Paradise in the Valley

Allegation investigated: . Staff dislocated resident's arm 2. Staff did not treat resident with dignity and respect 3. Facility is not kept clean 4. Facility is infested with scabies

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit and intially met with Evelyn Pena, Wellness Director until Yehuda Cohen, Administrator arrived. The reason for today's visit was explained. Face to face interviews were conducted with the Administrator at 9:43am, Staff #1 at 11:48am, Staff #2 at 12:20pm and an attempted interview with Resident #2 at 11:34am. Telephone interviews were conducted with Resident #1 at 9:42am and Staff #3 at 12:54pm. Per interviews conducted regarding Allegation #1 - Staff dislocated resident's arm - per staff, they do not manually transfer Resident #1 to and from the bed. Resident #1 is too Continued on LIC9099-C Unsubstantiated heavy to manually transfer, even with a two men assist. Staff have to use a Hoyer lift to transfer Resident #1 from the bed to the wheelchair. Staff are not aware that Resident #1 ever sustained a dislocated shoulder. Resident #1 did not complain or mention any shoulder pain while living at the facility. Per interviews conducted regarding Allegation #2 - Staff do not treat resident with dignity and respect. Staff stated that they do not call residents names, cuss at them or tell then that they are annoying. Staff treat residents with respect. In fact, staff all stated that Resident #1 would scream, call them names and cuss out the staff if they told Resident #1 not to smoke drugs in the bedroom or if Resident #1 brought homeless people back to the facility for overnight stays or exchanged drugs in return for televisions and refrigerators from the other residents. Resident #1 would call staff "stupid" and "dumb." Staff got to the point where they did not know how to deal with Resident #1. Three staff have quit as a result of Resident #1's behavior. Regarding Allegation #3 - Facility is not kept clean. Per interviews conducted with staff, the bedrooms are cleaned daily and they all stated that Resident #1 was a hoarder. Resident #1 would have so many things that there was barely room to walk sometimes. Staff would clean Resident #1's bedroom and immediately after it was cleaned, Resident #1 would dirty the room. Resident would throw cigarette butts on the floor, clothing and other items. . Regarding Allegation #4 Facility is infested with scabies. Per information obtained from staff interviews, Resident #3 went to the hospital for a fall and Resident #4 due to lack of appetite in January 2023. The facility was notified by the hospital staff that Resident #3 had scabies and that all the residents should be treated for scabies as a precautionary measure. A physicians order was obtained for Elimite and the residents were treated. The scabies incident was reported to the Health Department but no visit was conducted by the health department nurse as a result of the single case of scabies. Based on the information received, the above allegations are all Unsubstantiated Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 29, 2023 · control 29-AS-20230327161826

Allegation investigated: . Staff did not prevent resident from assaulting another resident in care

Licensing Program Analyst (LPA) Christine Yee conducted an inital complaint visit to investigate the above allegation and initially met with Evelyn Pena, Wellness Director. Yehuda Cohen, Administrator arrived at 10:07am to conduct the visit. The reason for today's visit was explained. LPA Yee conducted face to face interviews with Evelyn Pena at 10:01am, Administrator at 10:26am, Resident #1 at 10:51am and conducted telephone interviews with Staff #1 at 12:29pm, Staff #2 at 2:31pm and Witness #1 at 11:26am. Facility files were reviewed and copies of files requested from 11:45am - 12:25pm, Resident #1's room and area directly in front of the room was toured at 1:30pm. Continued on LIC9099-C Unsubstantiated Per information received from interviews conducted with the Administrator, Wellness Director, Staff #1 and Resident #1, on 2/28/23 around 7:00pm screaming was heard coming from the area where Resident #1's room is located. Resident #3 also came to get Staff #1 in the dining room and gestured to staff to hurry. Staff #1 followed Resident #3 around to the other side of the building and found Resident #2 standing over Resident #1. Resident #2 was beating and dragging Resident #1 in the hallway directly outside their shared bedroom. Staff #1 intervened and told Resident #2 to let Resident #1 go. With the assistance of Staff #1, Resident #1 was able to get away. Resident #2 attempted to hit Staff #1 and succeeded in hitting staff on the collar bone. Resident #2 also attempted to choke Staff #1. Staff #1 was screaming for assistance and trying to calm the resident down. Staff #1 wanted to know why Resident #2 was acting that way. Staff #2 had also heard the screaming and ran towards the screaming just in time to see Staff #1 being hit by Resident #2. Resident #2 also attempted to hit Staff #2 and a caregiver hired from an agency. Resident #2 was very agitated. Staff #2 contacted family to assist Resident #2 calm down but the phone was disconnected by resident so 911 was called. When the paramedics arrived, Resident attempted to attack Staff #1 a third time but the paramedic's intervened. Resident #1 refused to be transported to the hospital to be checked on the day of the incident. Resident sustained injury to both elbows and to the top right side of face and to the back of the right ear. First aid was rendered by the paramedics. However, Resident #2 was transported to the hospital and is currently still under observation. Two days later, Resident #1 agreed to be transported to the hospital for a CT scan. No internal injuries were noted. Per interviews conducted with staff and Resident #1, all indicated that Resident #2 is very calm and is not aggressive. Everyone indicated that this was not Resident #2's normal behavior. Based on the information obtained during the investigation, the finding for the above allegation is UNSUBSTANTIATED. Exit interview was conducted with the Administrator and a copy of report provided.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 29-AS-20230307132101

