Pasadena Villa Senior Living

Allegation investigated: Staff did not ensure resident was clothed Staff did not ensure resident had eaten Staff did not check on resident during the night

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit at the facility regarding the above allegations. LPA met with Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 8/22/23 LPA Trueman conducted an initial investigation visit and collected documents. On 11/13/23 LPA Flores conducted interviews with assistant administrator, 3 staff, and 6 residents. LPA collected the following documents: physician’s report, admission agreement, identification and emergency information, medication sheet for July – September 2023, needs and care plan, incident report dated 8/12/23, other documents for resident #1 (R1). The investigation revealed the following: Regarding allegation: Staff did not ensure resident was clothed. It is alleged R1 was completely nude sitting on R1’s wheelchair outside the facility around 9:50am. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with residents revealed, residents stated that upon residents needing assistance in a situation like R1’s caregivers attempted to assist residents by redirect them even when the residents refuse. Interviews with staff revealed providing assistance with dressing to the residents is part of their duties. There are times when residents become impatience and they may go out without clothes. Residents become distraught and refuse caregivers’ assistance. Caregivers at that point seek for management’s assistance to help the residents. Document reviewed revealed; Incident Report dated 8/12/23 notes the morning of 8/12/23 at 9:00am management observed R1 “was naked in the front patio. Caregiver and manager attempted to assist R1 to return inside and get changed but refused. Management proceeded to set up transportation for a 5150 and contacted Pasadena Police Department”. Additional incident report notes, on 8/12/23 staff attempted at least 5 times to provide care to R1, who refused each time. Although R1 may have been nude, staff attempted to assist and redirect R1 to get dress. However, R1 refused the assistance. Due to R1’s behavior, management team reached out to Pasadena Police Department to assist with a 5150 for R1 to provide proper 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. Regarding allegation: Staff did not ensure resident had eaten. It is alleged R1 was upset because R1 wanted food when found outside around 9:50am. Interviews conducted revealed 5 out of 6 residents stated facility provides meals, reminders, or assistance with feeding the residents. 1 out of 6 residents stated to not be receiving meals at the facility as resident is out most of the day. Interviews with staff revealed residents receive meals three times a day and staff provides assistance with feeding to those residents that cannot feed themselves. Assistant administrator stated R1 can feed self as long as R1’s prosthetics are on. Document review revealed R1’s physician’s report notes R1 needs assistance with feeding. However, needs and service plan notes R1 is able to feed self and staff will assist as needed. Incident report dated 8/12/23 notes staff prompted assistance to feed R1 on 8/12/23 during breakfast but R1 refused the assistance. Although R1 may have wanted food and did not receive breakfast the morning of 8/12/23, staff attempted to provide breakfast and R1 refused the assistance. 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.(CONT.LIC9099C) Regarding allegation: Staff did not check on resident during the night. It is alleged R1 was naked in the morning because R1 had not been checked up on during the night. Interviews conducted with residents revealed, 5 out of 6 residents stated there is staff overnight, who provide assistance or check on the residents as needed and 1 out of 6 residents stated assistance is not provided at night. Interviews with staff revealed that part of the duties of the night shift is to check on the residents during the night and provide care as needed. Documents reviewed revealed, Personnel Report notes there is at least 1 staff during the night shift on duty. Appraisal/needs and services plan dated 3/14/23, notes R1 is to receive assistance with activities of daily living (ADL)’s as needed and provide “extra assistance” with physical health services. However, it also notes R1 is non- compliant with care provided. Although facility staff has been providing care, R1 has not been complaint with staff. LPA was provided a copy of communication between assistant administrator and agencies involved in R1’s care in which R1’s non-compliance is discussed and a plan of action is discussed to better assist R1. 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. Exit interview was conducted with Alexander Solario and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2023 · control 28-AS-20230814105348

Allegation investigated: Resident's needs are not being met Administrator is unavailable Staff did not clean resident's room Staff did not safeguard resident's personal belongings Facility did not maintain a comfortable temperature for resident Staff not following resident's dietary plan Staff not serving meals in a timely manner

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegations listed above. LPA met with Alexander Solorio, Administrator for the facility, and explained the reason for the visit. The investigation consisted of the following: during the initial visit conducted on 06/11/2021, LPA Joe Katrdzhyan obtained documents from Resident #1's (R1) file, along with a copy of the staff roster and resident roster, and on the subsequent visit LPA Zaragoza interviewed Residents# 2 – 11 (R2 - R11), Staff # 1 – 5 (S1 - S5), and toured rooms #3, 7, 18, 21, and 27. LPA Zaragoza also obtained copies of the following documentation during the subsequent visit: Staff Roster, Client Rosters, List of Residents with a Specialized Diet, along with the Admissions Agreement, Physician's Report, Appraisal/Needs and Services Plan, Functional capability assessment, Care Plan, and Inventory list for R1. During today’s visit, LPA Zaragoza interviewed Staff #6 (S6). LPA attempted to interview R12, however R12 is no longer a resident at the facility. Unsubstantiated The investigation revealed the following: In regards to the allegation “Resident’s needs are not being met”, it was alleged that staff did not meet the needs of R1 by not assisting R1 with their showering needs in weeks, and also did not assist R1 with brushing their teeth or responding to the pendant call light system when the residents request assistance. During interviews with the residents, nine (9) out of eleven (11) interviewed did not corroborate the allegation that their needs were not being met. R3 explained that the facility staff always assists R3 with their diaper changing needs and has no issues with their needs being met, and R10 explained that the facility staff does respond to the resident’s call light system in a timely manner. During interviews with the staff, none of them corroborated the allegation that they do not meet the resident’s needs. S1 explained that caregivers of the facility spent a lot of time in R1’s room due to her needs, and that the resident received 2 showers per week, or on an as-needed basis. In regards to the allegation that the “Administrator is unavailable”, it is alleged that the administrator of the facility Alexander Solorio is unreachable, never responds to any of the residents’ requests and blocks their calls. During interviews with the residents, eight (8) out of eleven (11) residents interviewed did not corroborate the allegation that Alex is not available to speak with and assist the residents of the facility. R2 explained that Alex is very nice, helpful, and available for the residents, and R10 explained that Alex assists R10 with scheduling transportation for doctors appointments and that the communication between them is good. During interviews with the staff, none of them corroborated the allegation that the administrator Alex is not available for the residents. S3 explained that Alex often works on the floor of the facility to assist with caregiving duties when the other staff ask for assistance. During an interview with Alex over the phone, he stated that he is very hands-on in his work with the facility, and that he also makes rounds personally to ensure the needs of all residents are being met. He states that he has an open door policy and that any resident that has questions, requests, or concerns to come talk to him, and if he is ever busy he will inform the resident of when he will become available. In regards to the allegation that “Staff did not clean resident’s room”, it was alleged that the resident rooms were not cleaned by the staff members when they should have been. During interviews with the residents, nine (9) out of eleven (11) interviewed did not corroborate the allegation that staff do not clean their rooms. R2 explained that the housekeepers clean R2’s room every other day and also make sure to take the trash out of residents rooms if there ever is any trash visible, and R6 also stated that he gets his room cleaned by the staff and that it is done in an adequate manner. During interviews with the staff, none of them corroborated the allegation that fellow staff members do not clean the rooms of the residents. S1 explained that each of the resident rooms get a deep cleaning at least once per week, and every other day rooms are checked to see if any trash needs to be thrown away, and S4 stated that at the time this complaint was filed it was more difficult to the zoning restrictions that the facility implemented from the Department of Public Health, however they did make sure to clean the rooms at least once per week when this complaint was filed. In regards to the allegation that “Staff did not safeguard resident’s personal belongings”, it was alleged that multiple possessions of R1’s had either gone stolen or missing during R1’s time living in the facility, including clothing, a Christmas Package, a chess set, and a polo winter vest that the facility replaced with an imitation vest. During interviews with the residents, nine (9) out of eleven (11) did not corroborate that their personal items have been stolen. Most of the residents indicated that they have never had one of their personal items go missing in the entire time they have lived in the facility, and all residents who have lived in the facility at the time the complaint was filed claimed none of their belongings have gone missing or gotten stolen. During interviews with the staff, none of them corroborated the allegation that they have failed to safeguard the personal belongings of the residents. S1 stated that she never recalled R1 reporting that her personal belongings had gone missing, and that in the event that this does occur they ask residents to report it as soon as possible so they can work toward finding it by first search the resident’s rooms and then around the facility, and if the item is of sufficiently high value they will also file a police report. S4 stated that R1 had nothing listed on their inventory log, and that they did once complain about not receiving a package, however it did eventually arrive, it was just two (2) days late. During record review of R1’s personal inventory list, they waived their right to have any of their personal belongings safeguarded by the facility staff. In regards to the allegation that “Facility did not maintain a comfortable temperature for resident”, it was reported that the temperature in their resident rooms were between 80-82 degrees, and that staff were deliberately turning off their air conditioning or refusing to turn it on. During interviews with the residents, seven (7) out of the eleven residents interviewed did not corroborate that the temperature is too hot or cold. R2, R4, and R7 all stated that at times the temperature in their rooms can feel a bit cold, however when they ask the facility staff to change the temperature they do help them with adjusting it. During interviews with the staff, none of them corroborated the allegation that they do not keep a comfortable temperature for the residents in the facility. During the physical plant tour of the facility, LPA measured the temperature in the air to be at 74 degrees Fahrenheit in all rooms of the facility and that it was of a comfortable temperature. In regards to the allegation that “Staff not following resident’s dietary plan”, it is alleged that staff was feeding R1 carbohydrate-heavy meals, when R1 was a diabetic and those types of meals were not appropriate for them. During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation that residents who have a specialized diet do not get food suited to their diet. LPA interviewed R2, R3, R8, and R9 because they were all indicated to require a diabetic diet, and none of them corroborated that the facility does not follow a resident’s specialized dietary plan if they require one. During interviews with the staff, none of them corroborated the allegation that the facility does not follow the dietary plans of the residents. S3 who works with the kitchen staff stated that within the kitchen of the facility there is a list of the resident’s dietary restrictions and their care plan which details what residents can and cannot eat so that staff know to avoid certain foods with residents. Additionally S4 explained that the facility staff did provide R1 food appropriate for R1’s diabetic diet which was submitted to them through their Care Plan by their physician, however R1 was not happy with the food that the facility offered and often went against their own Care Plan by ordering food from outside dining establishments. During the physical plant tour of the facility LPA observed in the kitchen that the facility does have a list of dietary restriction and Care Plans for all residents that require a specialized diet posted in an area where all kitchen staff can see it. In regards to the allegation that “staff are not serving meals in a timely manner”, it was alleged that around the time this complaint was filed in March of 2021 that food was being delivered to resident rooms late, that the food was served cold, and that staff did not respond to requests to reheat the food. During interviews with the residents, ten (10) out of eleven (11) interviewed could not corroborate the allegation that their food is not served warm. R5 and R6 both lived in the facility around the time that this complaint was filed in March of 2021 and they both explained that the facility did serve meals in a timely manner and never experienced an issue with being served cold meals around this time or in the present day. During interviews with the staff, none of them corroborated the allegation that meals are not served to residents in a timely manner. S1 explained that R1 was served meals on time which was delivered to her room, and that the facility’s kitchen staff made sure to wrap food in saran wrap to ensure that food got delivered warm to residents, and S4 said that around this time it was more difficult for residents to be delivered their food due to the zoning restrictions the facility had to implement due to COVID-19 which forced them to deliver food to residents one zone at a time, however each resident did get their food delivered in a timely manner at the time this complaint was reported and in the current day as well as kitchen staff make sure to deliver food to residents who eat in their rooms first to ensure that it stays warm. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 above allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. In regards to the allegation that “Facility is without hot water”, it is alleged that there is not hot water in the showers or faucets of the resident bathrooms. During interview with the residents, three (3) out of eleven (11) interviewed corroborated the allegation that the water is too cold. R6 explained that the water has not been sufficiently hot in his time living at the facility, which has been since before the complaint was filed. A separate resident who was not fully interviewed, Resident #13, told LPA and the Resident Care Director Maria Razo in a hallway during the physical tour of the facility that the water in R13’s room was too cold for them to take a shower that morning. During an interview with the staff members, none corroborated the allegation, however they did explain that in certain rooms it can take time for the showers to warm up. S1 explained that it can take 5 – 10 minutes for hot water to turn on in the morning in certain rooms while the hot water temperature is within range for other rooms, and that maintenance is working on the issue and additionally that maintenance states that the issue is being caused by old pipes. S4 likewise stated that hot water is delivered to all rooms in the facility however it can take 5-10 minutes for the hot water temperature in some rooms to reach the required range, and that this is due to the building being old. LPA measured the hot water temperature in rooms 3, 7, and 18 and they all measured 102.3 Degrees F, 88.7 Degrees F, and 84.5 Degrees F respectively. Based on LPAs interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights was provided to the administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 28-AS-20210302100806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Nov 17, 2023

