confirmed ant problems in the facility. LPA Calderon could not interview R1 because R1 family moved resident to another facility and R1 has dementia and could not be interviewed. On LPA Calderon received and reviewed 2 videos taken from family members on 6/5/2021 and 6/7/2021 which shows ants on R1 who was sleeping in the bed Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC9099D. A exit interview was conducted with Administrator Morris Stricher, and a hard copy was provided via email for recordsthe state’s words, verbatim · CDSS document, Jun 10, 2021 · control 11-AS-20210609104746

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jun 15, 2021

87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based on observation, interviews facility faciled to control ant problems and LPA Calderon witness ant problems in room 103 which poses an immediate health, safetythe state’s words, verbatim · CDSS document, Jun 10, 2021

Plan of correction: TAdministrator will contac pest control for the best options to treat the facility and will provid a outline of a POA by the due date.ining of staff and updated DSS no later than 06/15/2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(2) · Plan of correction due date: Jun 11, 2021

87468 Personal Rights:(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities,..(1) "Privately operated facility" means a residential care facility for the elderly that is licensed to an individual, firm, partnership. his requirement is not met as evidenced by: Based on observation, interviews and video it is confirmed that there were ants on R1 face and body and ant issues for the total facility which poses an immediate health, safetythe state’s words, verbatim · CDSS document, Jun 10, 2021

Plan of correction: Adminsitrator will confirm all staff training in personal rights in residents in care. Adminstrator will provide proof and training and sign in sheet for all staff by POC due date of 6/11/2021

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Administrator did not keep responsible party appraised of resident care. Resident was not appropriately assessed. Facility staff failed to report an incident Staff failed to assist in the administration of medication. Staff falsified records. Facility staff failed to adhere to the admission agreement

On 04/19/2021 around 3pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019(COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically via face time with Administrator Lesly Figueroa. The Investigation consisted of the following: On 02/16/2021 LPA Calderon interviewed (S1) and conducted a tour of the physical plant. On 2/23/2021 LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), medical records, Physicians Report and Medication list). On 2/23/2021 LPA Calderon interviewed (W1). On 2/23/2021 LPA Calderon interviewed S2 and on 3/1/2021 LPA Calderon interviewed S3-S6. On 2/26/2021 LPA Calderon reviewed 2nd round of medical records for R1. ON 03/01/2021 LPA Calderon interviewed R2 – R10 for complaint. Unsubstantiated The investigation revealed the following: Allegation: Administrator did not keep responsible party appraised of resident care. It is alleged on facility administrator failed to keep responsible party appraised of resident care. On 02/23/2021 witness 1 stated that facility administrator did not keep W1 informed of resident care. On 02/16/2021 LPA Calderon interviewed S1 who stated W1 call resident R1 family and kept them informed of medical status of R1. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that they did always keep witness 1 informed and R1 medical status was provided to S1 to document R1 medical file. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that staff kept them informed of their medical status and kept their families informed. R2-R10 were informed daily of their medical status. Allegation: Resident was not appropriately assessed. It is alleged on facility that resident was not appropriately assessed while in care. On 02/23/2021 W1 stated that S1 did not assess R1 prior to moving into facility. On 02/26/2021 LPA Calderon reviewed R1 medical records which included needs and service plan, physician report. The report stated that level 4 extensive care and assistance including allowable health, helps bathing, dressing, toileting, brushing teeth, taking medication, emotionally unstable, inappropriate behavior, possible hostility, dementia. On 3/1/2021 LPA Calderon interviewed S2-S6 who stated R1 was assessed prior to moving into the facility and a copy of the assessment was given to R1 family. On 03/01/2021 LPA Calderon interviewed R2 – R10 who stated that they were provided assessment prior to coming into the facility to live. Allegation: Facility staff failed to report incident. It is alleged on facility staff failed to report an incident while in care. On 02/23/2021 W1 stated that S1 did not keep W1 family informed of resident falling to the ground while in care. On 02/16/2021 LPA Calderon interviewed S1 who stated that S1 staff did call W1 family regarding R1 fall and they generated a LIC624 to make sure the exact facts of the fall were known. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that they did keep W1 family informed of R1 medical status and fall and that they also advised S1 of resident medical status. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that staff kept their family informed of any fall while in care Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator Lesly Figueroa, and a hard copy was provided via email for records Allegation: Staff failed to assist in the administration of medication. It is alleged on facility staff failed to assist in the administration of medication of residents while in care. On 02/23/2021 W1 stated that facility staff did not help residents with their medication. On 02/16/2021 LPA Calderon interviewed S1 who stated staff did assess residents with their medication and give medication to residents and document residents MAR. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that they did assist residents with their medications and document residents MAR, but some residents take their own medication without staff help. On 3/1/2021 LPA Calderon interviewed R2-R10 who all stated staff gave their medication on time with no mistakes, some state that they take their own medication with no staff assistance. Allegation: Staff falsified records. It is alleged on facility staff falsified records of resident while in care. On 02/23/2021 W1 stated that facility administrator gave W1 a blank medication list and then changed information and gave W1 other medical paperwork. On 02/16/2021 LPA Calderon interviewed S1 who stated S1 gave W1 medical records for R1 which were correct. S1 stated S1 staff gives the medication on time and any errors are written down by administrator and the resident MAR is updated. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that R1 MAR could not be changed after final entry and no one they know made any changes. Staff state that no one has asked them to change the MAR for R1 or alter any medical records and if this had happened, they would inform DSS. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that staff kept them informed of their medical status and kept their families informed and any time they requested medical records they were given the paperwork without changes. R2 – R10 state they have no knowledge of any staff or person falsified records. Allegation: Facility staff failed to adhere to the admission agreement. It is alleged on facility administrator failed to keep responsible party appraised of resident care under the admission agreement. On 02/23/2021 W1 stated that facility administrator did not keep W1 informed of changes to the admission agreement. On 02/16/2021 LPA Calderon interviewed S1 who stated S1 went over the admission agreement with W1 prior to signing the form and that any change to the admission agreement was done in front of W1 and W1 family and all signed the agreement. S1 states that a copy was given to W1 family for their records. On 3/1/2021 LPA Calderon interviewed S2-S6 who all stated that administrator did go over admission agreement with W1, but staff does not have any information on this matter. On 3/1/2021 LPA Calderon interviewed R2-R10 who state that any change to their admission agreement is signed by S1 and the resident or family and they are given a copy.the state’s words, verbatim · CDSS document, Apr 19, 2021 · control 11-AS-20210208123416