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Incident Visit to the facility above. LPA met with Wellness Director Evelyn Pena at 10:15 a.m. This visit was regarding an incident report to Community Care Licensing (CCL) that was received on 12/29/2022, indicating that a staff member has been abusive toward residents. LPA Ascencio spoke to Administrator Yehuda Cohen on 12/30/2022. Administrator added that they received a call from staffing agency manager stating that various staffing agency personnel observed a staff member be verbally and physically abusive towards residents. Administrator added that the staff member in question has been placed on administrative leave pending an internal investigation. Administrator added they are waiting for a written statement from the caregiver agency with additional details. On 01/05/2023, LPA spoke to Administrator regarding the incident. Administrator stated that the staffing agency did provide a written statement but could not provide sufficient information on the dates, times and residents involved. On 1/13/2023, starting at 11: 20 a.m., LPA spoke to staffing agency manager regarding the allegation. Agency manager stated that multiple agency staff members observed a staff member hit residents on the head, violently grab residents, and not thoroughly shower them. Agency manager added that their staff did not want to provide names or dates and times the alleged incidents happened. Later that same day, LPA interviewed four (4) facility staff members beginning at 10:51 a.m.. Interview with staff revealed that staffing agency personnel are providing care in the evening and night. Further interviews revealed that the staff have not observed or heard of any staff being physically or verbally abusive to residents. Staff interviews also revealed that if they were to hear of any misconduct from staff or residents, they would directly notify their manager, community care licensing or the ombudsman office. Interview with six (6) residents, starting at 11:38 a.m. revealed that staff are very pleasant and respectful toward resident. Resident added that they have not observed or heard of any type of abuse within the facility. Lastly, resident feel safe and comfortable around the staff that are currently present at the facility. Based on evidence gathered, there was no citation made during today’s visit. A copy of the report was provided to the Wellness Director and Administrator.the state’s words, verbatim · CDSS document, Jan 13, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced required annual visit to the above facility. LPA Ascencio met with the Administrator Yehuda Cohen and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. At 1:25 p.m., LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards. BEDROOMS: All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds. The facility has a total of 28 bedrooms - 17 are shared bedrooms, and 9 are private. RESTROOMS: There are about 20 total bathrooms at the facility. The resident bathrooms consist on a sink and toilet. There are 4 shower rooms with non-skid materials. Hot water temperature was tested throughout the facility and was within normal ranges between 105.0 F and 120.0 F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. Continued on LIC 809 - C The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. The medication room was observed to be locked and contained at least 30 days of worth of medication. A locked staff room was observed that contained the laundry room and laundry supply. The outdoor patio has a covered outdoor area equipped with furniture for resident use. The There are no bodies of water noted. KITCHEN: Kitchen knives are stored in a cabinet in the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked staff room. No flies or other vermin were observed INFECTION CONTROL: During today’s visit, the LPA spoke with Administrator regarding the facility’s infection control practices at 2:15 p.m. There is 1 entry into the facility. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate. No citations were issued during today’s visit. Recommendations: - Upon entry, continue to symptom screen staff, resident and visitors per PIN guidelines. Exit interview conducted, and a copy of the report provided to Admin via email.the state’s words, verbatim · CDSS document, Dec 20, 2022