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water (...) to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on interviews and observation, LPA determined that the hot water temperature in the facility fell below the 105 degree threshold in Rooms 3, 7, and 18, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: Administrator shall ensure that the hot water temperature will remain within the required range at all times. Administrator will maintain a log of water temperature for the above resident rooms by the POC due date.

Allegation investigated: Resident's room has no call light. Resident's needs are not being met by staff. Staff is not treating resident with dignity. Staff are retaliating against resident.

Licensing Program Analyst (LPA) Ashley Calderon conducted a subsequent unannounced complaint visit regarding the allegations listed above. This licensing report supersedes the licensing report dated 3/27/23. LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit. Findings remain the same. During visit conducted on 3/27/23, LPA obtained a copy of the resident roster, staff roster, Resident #1 (R1's) file and obtained relevant documentation: R1's Face Sheet, R1's Physician Report, R1's Medical Consent Form, Pre-Placement Appraisal Information, R1's Appraisal, R1's Care Plan, R1's Appraisal/Needs and Service Plan Special Incident Reports,R1's Medical Refusal, Email with R1's Psychiatric Social Worker and Clinical Program Manager, R1's Behavior Contract, R1's Call Button Pendant Agreement. Fire Alarm Notice. LPA toured common areas and R1's bedroom. LPA interviewed Assistant Administrator Alex, Staff #1-4 (S1-S4), attempt interview with Resident#1 and #6 (R1 and R6) and interviewed Resident #2-5 and #7 (R2-R5 and R7). CONTINUATION ON 9099-C... Unsubstantiated LPA Calderon attempt to interview via telephonically R1's Psychiatric Social Worker and LPA via telephonically interviewed R1's Clinical Program Manager from Worker Office of Diversion of Reentry. On 10/20/23 LPA Calderon toured random resident bedrooms: Room’s #4, 6, 18, 39 and 44 to check call light button pendants and redelivered report. Regarding Allegation: Resident's room has no call light. LPA Calderon interview with staff revealed that (5) out of (5) call light buttons are distributed to residents based on their needs; facility uses call pendent buttons. Interviews with (3) out of (5) staff informed LPA Calderon that R1 has a call button pendant. LPA Calderon reviewed R1's call button pendant agreement documentation which stated R1 received a call button pendant. R1 refused to show LPA call button pendant when R1’s room tour was conducted. LPA observed random rooms for call button pendants and residents in rooms # 4,6,18,39 and 44 all had call light buttons /pendants, either on a string or on the wall near bed. Regarding Allegation: Resident's needs are not being met by staff. LPA Calderon interviewed staff, (5) out of (5) staff denied the above allegations, staff informed LPA residents and R1 are receiving services to meet their needs. (5) out of (5) staff during interview with LPA stated R1 does not have a prescription order for bed rails, staff provide laundry service, food service, transportation when needed and medical services when required. Staff stated R1 at times refuses assistance provided by staff and medical professionals and R1 is an independent individual. LPA interviewed R2-R5 and R7 all denied the above allegation and stated they are assisted by staff to meet their needs and staff clean, do laundry and provide meals. During telephone interview with Clinical Program Manager for R1 informed LPA R1 refuses assistance and services offered to R1 to assist with their needs, facility support R1, R1’s medical team is involved with R1 and R1 does not allow assistance. LPA observed R1’s bedroom and observed no half/full bed rails in R1’s bed. LPA reviewed R1’s file, physician report states R1 is not on Hospice, no bed rail order was noted in R1’s file and R1’s Appraisal/Needs and Service Plan states R1 is independent with all Activities of Daily Living. CONTINUATION ON 9099-C... Regarding Allegation: Staff is not treating resident with dignity. LPA Calderon interviewed staff Assistant Administrator and staff S1-S4, staff denied allegation stating all residents are treated with dignity and respect and are do not treated any residents differently. LPA Calderon interviewed residents, R2-R5 and R7 whom denied the above allegation stating staff treat them with dignity and respect and have not observed staff treating residents disrespectfully. During telephone interview with Clinical Program Manager for R1 informed LPA: not having concerns with how staff treat residents and R1 as they’ve observed staff treat residents with dignity and respect, facility is diligent, clean space, and knowledgeable. Regarding Allegation: Staff are retaliating against resident. LPA Calderon interviewed staff Assistant Administrator, S1-S4, staff denied above allegation stating they do not retaliate, and they respect and treat residents the same, staff talk calm and talk with residents. LPA interviewed R2-R5 and R7 denied the above allegation and informed LPA Calderon staff do not retaliate against them or other residents. During telephone interview with Clinical Program Manager for R1 informed LPA staff does not retaliate against R1. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted and a copy of this report was provided to Alexander Solorio/Assistant Administratorthe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 28-AS-20230324105203

Type of visit: Office

Present during this meeting were Licensing Program Manager (LPM) Fernando Fierros, David Sicairos, and Former Caseload Licensing Program Analyst (LPA) Ashley Calderon conducted an announced informal meeting at Monterey Park Adult and Senior Care Regional Office. Present from Pasadena Villa Senior Living was Licensee/ Eyal Shtorch and Assistant Administrator / Alexander Solorio. The following items listed below were discussed during today's meeting: High Volume of complaints reported to CCL since licensed. Discussed appropriate placement for residents in care. Number of in-house Residents from Department of Health (DHS): 30 residents Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility Licensee agrees to participate in the Technical Support Program (TSP) referral will be submitted by Licensing , TSP: CCL program assisting with free service in assisting facilities with facility issues/concerns. Facility will conduct a Resident meetings to discuss with residents when it is appropriate to call 911. Facility will submit plan by 10-31-23 to ensure staff are being trained to communicate with residents and working with residents to resolve issues in house. Discuss Three (3) Day versus Thirty (30) day eviction procedures and Illegal Eviction Discussed Substantiated complaints 2021/ 2022 / 2023. Continuation 809-C... Change of Administration -CCL waiting hard copy of Board of Resolution Letter, to be submitted to LPA Calderon by 10/27/23. Topics covered: Personal Rights 87486, Personal Accommodations and Services 87307, 87618 Oxygen Administration, Reporting Requirements 87211, Maintenance and Operations 87303, Incidental Medical and Dental Care 87465, Postural Supports 87608, Night Supervision 87415, Eviction Procedures 87224, Basic Services 87464, Criminal Record Clearance 87355, Personnel Requirements- General 87411, Managed Incontinence 87625, Additional Person Rights of Residents in Privacy Operated Facilities 87468.2, and 87468.1 Personal Rights of Residents in All Facilities An exit interview was conducted with Licensee/ Eyal Shtorch and Assistant Administrator / Alexander Solorio, a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2023

Allegation investigated: Staff not assisting resident with medications.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced visit at the facility for the purpose of investigating the above-mentioned allegation. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose for the visit. During the initial visit on 9/29/2020, Licensing Program Analyst (LPA) Renee Arterberry conducted an unannounced 24 Hour Health and Wellness Check telephonically and virtually (via FaceTime) with Alexander Solorio facility administrator and facility nurse Marisol Cruz, employees of the facility. LPA Arterberry interviewed S1-S2, reviewed the facility file for R1, obtained copies of the following documents: Identification Page/Face Sheet, Pre-Appraisal Assessment, Medication Administration Record (MAR), Admission Agreement, Medical Assessment, Unusual Incident Reports (SIR) and hospice documents. LPA Arterberry also toured the physical plant: kitchen, dining room, and medication room. During the subsequent visit on 2/17/2023, Licensing Program Analyst (LPA) Bennette Pena conducted a tour of the physical plant and obtained copies of the following documents: current resident/staff roster and R1's files such as: Face sheet, Physician's Report, Admission's Agreement, Resident Appraisal, Hospice Health Information, Incident Reports and Medication Administration Records (MARs) for Aug 2020-Oct 2020. LPA also interviewed Resident #2 (R2) - Resident #6 (R6), Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and telephonically interviewed Staff #2 (S2). During the 2nd subsequent visit on 3/10/2023, Licensing Program Analyst (LPA) Bennette Pena obtained additional documents for R1 such as: National Rehab Center Discharge Instructions (dated 8/11/2020), Plan of Care (POC) Summaries (dated 9/09/2020, 9/24/2020), Physician’s medication order (dated 10/02/2020) and Huntington Hospital Discharge Instructions (dated 10/02/2020). During today's visit, LPA Bennette Pena obtained the staff & resident rosters and conducted a facility tour of the common areas. *****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Regarding allegation: "Staff not assisting resident with medications." It is alleged that the last time the resident received his medication was two days prior to being admitted at the hospital. And the resident alleged that the staff does not check on the resident enough and that he has been in pain for eight days and constipated for three. Based on documents reviewed, R1 was admitted at Huntington Hospital on 9/23/2020 complaining of severe abdominal pain and was diagnosed of pneumonia and renal failure. R1 was assessed by EMS and observed rigidity, pain, distension and tenderness in all four quadrants. On 9/20/2020, R1 complained to staff of having pain related to his catheter and the staff gave R1 medication. Staff indicated that they emptied R1's urine bag but did not document how much nor how the urine looked. LPA reviewed R1's Medication Administration Record (MAR) for Sep. 2020 which indicated that no pain medication was given to R1 except on the evening of 9/20/2020 for moderate to severe pain and in the afternoon on 9/21/2020. On 9/22/2020, the staff indicated that R1's stool was normal and R1 appeared lethargic but noted to have irregular heart rate. However, there was no evidence that the staff re-checked R1 if the pain medication was effective and no evidence that the foley catheter and urine was checked. Reviews of the documents revealed that the facility did not properly monitor the resident who started to deteriorate on 9/20/2020 and did not provide the available medications to R1 to help alleviate his fever on 9/22/2020 and R1's pain. Additionally, based on the records reviewed, the facility did not properly care for R1's foley catheter as there was no documentation that the instruction for catheter irrigation was followed by staff. The facility did not properly care for R1 when the last foley catheter placement was 10 days prior to being admitted to the hospital. Documents showed that this was not performed by the hospice skilled nurse as the last foley catheter change/insertion by hospice was 8/25/2020. Interview with a staff indicated that a NOC shift caregiver pulled out the catheter and pushed it back in while providing care. Other staff interviewed indicated that they were also aware of it. Therefore, there was enough supportive evidence to corroborate the allegation. Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 28-AS-20200925154403

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Oct 11, 2023

87465 Incidental Medical and Dental Care...(c) ...resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2)..the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for Sep. 2020, no medication was given to R1 to help alleviate his severe pain and fever except on 9/20/2020 and 9/21/2020 only which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 10, 2023

Plan of correction: Administrator will submit an effective and written plan to ensure residents receive their medication as prescribed by their Physicians. The written plan will be submitted to CCL/LPA by POC due date.

Allegation investigated: Resident in care was assaulted by unknown individual in the facility.

Licensing Program Analys (LPA) V. Maldonado made a subsequent unannounced visit at the facility for the purpose of continuing the investigtion regarding the above-mentioned allegation. LPA Maldonado met with Assistant Administrator Alex Solorio and explained the purpose for the visit. On 8/17/23, LPA Maldonado made an initial complaint visit and obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Needs and Services Plan, incident reports for July-August 2023, and police reports- if any. LPA also requested to review surveillence video footage for the night of 08/08/23, but was unable to due to time contraints. LPA also interviewed Staff# 1 (S1). During today's visit, LPA conducted interviews with Residents# 2-7 (R1-R7) and Staff# 1-3 (S1-S3). LPA was unable to interview R1 due to R1 being out of the community during the visit. No additional contact information for R1 was avilable for LPA to attempt a telephone interview. (Report continued on LIC9099-C...) Unsubstantiated The investigation revealed the following: Regarding allegation: Resident in care was assaulted by unknown individual in the facility. It is alleged that on Sunday, August 8, 2023 at about 10PM, R1 was using the phone in the staff area and was confronted by a staff named Salvador, who yelled at and hit R1 with two closed fists to the chest, for being in a restricted area. After review of R1’s Physician’s Report, dated: 1/24/23, it was discovered that R1 has an altered mental status and has a history of substance abuse. Per R1's Needs and Serviced Plan, dated: 2/17/23, R1 has frequent outbursts towards other residents and staff due to exhibits of paranoia. It is also noted that R1 is normally alert and oriented, but appears to be disoriented and confused at times due to substance abuse. Per interviews conducted, (3) of (3) staff stated that R1 called the police to report the alleged incident. The police came and investigated the incident with S1, however, it was discovered that there are no staff working at the facility by that name. The police and staff also confirmed through review of surveillance footage that R1 was never in the area during the time R1 stated to have been, when the incident occurred. Per the staff roster, LPA confirmed there is no staff by the name, Salvador. During today's visit, LPA was unable to review surveillance footage for the date of 8/08/23, due to the system keeping footage for the last 30 days only, and no longer available. Per interview with R4, it was stated that R1 told R4 about the incident of staff hitting R1. However, R4 states R4 did not observe any marks on R1 that would indicate R1 was physically assaulted. R4 stated to "personally believe" R1 "hallucinates at times". R1 did not tell R4 who the staff was, where the incident occurred, and when it occurred, but simply stated R1 was hit by a male staff. (4) of (6) residents interviewed could not corroborate the allegation. This allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited. An exit interview was conducted with Assistant Administrator, Alex Solorio, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2023 · control 28-AS-20230810135252

Allegation investigated: Facility placed resident on hospice without meeting criteria. Resident is not receiving care as needed.

***This report supersedes the report dated 08/21/23 to make corrections to the visit date on that report. The visit date for that report should have been 08/25/23 not 08/21/23*** Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 08/17/2023, LPA Mora obtained copies of staff & resident rosters, and interviewed Assistant Administrator, Admission Director, and Resident 1 (R1). LPA also called to interview R1's home health agency, hospice agency, previous skilled nursing facility and placement agency. LPA obtained copies of R1’s face sheet, admission agreement, physician report and hospice care documentation. On 08/25/23, LPA interviewed Resident 1 (R1), Assistant Administrator, Resident Care and Planet Home Health Manager. (Continued to LIC 9099-C) Unsubstantiated The investigation revealed the following: regarding the allegation "facility placed resident on hospice without meeting criteria", it is alleged that R1 does not meet hospice criteria and facility placed R1 on hospice. Facility denied the allegation stated that they had nothing to do with R1’s hospice admission. They also stated that when R1 arrived at the facility R1 already had a hospice referral. The placement agency representative that assisted the resident in finding this facility stated that they provided R1 the contact information of a hospice agency due to R1 being unhappy with the home health services, and that R1 made the decision to be admitted to hospice services and the facility had nothing to do with it. Review of hospice agency documentation shows that R1 signed the Hospice Admission Service Agreement on 08/03/2023. R1 is self-responsible and has no conservatorship. R1 was not able to provide much details that could assist with this investigation. R1 was confused about the whole situation and did not remembered signing the hospice documents or who talked to R1 about signing up to hospice. Regarding the allegation "resident is not receiving care as needed", it is alleged that R1 was discharged from a skilled nursing with a doctor's order for R1 to receive wound care services from a home health agency and since facility placed R1 on hospice the resident is not receiving this service. Facility denied the allegation stated that R1 was receiving wound care services from home health and they have came to the facility on 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/12/2023, and 08/14/2023 per their sign-in sheet. However, once it was confirmed that R1 was on both hospice and home health, the home health agency discharged R1 and the hospice agency took over and provided the wound care services. Interview with Planet Home Health Manager on 08/17/23 confirmed this information. During 08/25/23 visit, Resident Care told LPA that R1 is back on home health and per their sign-in sheet they started coming as of 08/21/2023. LPA contacted the Planet Home Health Manager to confirm and the Planet Home Health Manager confirmed that R1 is back on home health and will be seen daily. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Sep 14, 2023 · control 28-AS-20230811103641

Allegation investigated: Staff did not comply with an infection control practice resulting in a H&S risk

Licensing Program Analyst (LPA) Ashley Calderon conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit. On today's visit, LPA collected resident and staff roster. Collected Mass testing results for staff and residents, staff in-service training roster conducted and materials regarding covid. LPA collected up coming flyer regarding in-service on covid policies and procedures. LPA collected Special Incident Reports regarding covid residents/ exposures and facility line list. LPA toured random residents rooms: 3,7,14,24,and 39. Along side Assistant Administrator LPA observed storage rooms that have sufficient ppe supplies and LPA observed ppe carts. LPA interview Residents #1-7 (R1-R7) and staff, Assistant Administrator and Staff #1-#5 (S1-S5). (Continuation on 9099-C...) Unsubstantiated Regarding allegation: Staff did not comply with an infection control practice resulting in a H&S risk. Investigation revealed based on staff interviews with Assistant Administrator and Staff (S1-S5) all denied the above allegation, staff stated facility is following infection control policies and procedures, are cleaning and disinfecting rooms and common areas, wearing masks and encourage residents to follow covid policies. 6 out of 6 interviewed staff stated residents are not at a health and safety risks due to facility following covid practices. Interviews with residents R1-R7 all denied the above facility stating facility is not putting residents at a health and safety risk and are regularly cleaning and following covid policies and facility are following infection control practices. 4 out of 7 residents stated during interviews that staff encourage/ notify residents to follow covid practices like wearing masks and wash hands. LPA reviewed in-service training for staff scheduled with professional nurse/ Infection Preventionist on 9/15/23 regarding covid policies, training is conducted annually stated on Infection Control Plan LIC 9282. LPA reviewed in-service training roster/ material for dates 8/2/22 and 8/30/23. LPA reviewed infection control plan that has been updated and previously submitted to Licensing. LPA observed the facility is following infection control plan and Pasadena Public Health Guidelines based on interviews, observations and record review. LPA observed and toured random residents rooms: 3,7,14,24,and 39 all contained soap, hand sanitizers available for residents in hallways, and LPA observed covid signs in hallways, common areas and residents restrooms for covid precautions throughout the facility. LPA observed sufficient ppe supplies in storage closets and ppe bins containing disinfectant spray, gowns, gloves, masks, eye protection wear, booties, and hair nets. LPA toured facility, facility was observed clean. LPA reviewed Special Incident Reports (SIRs) regarding covid, facility is taking action using covid precautions and are following covid procedures and policies, based on SIRs facility is reporting to the proper agencies like public health and licensing, are reminding residents on covid policies and procedures and are providing residents with medical help when needed. LPA did not observe a health and safety risk based on observation, interviews and record review. LPA was provided a line list, during time of visit there were 0 covid cases at the facility, therefore, based on interviews, record review and observations there was insufficient evidence to corroborate with this allegation. Based on LPA's interviews, observations and record review investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided via email due to printer issues..the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 28-AS-20230906093033

Allegation investigated: Resident call buttons are in disrepair

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Carin Mendoza, Assistant administrator arrived 5 minutes later and explained the reason of the visit. The investigation consisted of the following: LPA Flores requested copies of resident/staff roster, conducted a tour of the facility's kitchen, observed 7 resident rooms and tested call buttons in rooms #12,14, and 3. LPA interviewed Residents #1-7(R1-R7) and staff #1-5(S1-S5). LPA requested copies of menu for 4 weeks, physician's report, resident information/care plan, and needs and care plan for 7 residents and incident report dated 8/23/23 and 9/12/23. The investigation revealed the following: Regarding allegation: Resident call buttons are in disrepair. It is alleged call buttons are broken. (CONTINUED ON LIC 9099C) Substantiated Interviews with 4 out of 7 residents revealed they did not have a call button in their room and were not able to provide a reason to not having one. 3 out of 7 residents interviewed revealed to have a working call button and staff respond to the call button. Interviews with staff revealed residents should or have a call button in their rooms. Interview with assistant administrator revealed that some call buttons have been in disrepair or residents have lost them and the facility is going through the process of repairing/replacing them as they were not aware. Based on LPAs observations and interviews which were conducted, 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. Exit interview was conducted with Alexander Solorio Assistant Administrator and a copy of this report, LIC 9099D, and appeal rights were provided. Interviews with 3 out of 7 residents revealed that residents usually scream to call the staff and they do not come right away. 3 out of 7 residents stated that when they use the call button staff come to assist them. 1 out of 7 residents stated to not be able to use the button and prefers to use cellphone and staff do not respond. Interviews with staff revealed staff respond to residents' calls. During the facility tour LPA Flores tested the call buttons in 3 resident rooms. Staff responded to the calls within one minute each time and ask the resident if they can assist them. 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. Regarding allegations: Staff are not providing adequate food service to residents and Staff are not meeting resident's dietary needs. It is alleged that the food is substandard and not nutritional and resident who is diabetic was told to make own diabetic menu. Interviews with 5 out of 7 residents revealed facility provides all nutritional items. 2 out of the 5 residents stated even if the food is bad, or does not provide alternatives facility provides a nutritional meal. 2 out of 7 residents interviewed stated the food does not meet nutritional guidelines or facility does not follow special diet guidelines. Interviews with staff revealed kitchen staff follow menus and recipes to prepare meals for all residents and for those with special diets. Staff stated plates are label with residents names for those with special diets. During facility's kitchen tour LPA observed special diet list board and residents needs and care plan posted in the kitchen's wall. Food store in refrigerators and pantry was observed to be a variety of fresh fruits and vegetables, frozen vegetables, proteins,sufficient grains and breads. Document review revealed 2 out of 7 residents had a special diet per physician's report and resident's information/care plan for each note food pref./diet for facility's care to be provided for those two residents. Menus have a variety of food items which provide a protein, a carbohydrate, vegetables/fruits in each meal and an alternative menu sheet is available for residents to choose from. 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. Regarding allegation: Staff did not prevent resident from engaging in inappropriate behaviors. It is alleged resident who was COVID 19 positive was yelling, “Don’t tell me what to do!” while staff were trying to get him to his room and another resident had flip tables in the dining room. (CONTINUED ON LIC 9099C) Interviews with 2 out of 7 residents revealed staff intervene when they observed residents having behaviors, 2 out of 7 residents stated to not have observed any disruptive behaviors in the facility, 2 out of 7 residents stated behaviors have happened and staff have not stopped it, and 1 out of 7 residents was unable to answer as assistance with care was to be provided at that time. Interviews with staff revealed incident of resident with COVID 19 did occur. However, the resident was being redirected to the room to quarantine. Regarding the other resident flipping the table they stated resident got impatience waiting for the food to be served, however the staff was present and are always around to assist or redirect. Document review revealed on 8/23/23 and incident report was submitted to the department noting incident of resident becoming inpatient and breaking dining room furniture. Facility created has a plan in place for that resident. Incident report dated 9/12/23 address the incident of resident with COVID in which notes staff redirected resident to the 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. Regarding allegation: Staff are not meeting residents' needs. It is alleged resident yells for hours for help or water. Interviews with 4 out of 7 residents revealed staff provide assistance when needed and or are meeting their needs. 3 out of 7 residents stated to not being provided assistance when needed and have to wait for hours to be care for. Interviews with staff revealed staff respond promptly to residents calls and or needs and are aware of the residents needs upon admission or returning from the hospital. Assistant administrator stated that for residents with more needs staff have a chart to track every time they are providing care. During facility's tour LPA observed a chart in room #40 which noted on 9/12/22 staff provided water to the resident at 8:00am and 9:17am. Document review revealed each resident has a current needs and service care plan in place. 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. Exit interview was conducted with Alexander Solorio Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 28-AS-20230906112519