Allegation investigated: Staff are not wearing PPE

On 11/17/2022, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to investigate the allegation named above. LPA Urena arrived at the facility at 1:30 p.m., met with Business Office Manager, Aubriana Thomas, and spoke via phone with the administrator Yudah Cohen (323-806-0786), and explained the reason for the visit. LPA Urena conducted a brief interview with the administrator over the phone, and asked about the staff’s use of face coverings/masks, and if any outside agencies had observed staff not wearing masks. The administrator stated that an outside agency had visited the facility, and that the agency representative had brought to their attention the use of the face coverings/masks. Continues on LIC 9099 C... Substantiated Regarding the allegation, ‘Staff are not wearing PPE’, it is the concern of the Reporting Party (RP) that the facility has not been safeguarding residents by not practicing proper infection control. Upon arrival the LPA was allowed into the facility by a staff member wearing a mask. The office staff were found to be wearing a mask as well. At 1:45pm. and the LPA conducted the tour of the facility, and noticed caregivers and other staff wearing a mask. Additionally, the LPA asked staff if an outside agency had visited the facility recently, and had brought to their attention wearing personal protective equipment (PPE)? The staff stated that 'yes' an outside agency had visited the facility. Based on the LPA’s interview with the administrator, and staff, and based on the information provided by a credible witness, there is sufficient evidence to support the allegation that the 'Facility was not following COVID-19 health, and safety protocol’. Therefore, this allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted with facility representative, a copy of the report, and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Nov 17, 2022 · control 29-AS-20221115114033

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 28, 2022

87468.1(a)(2) 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... This requirement is not met as evidenced by: Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, staff did not wear mask/face covering, while providing care and supervision to residents in care, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 17, 2022

Plan of correction: Submit staff training sign in sheet and supporting documentation on Infection Control Practices- PIN 21-38-ASC regarding masks wearing in the facility to LPA by 11/30/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Designee Sonia Aquino at 2:00 p.m., and explained the reason for the visit. The LPA toured the physical plant areas inside and outside with the Designee at 2:07 p.m., to ensure there are no health and safety hazards. Kitchen: The kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food, and has an arranged meal delivery contract with ‘Grand Valley Health Care Center.’ Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 115.9 degrees Fahrenheit at 2:20 p.m. Bedrooms: The LPA observed resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. Restrooms: Each resident restroom is designed as a ½ bathroom; the facility has designated shower rooms throughout the facility. The resident bathrooms and shower rooms are properly equipped with grab bars and shower rooms are equipped with non-skid material. Hot water was randomly tested throughout the facility inspection; temperatures ranged between 105.0 – 119.8 degrees Fahrenheit in common/ private restrooms. Common Areas: Five (5) Fire extinguishers were observed throughout the facility fully charged, with an annual Maintenance expiration date of 09/22/2024. The building is a one-level facility, which consists of offices, an activity room, a library, medication room, laundry room, multiple supply closets, staff room, kitchen/dining room, and multiple shower rooms. The LPA observed common areas, including furniture and activity equipment, to be clean and in good condition. Continue on LIC 809C.. Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room. The First Aid Kit was complete with a thermometer, scissor, tweezers, bandage and a first aid manual. BACKYARD: The patio has covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator via telephone at 3:56 p.m. regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time, and the LPA reviewed facility’s policies and procedures as it pertains to infection control. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Salia Walker arrived unannounced to conduct a joint Case Management- Incident visit in lieu of COVID-19 Positive outbreak at the above facility. In attendance included LA County Public Health Nurse Ovsanna Dermenjyan, LA County Physician Specialist Cammy Babaie MD and Administrator Yehuda Cohen. The purpose of the visit had a specific emphasis on infection control practices. Upon entry, the facility has a central entry point for signing in, symptom screening, and temperature checks. The facility has appropriate signs in the common spaces to promote proper hand hygiene, physical distancing, and symptom reporting. Staff and residents were observed wearing masks throughout the common spaces. Hand sanitizer was available throughout the common spaces for resident and staff use. During today's visit, a discussion was held regarding the current status of Covid-19 positive residents and staff, testing, communication to staff and families, symptom screening, and adjusted procedures around visitation and excursions. The community is not experiencing any issues with staffing or obtaining Personal Protection Equipment (PPE) at this time. Cleaning and disinfectant protocol is adequate. No health and safety hazards noted during today's visit. Exit interview conducted. A copy of the report was emailed for signature.the state’s words, verbatim · CDSS document, Aug 12, 2021