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Sep 19, 2023

87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... buildings shall have a signal system which shall: This requirement is not met as evidence by: Based on observation and interviews licensee failed to ensure residents had a signal system in place which poses a potential risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Sep 12, 2023

Plan of correction: Administrator will provide a working call button to each resident and will submit plan to replace or maintain call buttons to the department by POC due date 9/19/23.

Allegation investigated: Staff did not provide adequate supervision resulting in resident eloping from facility

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Assistant Administrator Alexander Solorio, Staff 1-3 (S1-3) and Residents 1-7 (R1-7). R7 was not interviewed as resident was not at the facility at the time of the visit. LPA collected copies of Staff and Resident Rosters. LPA reviewed R7's facility file and collected copies of documents relevant to the investigation. LPA also collected a copy of Unusual Incident/ Injury Report dated 09/07/23 and Facility Sign Out Sheet for dates 09/02/23 - 09/12/23. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff did not provide adequate supervision resulting in resident eloping from facility, it is alleged that on 09/05/23 at approximately 8am, a resident left the facility on their own and did not advise facility staff where they were going and has not returned since. Interviews conducted with Assistant Administrator and S1-3 revealed that there is always enough staff on schedule everyday to provide adequate supervision for facility residents. Staff stated that there are many residents that are able to leave the facility unassisted and they just have to sign in and out. Interview conducted with Assistant Administrator revealed that R7 recently moved into the facility and is able to leave the facility unassisted. He stated that R7 did leave the facility on 09/05/23 and did not inform any staff. He stated that staff made the appropriate reports to CCLD, LTCO and Pasadena Police Department. Assistant Administrator stated that he also submitted the SOC341 as this resident had not left the facility before without first signing out. He stated that R7 did return to the facility on 09/08/23 and reported to staff that they had been visiting with family. LPA also reviewed Unusual Incident/ Injury Report dated 9/07/23 which is reporting the above referenced incident and notifying CCLD of what occurred. Assistant Administrator denied that the facility does not provide adequate supervision. He stated that he always ensures that the facility is fully staffed to provide proper care and supervision to facility residents. He stated that there is always someone in the front desk as that is where residents have to go when exiting the facility. Interviews conducted with 6 out of 7 residents revealed that they believe there are enough staff on schedule to provide adequate supervision. R7 was not interviewed as they were not at the facility during the visit. During the time of the visit, LPA observed that there were enough staff on schedule. LPA reviewed R7's Physician's Report for Residential Care Facilities for the Elderly (RCFE) and observed that R7 is able to leave the facility unassisted. LPA also observed that the proper reporting was done by facility staff as well as proper follow up calls upon resident's return to the facility. LPA reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and care for the residents in placement. LPA additionally reviewed Resident Sign out sheet and observed that R7 signed out on 09/12/23. Based on statements gathered from interviews conducted with staff, residents and LPA review of documents, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 28-AS-20230908142831

Allegation investigated: Facility staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Ashley Calderon conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit. On today's visit, LPA collected resident and staff roster. Collected Resident #1 (R1) Physician Report, Face sheet, Appraisal Needs and Service Plan and Admission Agreement. LPA collected R1-R8's client/resident personal and valuables (LIC 621) and Pasadena Villa Senior Living Policy and Procedures regarding Theft and Loss Prevention. LPA toured random rooms of residents rooms: 3,8,14,21,22,24,29 and 31. LPA interview Residents #1-8 (R1-R8) and staff, Assistant Administrator and Staff #1-#4 (S1-S4). LPA interviewed an Officer from the Pasadena Police Department who was present during LPA's visit, incident number provided: #23-72282. (Continuation on 9099-C...) Unsubstantiated Regarding Allegation: Facility staff did not safeguard resident's personal belongings. LPA interviewed staff Assistant Administrator, and Staff, S1-S4 during interviews with staff the following was revealed: Staff denied facility not safeguarding residents belongings. Assistant Administrator ,S1-S3 stated facility has a locked space in the front office if resident's choose to have their personal items inventoried. Interviews with Assistant Administrator and S1-S4 stated facility assist residents if and when things are misplaced, stolen or missing and resident's have their own space for personal belongings. LPA interview with Assistant Administrator and S2-S4 stated facility has camera footage to review if resident(s) has a concern regarding personal belongings. LPA interview with residents revealed: R1-R8 denied the above allegation regarding facility not safeguarding resident's personal belongings. 8 out of 8 residents stating their belongings are safeguarded at the facility. R1 during interview revealed not being certain if their roommate steals their monies and did not have an issue with facility not safeguarding R1's personal belongings. LPA interview Officer from Pasadena Police Department, officer was investigating the allegation listed above. Officer from Pasadena Police Department stated speaking to R1 and R1 stated there wasn't any issue with R1's roommate or no issues with facility not safeguarding resident's personal belongings including monies. LPA reviewed residents inventory list and facilities Policy and Procedures regarding Theft and Loss prevention that is located in the facility Admission Agreement and provided to each resident upon admission. LPA reviewed facilities Policy and Procedures regarding Theft and Loss prevention for the following residents R1-R8, showing residents denied having their personal items inventoried. LPA Calderon observed random rooms of residents and observed each resident having adequate / required furniture per Title 22 for personal belongings. LPA observed front office having a secured space for safeguarding resident's belongings if a resident choices for personal items to be inventoried. Therefore, based on interviews, record review and observations there was insufficient evidence to corroborate with this allegation. Based on LPA's interviews, observations and record review investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 28-AS-20230825140302

Allegation investigated: Staff did not provide medical attention to resident. Staff refused to provide resident breakfast. Staff did not provide resident with a towel to shower. Staff does not treat resident with respect and dignity. Staff took resident’s debit card.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegations listed above. LPA met with Assistant Administrator, Alex Solorio, and explained the reason for the visit. On 7/21/23, LPA conducted the initial visit and obtained copies of the staff roster, resident roster, and documents pertaining to Resident #1 (R-1). LPA also interviewed the Assistant Administrator and 4 Staff today. During the visit today, LPA interviewed 9 Residents. The investigation revealed the following: Allegation - Staff did not provide medical attention to resident. It was alleged that Resident #1 (R-1) had bruises and scratch marks that R-1 felt needed to be treated, however, staff did not provide an answer. Unsubstantiated LPA interviewed 5 Staff, and all denied not providing medical attention to anyone who needs it. They stated that in R-1’s situation, they would notice R-1 returning to the facility with scratch marks and bruises. Per staff, they are sometimes able to provide first aide to clean the marks and often times, R-1 refuses any medical attention or assistance from staff. LPA interviewed 9 Residents and all reported that staff provide medical attention when necessary. Allegation - Staff refused to provide resident breakfast. Per staff interviewed, residents are served 3 meals a day plus snacks. Breakfast is normally served between 8 – 9am. If a resident requests a plate after the breakfast hours, they would offer an alternative since the kitchen staff are preparing for lunch. Staff will try their best to accommodate residents when they request for food and would never allow them to be hungry. Interviews with residents revealed that they are served 3 meals a day and provided with snacks. Some stated they eat before going out in the mornings. Some also stated they choose to eat out because they do not like the selection and not because they are not denied food. Allegation - Staff did not provide resident with a towel to shower. Per Staff, the residents are provided with 2 towels and washcloths a week for showers and are replaced weekly. If a resident requests for more towels, the staff will provide to them. During the visit today, LPA observed new bath towels that were recently purchased. LPA interviewed 9 residents and 8 of them stated that staff will provide towels for showers and will get extra upon request. Allegation - Staff do not treat resident with respect and dignity. Staff interviewed stated that they show dignity and respect to residents. They are careful with the things they say and will explain to residents calmly when situations arise. They listen to resident concerns and will address the matter. Staff stated sometimes they need to be firm with residents but not done in a way to disrespect them. LPA interviewed 9 residents, and none felt mistreated. They stated that staff are respectful and show dignity. They do not have any concerns with staff treatment. (Continue on LIC9099C) Allegation - Staff took resident’s debit card. It was alleged that staff took Resident #1’s (R-1) debit card and then returned it a few days later. Per interview with the Assistant Administrator (AA), R-1 had lost the debit card multiple times and offered to keep the card in the office starting in July 2023. R-1 accepted the offer and AA kept the card in the office safe. Nobody had access to it besides AA. AA stated that when R-1 wanted money, resident came to the front and request for the card. The card was provided upon request. Per AA, after this incident, they started having R-1 sign in and out when the debit card is taken. Staff interviewed denied ever taking a debit card from any resident room. Staff stated that if they see a card on the floor, they will return it to the resident right away. 8 out of 9 interviews with the residents indicated that staff have never taken any debit or credit cards from them. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Alex Solorio. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 28-AS-20230717153428

Allegation investigated: Staff left resident soiled for an extended period of time. Staff do not provide quality food to residents. Staff do not assist with resident's showering needs. Staff do not provide resident with clean clothing. Staff do not provide resident with clean linen. Resident's call button is in disrepair. Staff do not respond to resident's call button. Resident's urine container is not properly disposed. Staff do not treat resident with dignity or respect.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 11/03/2022, LPA obtained copies of staff & resident rosters, interviewed Assistant Administrator, Resident 2 - Resident 7 (R2-R7) and toured the facility kitchen and R1-R7 bedrooms. Resident 1 (R1) was admitted at a hospital on 10/18/22 and was not available for an interview. LPA also requested R1's admission agreement, appraisal/needs and service plan, pre-appraisal, physician report, functional capability assessment, resident appraisal and a copy of a text message regarding R1. During today's visit, LPA toured the kitchen, facility and 3 resident bedrooms, and interviewed Staff 2 - Staff 3 (S2 - S3). During today's visit, LPA was informed that R1 no longer resides at this facility as of 11/24/2022 and S1 is no longer working at this facility as of 03/06/2023. (Continued to LIC 9099-C) Unsubstantiated The investigation revealed the following: Regarding the allegation "staff left resident soiled for an extended period of time", it is alleged that on 09/06/2022, R1 had a bowel movement and requested assistance from S1 to get changed, but S1 refused to assist R1 and R1 had to wait until 2am to be changed by S2. Assistant Administrator stated this incident was never brought up to his attention by R1. S2 denied the allegation. Residents interviewed could not corroborate the allegation. There were 3 residents that stated they have never soiled themselves, but believed that staff would provide timely assistance. The other 3 residents stated that they have soiled themselves in the past and staff provided timely assistance. Regarding the allegation "staff do not provide quality food to residents", it is alleged that the food at the facility tastes and looks like cat food. Facility denied the allegation and stated they follow a dietician's recipe to prepare good quality food. Residents interviewed could not corroborate the allegation. During the tour of the kitchen on 11/03/2022 and today, LPA observed that the food had good presentation. Regarding the allegation "staff do not assist with resident's showering needs", it is alleged that R1 did not received the scheduled shower on 09/02/2022. Assistant Administrator stated that R1 did not received his scheduled shower on that day because R1 was not at the facility. There is text message dated 09/04/2023 between Assistant Administrator and a staff where the staff texted the Assistant Administrator that R1 was not in the facility on 09/02/2022. Residents interviewed could not corroborate the allegation and expressed no concerns. Regarding the allegation "staff do not provide resident with clean clothing", it is alleged that R1 is not getting assistance with changing clothes. Assistant Administrator and staff denied the allegation. They stated that R1 was offered a change of clothes every morning. Residents interviewed could not corroborate the allegation and expressed no concerns. Regarding the allegation "staff do not provide resident with clean linen", it is alleged that R1's bed sheets are supposed to be changed twice per week, however that does not happen. Assistant Administrator and staff denied the allegation and stated that bed sheets are changed once a week or as needed. Residents interviewed could not corroborate the allegation and expressed no concerns. (Continued to LIC 9099-C) Regarding the allegations "resident's call button is in disrepair" and "staff do not respond to resident's call button, it is alleged that R1's call light button either does not work or staff do not respond. Assistant Administrator and staff interviewed stated that R1 did not report any issues with the call light button. They also stated that staff do respond to all call light request in a timely manner, usually within 10 minutes. Residents interviewed could not corroborate the allegation and stated that staff show up quickly, right away or within 10 minutes. Regarding the allegation "resident's urine container is not properly disposed", it is alleged that R1's urinal container on the side of resident's bed is not emptied in a timely manner. Assistant Administrator and staff denied the allegation and stated that those containers are emptied as needed. Facility does not have many residents that use a urine container. During the 11/03/2022 visit, LPA interviewed 2 residents that use it and they expressed no concerns, and observed that their urine containers were empty and cleaned. During today's visit, LPA walked into 3 resident bedrooms that use the urine containers and observed that the containers were emptied and cleaned. Regarding the allegation "staff do not treat resident with dignity or respect", it is alleged that when R1 request for assistance with care and housekeeping duties, the staff respond with an attitude. Staff denied the allegation and stated that all residents are treated with respect. Residents interviewed could not corroborate the allegation and expressed no concerns. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Aug 25, 2023 · control 28-AS-20221028165455

Allegation investigated: Facility is not kept clean. Facility does not have an adequate supply of hygiene items. Facility staff were not notified of resident's dietary restrictions. Facility staff are not keeping accurate resident records. Facility is not providing residents with a good quantity of food. Facility is not providing residents with a good quality of food. Facility staff are not properly trained. Facility staff are not using universal precautions when changing resident's diapers.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit investigate the above allegations. Upon arriving at the facility, LPA met with Assistant Administrator - Alex Solorio and the purpose of today’s visit was explained. The investigation consisted of the following: LPA Joe Katrdzhyan conducted the initial complaint investigation on 01/28/2021 for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the investigation was conducted telephonically and due to insufficient information available at the time further investigation was needed. LPA Tena Herrera conducted a subsequent on 8/24/23. LPA obtained a copy of the Staff/Resident rosters, suggestion form and the food menu, toured the facility with Staff #1, interviewed Staff #1 to #8, reviewed 11 (Continued on 9099-C) Unsubstantiated resident files and 4 staff files. Due to time constraints and insufficient information available at the time investigation further investigation was needed. During todays subsequent on 8/25/23 visit LPA interviewed 8 Residents and reviewed 6 Staff files. The investigation revealed the following: Allegation: Facility is not kept clean. It is alleged that the facility "was not clean in any sense", there is no staff assigned with cleaning the facility, all trash cans were overflowing, and "all the rooms are not kept well in any way". During the tour of the facility LPA entered 10 rooms and all trash cans in rooms and restrooms visited were observed to be empty or with little trash. The housekeepers were making there rounds while tour was conducted and LPA observed them to be emptying the trash cans, sweeping, and cleaning the restrooms. Rooms appeared to be clean and sanitary. LPA reviewed the housekeeping schedule and there is an itinerary with assigned cleaning duties throughout the day/week. LPA conducted 8 staff interviews, 8 out of 8 staff stated that the facility is cleaned regularly and there are housekeepers assigned with cleaning duties. LPA conducted 8 resident interviews, 7 out of 8 residents denied the above allegation and stated that the facility is cleaned regularly and their trash is taken out 2 times a day. Allegation: Facility does not have an adequate supply of hygiene items. It is alleged that there was no toilet paper available for the residents. During tour of the facility LPA observed 10 resident restrooms and saw that there was sufficient amount of toilet paper readily available for residents, there was one on the spool along with one more roll on counter in each of the restrooms. LPA observed housekeepers while cleaning restroom and saw that the toilet paper was being replenished during their rounds. LPA checked the stock room for supply of toiletries and there was a sufficient amount available. Interviews conducted with staff revealed that residents are able to ask for toilet paper if they run out or are low and a surplus stock is kept at front office in the case that a resident is in need. LPA interviewed residents 8 out of 8 residents deny the above allegation and stated that they always have sufficient supply of toiletries and if they are ever in need they ask housekeeping or front staff for more and it is provided to them without any issues. (Continued on 9099-C) Allegation: Facility staff were not notified of resident's dietary restrictions. It is alleged that when staff passed out food for breakfast and lunch, they were not made aware of any of the resident's allergies or food restrictions. During facility tour LPA observed the kitchen and list of individuals with special diets or allergies was posted on a pegboard. This list had a photo of the individual, along with name and what their dietary restrictions are. LPA observed the foods prepared for the individuals with these special diets and they are individually wrapped with their names on the plates, LPA asked kitchen staff and staff assisting with serving meals if they knew who these meals go to and each were able to identify the correct resident. During interviews with staff who work in the kitchen 2 out of 2 staff stated that they are aware of the residents who are on special diets and prepare the meals to meet the needs of their doctors orders, interviews also revealed that staff are trained on which residents have food restrictions and information is posted within the kitchen for all employees who assist in serving to see. LPA interviewed 8 residents of the 8 residents 2 were on special diets and stated that they do get their meals that meet their doctors orders and meals come wrapped with their names on it. Allegation: Facility staff are not keeping accurate resident records. It is alleged that facility staff are not accurately updating residents’ files and that "no one documents anything". LPA reviewed 11 resident files, 11 out of 11 files reviewed were up to date with Physician Reports that were updated yearly. The initial appraisals were in each file with reappraisals for the individuals who have had a change in condition. During interviews with staff 2 out of 8 staff update resident files and both stated that the Physicians Reports are updated yearly and there is a calendar that has a reminder of which resident is due for their yearly assessment. Although most residents at the facility are independent, the facility does try to upkeep their files with any doctor visits the residents schedule themselves with. However, sometimes that information is not given to the facility, therefore, to ensure the residents needs are being met the facility has Physician Reports updated annually. Allegations: Facility is not providing residents with a good quantity and quality of food. It is alleged that the residents are not provided with an adequate amount of food. LPA toured kitchen and food supply for perishables and nonperishable was sufficient to meet the needs of the residents. During tour LPA observed the meal served for the day and lunch consisted of rice, vegetables, chicken, garlic bread and 3 drink choices. LPA observed the weekly/monthly food menu and alternative food menu and all seemed to have a variety of foods and deserts. LPA interviewed 8 residents, 8 out of 8 residents denied the allegation and stated that although the food could be of better taste to accommodate(Continued on 9099-C) their personal preference they feel the food is decent and are given seconds when asked. Residents also stated that snacks are provided 2 times a day or when they ask. Allegation: Facility staff are not properly trained. It is alleged that staff does not appear to be properly trained as they do not appear to be comfortable when changing resident's diapers. LPA reviewed 6 staff files, 6 out of 6 files had the staffs initial training documented along with continuous training that's done yearly. Within the training for the caregivers that provide assistance with incontinence care there is a section covered that is specific with assisting the resident with toileting. LPA conducted 8 staff interviews, 4 out of the 8 staff assist residents directly and confirmed that they are provided training at hire, yearly and there are several in house training's conducted regularly. LPA interviewed 8 residents and 7 out of 8 residents denied the above allegation and stated that they feel the staff that assist them are properly trained and seem to know how to handle residents properly. Of the 8 residents 2 confirmed they have incontinence care and feel comfortable with the staff that assist with changing and feel they are trained and professional when doing so. Allegation: Facility staff are not using universal precautions when changing resident's diapers. It is alleged that staff is not changing gloves or washing hands after changing resident's diapers. During tour LPA observed sufficient supply of gloves for staff. LPA interviewed staff 3 out of 8 staff either assist with incontinence care or are trained to be able to assist all 3 staff stated that their procedure when assisting with incontinence care they first put on gloves (some double glove) and when finished assisting they dispose of gloves immediately, wash hands and put on a new pair if other care is needed. Staff stated that they never use the same pair of gloves on multiple residents. Upon interviewing residents with incontinence care 2 out of 2 residents confirmed that the staff switch out their gloves after care is provided. Upon reviewing the training on toileting, staff are trained to use a new pair of gloves before assisting resident and dispose gloves, then wash hands after care is provided. Based on statements and interviews conducted with staff and residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Assistant Administrator Alex Solorio.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 28-AS-20210119112942

Allegation investigated: Facility placed resident on hospice without meeting criteria. Resident is not receiving care as needed.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit regarding the above allegations. LPA met with Alexander Solorio (Assistant Administrator) and explained the reason for the visit. The investigation consisted of the following: On 08/17/2023, LPA Mora obtained copies of staff & resident rosters, and interviewed Assistant Administrator, Admission Director, and Resident 1 (R1). LPA also called to interview R1's home health agency, hospice agency, previous skilled nursing facility and placement agency. LPA obtained copies of R1’s face sheet, admission agreement, physician report and hospice care documentation. Today's visit, LPA interviewed Resident 1 (R1), Assistant Administrator, Resident Care and Planet Home Health Manager. The investigation revealed the following: regarding the allegation "facility placed resident on hospice without meeting criteria", it is alleged that R1 does not meet hospice criteria and facility placed R1 on hospice. Facility denied the allegation stated that they had nothing to do with R1’s hospice admission. (Continued to LIC 9099-C) Unsubstantiated They also stated that when R1 arrived at the facility R1 already had a hospice referral. The placement agency representative that assisted the resident in finding this facility stated that they provided R1 the contact information of a hospice agency due to R1 being unhappy with the home health services, and that R1 made the decision to be admitted to hospice services and the facility had nothing to do with it. Review of hospice agency documentation shows that R1 signed the Hospice Admission Service Agreement on 08/03/2023. R1 is self-responsible and has no conservatorship. R1 was not able to provide much details that could assist with this investigation. R1 was confused about the whole situation and did not remember remembered signing the hospice documents or who talked to R1 about signing up to hospice. Regarding the allegation "resident is not receiving care as needed", it is alleged that R1 was discharged from a skilled nursing with a doctor's order for R1 to receive wound care services from a home health agency and since facility placed R1 on hospice the resident is not receiving this service. Facility denied the allegation stated that R1 was receiving wound care services from home health and they have came to the facility on 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/12/2023, and 08/14/2023 per their sign-in sheet. However, once it was confirmed that R1 was on both hospice and home health, the home health agency discharged R1 and the hospice agency took over and provided the wound care services. Interview with Planet Home Health Manager on 08/17/23 confirmed this information. During today's visit, Resident Care told LPA that R1 is back on home health and per their sign-in sheet they started coming as of 08/21/2023. LPA contacted the Planet Home Health Manager to confirm and the Planet Home Health Manager confirmed that R1 is back on home health and will be seen daily. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Aug 21, 2023 · control 28-AS-20230811103641

Allegation investigated: Facility retaliated against resident for filing a complaint. Facility staff did not seek medical attention in a timely manner. Facility staff did not notify resident's authorized representative of a change in resident's condition.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced follow up visit to deliver findings on the above-mentioned allegations. LPA met with Assistant Administrator Alex Solorio and the purpose for the visit was explained. The investigation consisted of the following: LPA's Joe Katrdzhyan and Nune Margaryan conducted the initial visit on 5/21/21, however, due to time constraints and insufficient information available at that time, the above allegations needed further investigation. During todays subsequent visit LPA Herrera obtained copys of Staff and Resident Rosters, C1's Records (Face Sheet, Physician's Report, Appraisal Needs and Services Plan, Admission Agreement, Exit Report, Eviction Notice, Relocation Agreement), interviewed Staff 1-6 (S1-S6) and Residents 1-8 (R1-R8). (Continued on 9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility retaliated against resident for filing a complaint. It is alleged that resident experienced retaliation after filing a complaint through different scenarios that took place thereafter. LPA interviewed 8 residents today and 8 out of 8 residents stated that have not heard of retaliation for filing complaints. Although some feel that some staff could be more kind when dealing with aggressive residents they stated that they haven't experienced retaliation of that sort. LPA's interviews with 6 staff also denied the above allegation and stated that they have not nor have they witnessed another staff retaliate against residents when they file complaints or complain to them personally. The investigation revealed the following: Allegation: Facility staff did not seek medical attention in a timely manner. It is alleged that staff did not seek medical attention in a timely manner for R1 when R1 was found unresponsive by non staff member. It was stated that staff were not "mindful" when asked to call 911. LPA interviewed staff and 5 out of 5 staff stated that when a resident experiences an emergency of that sort, staff will call 911 and a caregiver will stay with resident until paramedics arrive. Staff also stated that rounds are conducted every 2 hours or less depending on the resident needs, some require more frequent checks therefore it may be hourly rounds for those individuals. Interviews with residents, 8 out of 10 residents denied the above allegation and stated that they are given medical attention in a timely manner and see caregivers and staff conducting rounds regularly. The investigation revealed the following: Allegation: Facility staff did not notify resident's authorized representative of a change in resident's condition. It is alleged that R1's responsible party was not contacted when R1 was admitted to the emergency and when responsible party called the staff stated they did not know R1's whereabouts. After file review it was noticed that R1 never had an emergency contact listed and stated responsible party as "self". During interview with S1, staff indicated that R1 never provided an emergency contact and someone did call asking about R1 however, no information could be provided as R1 had not given authorization. S1 stated after this situation they asked R1 if they would like to add an emergency contact but R1 refused. Interviews with residents 8 out of 9 residents denied the above allegation and stated they believe staff will contact responsible party in case of emergencies. Although some residents did confirm they do not have an (Continued on 9099-C) emergency contact listed, therefore, staff would not have anyone to contact. 2 out of the 8 residents that have experienced medical emergencies stated that their responsible parties were contacted with details of their condition. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held with Assistant Administrator Alexander Solorio and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2023 · control 28-AS-20210517095247

Allegation investigated: Facility does not have sufficient night staff to meet the needs of the resident in care. Resident was left for an extended period of time soiled in urine and vomit.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced follow up visit to this facility to assist Licensing Program Analyst (LPA) Joe Katrdzhyan with delivering findings on the above-mentioned allegations. LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted prior visits to this facility on 10/24/22, 6/29/23 and 7/24/23, in reference to the above-mentioned allegations. During the course of the investigation, interviews were conducted with various persons to include the Assistant Administrator, Staff 1 (S1) and Residents 1 – 8 (R1 – R8). LPA was unable to interview S2 as S2 no longer works for the facility and her whereabouts are unknown at this time. Also, copies of the following documents were obtained and reviewed in reference R1: Resident Face Sheet, Physician's Report, Functional Capability Assessment, Preplacement Appraisal Information, Resident Appraisal, Appraisal/Needs and Services Plan, Admission Agreement and Resident Roster. (Continued to LIC 9099-C) Substantiated The investigation revealed the following: Allegations: Facility does not have sufficient night staff to meet the needs of the resident in care & Resident was left for an extended period of time soiled in urine and vomit. The details of these allegations stated that, since 10/07/22, there has been inadequate overnight caregiver coverage, which has led to several hours of a resident laying in bed soiled in urine and sometimes in vomit. Also, residents diapers and soiled beddings are not changed for up 6 hours during the overnight shift. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegations. Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegations to be true. Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights. The investigation revealed the following; Allegation: Facility staff are not meeting resident's hygiene needs while in care. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Staff and residents interviewed stated that residents are given showers twice a week or as needed. Residents on hospice will normally receive three to four showers per week. Residents on hospice will receive showers twice by the hospice agency and once or twice by the facility staff, depending on resident needs. If a resident has an accident or requests an additional shower, staff will accommodate their request. Staff and residents interviewed denied staff not meeting residents hygiene needs. Residents interviewed did not present any concerns about not receiving or missing showers. Based on the investigation conducted, there is insufficient evidence to support the above-mentioned allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Aug 17, 2023 · control 28-AS-20221018150130

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

Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement is not being met as evidenced by: Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements – General and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2-3) · Plan of correction due date: Aug 24, 2023

Managed Incontinence. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not being met as evidenced by: Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 17, 2023

Plan of correction: Administrator will review Title 22 Regulations Section 87625 on Managed Incontinence and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Allegation investigated: Staff did not ensure that residents were adequately fed. Staff did not respond to residents call for assistance.

Licensing Program Analyst (LPA) Ashley Calderon conducted a visit in response to the above allegations. On today's visit, LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of today's visit. On LPA collected staff and resident roster. Resident #1 (R1) Facsheet, Physican Report, and Appraisal Needs and Service. LPA collected service tracker for Residents #1 (R1), #2 (R2), #3 (R3) and #5 (R5) and collected current food menu, collected special diet list and alterative food slips. LPA interviewed Assistant Administrator Alexander Solorio, Staff #1-Staff #5 (S1-S5) and LPA interviewed residents #1-#7 (R1-R7).LPA along side with S1 toured the kitchen and dining room. Continuation on 9099-C... Unsubstantiated Based on allegation:Staff did not ensure that residents were adequately fed. Investigation revealed the following Assistant Administrator Alexander Solorio, Staff S1-S5 denied the above allegation and stated all residents are adequately fed, and stated R1 has food preference and facility accommodate R1's needs although R1 still refuses food at times. Interviews with R1-R7 revealed all residents are adequately fed and some have food preference but are still provided with adequate food. LPA Calderon observed a food menu, observed sufficient perishable and non-perishable food items for residents in care and observed kitchen having a list of residents who are on a special diet and R1 is not one of those residents. Based on allegation:Staff did not respond to residents call for assistance. Interviews with staff Assistant Administrator Alexander Solorio, Staff S1, S3-S5 revealed residents who call for assistance are receiving assistance and are not waiting for a long period of time. Alexander and staff S1,S4 and S5 stated all residents are checked on and receive assistance even those who do not call,and residents have available and/or receive water and other liquids by facility staff. Alexander and S1, S4 and S5 stated the front desk receive calls from some residents inquiring assistance and caregivers are informed which resident is requesting assistance and staff will provide resident with assistance. Interviews with residents R1-R7 revealed residents get assisted and not all residents call the facility for assistance but are receiving assistance by caregivers and staff . R1, R2, R7 stated calling the facility and caregiver providing assistance. R1-R7 did not state having to wait got 6 hours and/or a long period of time. Based on LPA's interviews, observations and record review investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Aug 4, 2023 · control 28-AS-20230728164224

Allegation investigated: Facility staff did not prevent resident from being assaulted by another resident while in care.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegation of "Facility staff did not prevent resident from being assaulted by another resident while in care". LPA met with Assistant Administrator Alex Solorio and the purpose for the visit was explained. The investigation consisted of the following: LPA Kruz Long conducted a prior visit to this facility on 3/14/23 and obtained/reviewed a copy of the Staff/Resident rosters, Physician's Report and Appraisal Needs and Services Plan for Resident #1 and #2 (R1 and R2), Incident report and food menu, toured the kitchen with Staff #1, interviewed Staff #1 to #6 (S1-S6) in the office and interviewed R1-R7 in various locations of the facility. During subsequent visit conducted today 8/3/23 LPA Tena Herrera obtained a copy of the Staff/Resident Rosters, Behavior Contract for R2, Incident Report, Physician's Report and Appraisal Needs and Services (Continued on LIC9099-C) Unsubstantiated Plan for R1 and R2. LPA interviewed S1, S3, S6-S8 and R8-R12. The investigation revealed the following: Allegation: Facility staff did not prevent resident from being assaulted by another resident while in care. It is alleged that R1 was attacked by R2 and suffered minor injuries that were treated by paramedics. R1 pressed charges and R2 was issued a misdemeanor citation by the police. LPA interviewed 5 residents during todays visit and 5 out of 5 residents all deny the above allegation. Each stated that the staff do what they can and try their best to de-escalate aggressive situations. Interviews also revealed that staff try best efforts to arrive promptly to the altercation and take immediate action. During staff interviews 5 out of 5 staff stated that when an altercation between residents occur they take immediate action and try to de-escalate the situation. Staff carry walkie-talkies with them so when a situation occurs support staff is alerted immediately to assist. There are usually 3 staff members that work the altercation with best efforts to calm residents and separate them from one another. Depending on the seriousness of the alteration 911 or the non-emergency police telephone line is called. Medical attention is always suggested yet usually refused by the residents involved. Although it is confirmed that R2 assaulted R1, the facility took the proper steps to address the situation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Assistant Administrator Alexander Solorio and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 3, 2023 · control 28-AS-20230306123319

Allegation investigated: Staff did not treat residents with dignity or respect. Insufficient staff meeting the qualifications and competency to meet residents' care needs.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegations of "Staff did not treat residents with dignity or respect and Insufficient staff meeting the qualifications and competency to meet residents' care needs”. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 10/20/22, in reference to the allegations listed above. During the course of the investigation, interviews were conducted of various persons to include the Assistant Administrator / Alexander Solorio, Staff members 1 through 3 (S1 – S3) and Residents 1 through 5 (R1 – R5). Also, copies of the following documents were obtained and reviewed; • Resident Roster • Personnel Report • CPR/AED/First Aid Certificate for Staff 4 (S4) • Food Handler Certificate of Completion for S4 • New Hire Initial Training Record for S4 dated: 7/22/20 • Hands on Training Record for period 7/29/20 - 8/12/20 for S4. Substantiated The investigation revealed the following; Allegation: Staff did not treat residents with dignity or respect. The details of this allegation states that on 9/7/22, at approximately 12:40pm, S1 started shouting at R1 at the top of her voice while sitting inside the office, which was approximately 30 feet away from where R1 was standing. S1 shouted in Spanish and the tone she used was humiliating and intimidating towards R1. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. The alleged incident happened on 9/7/22, at approximately 12:40pm. R1 was standing in the hallway, near the office and was overheard yelling “bano” repeatedly, indicating he wanted a shower. S1 was on her break sitting inside the office, approximately 30 feet away from R1 and instead of getting up to address R1 that she was on break, S1 began yelling at R1 in Spanish, stating that “I’m on my break right now, I will shower you”. There were multiple witnesses who observed the incident and stated that S1 was observed yelling at R1 in a humiliating and intimidating manner and could have addressed the situation differently by getting up and explaining to R1 that she was on her break and would assist him with his shower upon returning from break. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true. Allegation: Insufficient staff meeting the qualifications and competency to meet residents' care needs. The details of this allegation states that on 9/7/22, at approximately 12:40pm, a witness observed that there were two caregivers on shift, one of whom was S1 and S1 was on break at the time. When the witness inquired with S3 if that meant that there is currently only one caregiver on the floor, S3 stated that "there are two kitchen staff who help too”. S3 was asked if that meant that kitchen staff were assisting with resident care needs, S3 replied “yes”. Based on interviews conducted, the statements obtained were consistent and corroborated with the above-mentioned allegation. Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. Also, S4’s CPR/First Aid Certificate had expired on April 30, 2022. Based on the investigation conducted, there was sufficient evidence found, proving the above-mentioned allegation to be true. (Please see LIC 9099C for additional information) Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights. The investigation revealed the following; Allegation: Staff did not respond to residents call for assistance in a timely manner. The details of this allegation states that R1 called out from the hallway "bano" repeatedly, indicating they required assistance with bathing. Despite this, no staff members came to assist him. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. The alleged incident happened on 9/7/22, at approximately 12:40pm. R1 was standing in the hallway, near the office and was overheard yelling “bano” repeatedly, indicating he wanted a shower. According to staff, R1 receives showers from the hospice nurse twice a week. R1 was not scheduled for a shower on 9/7/22 but staff told R1 that they would assist him with his shower once they were done giving showers to the residents on schedule for that day. At the time of the alleged incident, there were two caregivers working. One of the caregivers was on break. The Med Tech was assisting with passing out medications and the Activities Director and the Assistant Administrator were also on duty assisting other residents with care. Statements obtained from residents denied staff not responding to residents call for assistance in a timely manner. Based on the information gathered, there was insufficient evidence found regarding the above-mentioned allegation. Allegation: Facility is unsanitary. The details of this allegation states that on 9/7/22, between 12:40pm and 1:10pm, discarded plates of food were observed in the hallways and on the floor, as well as discarded soiled clothes. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. Statements obtained from staff stated that the only time empty plates of food can be found on the floors are after lunch as some of the residents have a habit of placing their empty plates on the floors, in front of their rooms so that staff can pick them up. Some residents also leave their dirty/soiled clothes on the floors, in front of their rooms so that staff can pick them up for laundry. Staff remind residents who tend to leave their plates on the floors to leave the plates in their rooms for staff to pick up but residents continue to leave them on the floors. Staff also remind residents not to leave dirty/soiled clothes on the floors and to call staff for assistance in picking up their dirty clothes for laundry. Residents interviewed stated that staff are quick to pick up empty plates from hallway floors after lunch and denied seeing dirty/soiled clothes in the hallways. During the visit conducted on 10/20/22, LPA toured the facility (physical plant / inside only) in the AM and also in the PM and did not observe discarded plates of food or soiled clothes on the hallway floors. Based on the information gathered, there was insufficient evidence found regarding the above-mentioned allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Jul 25, 2023 · control 28-AS-20221010164936

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 8, 2023

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: On 9/7/22, at approximately 12:40pm, S1 was overheard by witnesses yelling at R1 in a humiliating and intimidating manner. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2023

Plan of correction: Administrator will review Title 22 Regulations, Section 87468.1 on Personal Rights, and conduct an in-service training with all staff on the importance of resident personal rights. Administrator will submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Aug 8, 2023

Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not being met as evidenced by: Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2023

Plan of correction: The Administrator will provide training to S1 with the required training and submit proof of training record; training topic, date, time, training duration, along with signature of S1 to CCL, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Aug 8, 2023

Personnel Requirements – General Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not being met as evidenced by: During the visit conducted on 10/20/22, LPA reviewed the file of S1 and observed that the CPR/First Aid Certificate for S1 expired on April 30, 2022. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 25, 2023

Plan of correction: The Administrator will ensure that S1 has a current First Aid Certificate and submit current documentation to CCL by POC due date.

Allegation investigated: Staff did not provide proper supervision to residents Staff spoke inappropriately to resident

Licensing Program Analyst (LPA) Ashley Calderon conducted a visit in response to the above allegations. On today's visit, LPA met with Assistant Administrator Alexander Solorio and discussed the purpose of todays visit. On today's visit, LPA collected resident and staff roster. Collected Resident #1 (R1) Medical Notes, Discharge notes, Physician Report, Face sheet, Appraisal Needs and Service and Staff Communication Text for R1 Medical attention needs, Refusal Document for Medical needs dated 6/3/23, 6/14/23, and 7/2/23, and R1 Unusual Incident Reports , email to R1 team at A-Biz Health Systems and Resident #7 (R7) Unusual Incident Report for 6/19/23 and 6/26/23. LPA received Residents July Sign Out Sheet. and Staff Shift to Shift Reports. LPA visited residents room 8,11,21,27 and 31. LPA interview Resident #1-7 (R1-R7) and Staff Administartor and Staff #1-#3 (S1-3). Continuation on 9099-C Unsubstantiated Regarding Allegation: Staff did not provide proper supervision to residents. LPA Calderon interview 7 residents, 4 out of 7 residents stated they receive adequate supervision, get medical assistance when needed, staff assist when they request assistance and they notify front desk about their whereabouts when leaving to the community. LPA interviewed 4 staff all stated residents receive proper supervision, staff do their rounds, staff assist with any activity of daily living needs or medical needs, many residents are independent and staff communicate with each other on residents needs. LPA obtained and reviewed unusual incident reports that obtain information on how facility is providing appropriate care for residents. LPA obtained and reviewed Shift to Shift documentation obtaining documentation on residents care regarding residents appointments, medication changes, illness, injuries, behaviors, important issues to discuss or any medical needs that occur during staff shift to communicate with facility staff and provide resident proper supervision and care. LPA collected resident sign in and out sheet that provides facility with information on residents who leave to the community. Regarding Allegation: Staff spoke inappropriately to resident. During LPA's visit LPA interviewed 7 residents. 5 out 7 residents denied the above allegation and stated staff do not speak to them inappropriately and have not heard staff talking with residents inappropriately and have not experienced the above allegation. LPA interviewed 4 staff all who denied above allegation and stated staff do not speak to residents inappropriately and speak to them professionally. LPA Calderon observed interactions with staff and residents during LPA's visit and did not observe staff talking inappropriately to residents in care. Based on LPA's interviews, observations and record review investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Jul 18, 2023 · control 28-AS-20230713162451

Allegation investigated: Facility staff is providing medical care to residents in care

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegation listed above. LPA met with Alexander Solorio Assistant Administrator reason for the visit. The investigation revealed the following: during the initial visit conducted on 06/11/2021, LPAs Nicol Wesley and Nune Margaryan interviewed the Executive Director and Assistant Administrator, requested to review a random selection of residents files, requested a copy of the staff roster and resident roster. During today's visit, LPA Zaragoza interviewed Residents 1 - 9 (R1, R2, R3, R4, R5, R6, R7, R8, R9), Staff # 1 - 5 (S1, S2, S3, S4, S5). LPA also obtained copies of the following documentation: Staff Roster, Client Rosters, Physicians Reports for R1 - R9, and Medication Administration Records (MARs) for R1 - R9. The investigation revealed the following: in regards to the allegation "Facility staff is providing medical care to residents in care", it is alleged that S1 is providing in-house medical care to the residents as well as signing their physician's reports and prescribing medications while his license is on probation. Unsubstantiated During an interview with S1 over the phone, S1 stated they have provided medical care to the residents of the facility in the past and occasionally does come in to do so, however this should not be an issue. S1 explained that he is a board certified physician and has several years experience treating the elderly in assisted living facilities and skilled nursing facilities. S1 explained they also work with Department of Health Services (DHS) patients and that DHS has asked him previously for assistance in providing care to residents in the facility, and that other residents are former patients of S1's. During interviews with the residents, R1 - R9 explained that they have never heard of S1 before, nor have they ever received direct in-house medical care from S1. R1 - R9 also explained that they have the choices on whether they want to see the in-house doctors the facility provides or another medical provider, and they all stated that they do not pay for their medical services. R1, R8, and R9 also stated that they have their own medical team that they work with outside of the facility. Interviews with S2 revealed that S1 has not signed a physician's report for the residents in the past year, and that the facility is working with another medical provider who is signing the residents physician's reports and updating their medications if the residents choose to accept medical care from their in-house medical team, and that residents always have a choice in who they see as their primary medical provider. Interviews with S3 - S5 revealed that none have seen S1 providing direct medical care directly to the patients, and that residents are never forced to see S1 or their in-house physician. A review of the R1 - R9's medical assessments and MARs did not show S1 to have signed any assessments, they were all signed either from the facility's in-house medical provider or their own chosen physician from outside the facility. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2023 · control 28-AS-20210602161100

Allegation investigated: Illegal eviction.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegation of "Illegal evitcion". Upon arriving at the facility, LPA met with Resident Care Director / Maria “Luisa” Razo and Assistant Administrator Alex Solorio. The investigation consisted of the following: LPA Alberto Lopez conducted a prior visit to this facility on 11/23/22 in reference to the allegation listed above. During the course of the investigation an interview was conducted with Assistant Administrator / Alexander Solorio and copies of the following documents were obtained and reviewed: • Resident Roster • Staff Roster • 30 Day Termination Notice for R1 During todays investigation LPA Tena Herrera attempted to interview R1, however, R1 has been evicted from facility and LPA was unable to get ahold of resident. During todays visit LPA obtained copies of the following: • Resident Roster • Staff Roster • House Rules • Facility's 30 Day Termination Notice for R1 • Court Ordered Eviction Notice • Unusual Incident/Injury Reports involving R1 • Physicians Report for R1 Unsubstantiated LPA also conducted interviews during todays visit with Assistant Administrator Alex Solorio, Resident Care Director Maria "Luisa" Razo and S1. The investigation revealed the following: Allegation: Illegal Eviction. The details of this allegation states that R1 is being illegally evicted. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. After reviewing the file of R1, LPA discovered that R1 was issued a 30 Day Eviction Notice on 10/20/22, for breaking facility house rules and failing to pay rent. During the period of 9/1/22 - 10/20/22, R1 was observed violating house rules by having possession of an illegal substance and being verbally and physically abusive towards staff and other residents. R1 also stopped paying rent and had an outstanding balance of $1,620.46 owed to the facility. R1's last day at the facility was on 4/27/23. Based on the information gathered, there is insufficient evidence to support the above allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to Assistant Administrator Alex Solorio.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 28-AS-20221118141004

Allegation investigated: Allegation: Lack of supervision resulting in resident's engaging in an altercation

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegation of "Lack of supervision resulting in resident's engaging in an altercation”. Upon arriving at the facility, LPA met with Resident Care Director / Maria “Luisa” Razo who assisted with the visit. LPA Katrdzhyan conducted prior visits to this facility on 3/16/22 and 6/28/23, in reference to the allegation listed above. During the course of the investigation, interviews were conducted of various persons to include the Assistant Administrator / Alexander Solorio, Staff members 1 through 5 (S1 - S5) and Residents 1 through 4 (R1 – R4). Also, copies of the following documents were obtained and reviewed in reference to R1 and R2; • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Report / LIC 624. Unsubstantiated The investigation revealed the following; Allegation: Lack of supervision resulting in resident's engaging in an altercation. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. The alleged incident happened on 3/12/22, at approximately 9am. R1 was observed by S1 standing in front of R4’s door (in the hallway) having a verbal argument with R4. S1 intervened by de-escalating the situation and asked R1 to go back to his room. As R1 was going to his room, R2 came out of his room (nearby) and began yelling at R1 by saying, “you can’t be talking to R4 like that” and pushed R1 to the floor. S1 immediately intervened and separated both Residents and called S2 and S3 for help. R1 and R2 were separated and escorted back to their separate rooms. Shortly after, R1 and R2 went outside in the patio area (near their rooms) and began arguing a second time and S1, S2 and S3 immediately intervened and helped de-escalate the situation. The Pasadena Police Department was involved and spoke with both residents and no arrests were made or charges filed. R1 and R2 did not sustain any injuries, as a result of both incidents. The Assistant Administrator spoke with both residents after the incidents and asked them to stay away from each other to avoid further confrontations. R1 and R2 are independent and do not require one to one supervision. Although it appears an altercation did occur between R1 and R2, staff intervened immediately, conducted body checks and called the Police. All agencies were notified of the incident (via SOC 341). Therefore, there is insufficient evidence to indicate a lack of supervision on the part of the facility. Based on the information gathered, there is insufficient evidence to support the above allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Resident Care Director.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 28-AS-20220314170054

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joe Katrdzhyan and Associate Governmental Program Analyst (AGPA) / Jeannette Rodriguez conducted an unannounced case management visit to this facility. During a complaint investigation conducted on 6/29/23, LPA and AGPA toured the facility and observed that the facility did not have a functional signal system in all resident rooms, for all residents. Per Title 22 Regulations Section 87303 / Maintenance and Operation; (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. During the tour, the LPA and AGPA also observed Room #16 to be unsanitary. The room was dirty, the floors had stains and were sticky and there was debris/trash on the floor of the living area and also the bathroom. The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided to the Resident Care Director along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jun 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Jul 1, 2023

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not being met as evidenced by: During today's visit, LPA and AGPA toured the facility and observed that the facility did not have a functional signal system in all resident rooms, for all residents. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 29, 2023

Plan of correction: Administrator will ensure that the facility has a functional signal system installed in each resident's living unit and submit proof of correction to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jul 1, 2023

Maintenance and Operation. 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 being met as evidenced by: During the tour, the LPA and AGPA also observed Room #16 to be unsanitary. The room was dirty, the floors had stains and were sticky and there was debris/trash on the floor of the living area and also the bathroom. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 29, 2023

Plan of correction: The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87303. POC is due to CCL by the POC due date of 7/1/23.

Allegation investigated: Staff did not prevent a physical altercation between residents in car Staff illegally evicted resident Resident not treated with dignity by staff

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegations of "Staff did not prevent a physical altercation between residents in care, Staff illegally evicted resident and Resident not treated with dignity by staff”. Upon arriving at the facility, LPA met with Resident Care Director / Maria “Luisa” Razo who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 10/21/22, in reference to the allegations listed above. During the course of the investigation, interviews were conducted of various persons to include the Assistant Administrator / Alexander Solorio, Resident Care Director / Maria “Luisa” Razo, Business Office Director / Kevin Arutyunyan and Residents 1 - 3 (R1 - R3). LPA was unable to interview Staff 1 (S1) as S1 no longer works at the facility and his whereabouts are unknown at this time. During the initial visit conducted on 10/21/22, LPA reviewed surveillance video of the incident involving R1 and R2. Also copies of the following documents were obtained and reviewed; • Resident Roster • Facility House Rules • 30 Day Termination Notices for R1 and R2 • Unusual Incident/ Unsubstantiated Injury Reports involving R1, R2 and R3. The investigation revealed the following; Allegation: Staff did not prevent a physical altercation between residents in care. The details of this allegation states that R1 was involved in two separate incidents, involving two separate residents. The first alleged incident involves R2 and it is alleged that R2 slapped R1 on the left side of her face and pulled her hair. The second alleged incident involves R3 and it is alleged that R3 cut R1 with his fingernails. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. According to the surveillance video, on 10/9/22, at approximately 9:58pm, S1 is observed escorting R1 back to her room (in her wheelchair), after her shower. At the same time, R2 is observed coming in the direction of R1 (from the opposite side) in her wheelchair, to the left of R1. There is also a third resident observed coming in the direction of R1 (from the opposite side) in his wheelchair, to the right of R1. S1 is observed pushing the wheelchair of R1 through the middle of both residents at which time R2 is observed reaching over with her right hand and pulling the hair of R1. S1 is observed immediately intervening and breaking up the incident and separating both residents. After the incident, S1 is observed continuing to escort R1 back to her room. Interviews conducted of staff and R1 and R2 stated that there is nothing different that S1 could have done to prevent R2 from reaching over and pulling the hair of R1. This was an unexpected incident. In the Surveillance video, R2 does not slap R1. During the interview of R1, R1 denied R2 slapping her on the left side of her face. R1 and R2 did not sustain injuries as a result of this incident. The Pasadena Police Department was involved and spoke with both residents involved and no arrests were made. Although it appears an altercation did occur between R1 and R2, staff intervened immediately, applied first aid, and called the Police. All agencies were notified of the incident (via SOC 341). Therefore, there is insufficient evidence to indicate a lack of supervision on the part of the facility. On 10/18/22, there was an incident at the outside patio smoking area involving R1 and R3, where R1 sustained a scratch on her arm (unknown which arm). During the interview of R1, R1 stated that "R3 got too close to me and I pushed him back and he cut me". During the interview of R3, R3 denied hurting R1 intentionally and stated that he was having a conversation with R1 because R1 had accused him of bringing alcohol inside the facility (which he strongly denied), and during the conversation with R1, R1 became upset and tried to strike R3. As R1 was attempting to strike R3, R3 grabbed the arm of R1 to prevent R1 from striking him, causing a scratch on the arm of R1. According to both residents, there were no witnesses to this incident. Staff was notified after the incident and applied first aid to the arm of R1. Interviews conducted of R1 and R3 stated that there is nothing different that staff could have done to prevent this incident from happening. R1 and R3 and independent and do not require one to one supervision. Although it appears an altercation did occur between R1 and R3, staff applied first aid after learning of the incident and asked both residents to stay away from each other. All agencies were notified of the incident (via SOC 341). Therefore, there is insufficient evidence to indicate a lack of supervision on the part of the facility. Based on the information gathered, there is insufficient evidence to support the above allegation to be true. Allegation: Staff illegally evicted resident. The details of this allegation states that R1 is being illegally evicted. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the above-mentioned allegation. After reviewing the file of R1 and conducting interviews of staff, LPA discovered that R1 was issued a 30 Day Eviction Notice on 10/20/22, for breaking facility house rules and failing to pay rent. During the period of 9/1/22 - 10/20/22, R1 was observed violating house rules by being verbally and physically abusive towards staff and other residents. Additionally there was possession of an illegal substance found inside her room on 9/7/22. R1 also stopped paying rent and had an outstanding balance of $1,620.46 owed to the facility. Based on the information gathered, there is insufficient evidence to support the above allegation to be true. Allegation: Resident not treated with dignity by staff. The details of this allegation states that R1 was involved in a verbal altercation with the Business Office Director and was treated in an antagonizing manner. On 10/20/22, the Assistant Administrator, along with the Business Office Director went to R1's room to hand deliver the 30 Day Eviction Notice. After handing the eviction notice to R1 and explaining the purpose of why it was issued, R1 began screaming and using profanity towards the Assistant Administrator and the Business Office Director. R1 also threatened by stating that if they did not leave her room, she would strip naked and claim that they were assaulting her. During the interview of the Business Office Director, he denied speaking to R1 in an antagonizing manner. During the interview of the Assistant Administrator, it was stated that R1 was verbally abusive during the incident and threatened him and the Business Office Director. The Assistant Administrator denied the Business Office Director speaking to R1 in an antagonizing manner. There were no other witnesses present at the time of the incident. Based on the information gathered, there is insufficient evidence to support the above allegation to be true. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Resident Care Director.the state’s words, verbatim · CDSS document, Jun 28, 2023 · control 28-AS-20221014123935

Allegation investigated: Resident developed multiple pressure injuries Staff are not preventing the spread of infection Staff are retaining a resident that requires a higher level of care Staff does not ensure that resident receives adequate wound care

**** This amended report supersedes report dated 03/02/2023. It was created to add additional information from wound care physician, and medical records that were reviewed and obtained after the above date. The additional revision did not change any other aspects of the report, and all aspects including the findings remain the same. *** Licensing Program Analyst (LPA) Alberto Lopez made an unannounced subsequent visit to investigate and deliver findings for the above allegations. LPA Lopez met with Assistant Administrator Alex Solorio and discussed the purpose of the visit. Initial 10-day visit was conducted telephonically by LPA Joe Katrdzhyan 10/27/2020 The investigation consisted of reviewing and obtaining relevant medical documentation for R1 from interviews with staff, residents, and R1’s physician. Unsubstantiated Regarding allegation: Resident developed multiple pressure injuries. It is alleged that R1 developed additional pressure injuries while in care. The investigation revealed the following: Assistant Administrator S1 stated that a resident arrived at the facility on 09/28/2020 with a wound. According to Administrator, wound care was being provided by Pacific Pace, and a referral to Mission Hospice was completed on 10/01/2022. Wound care was approved effective 10/03/2020. LPA reviewed facility progress notes and Hospice documentation for R1 dated 10/06/2020 through 03/21/2021. Documentation of all care for R1 was received. Documentation from Hospice detailed daily wound care performed which included: removing soiled dressings, cleaning the wound(s), applying medicated creams, and wrapping the wound. Five of five staff (S1-S5) stated that no resident had developed a pressure injury while in care. LPA interviewed two residents with current wounds, and two of two residents (R2-R3) stated they arrived at the facility with wounds, and did not develop wounds at the facility. R1 was admitted on 09/28/2020 to facility, and LPA was unable to interview R1 due to R1’s passing on 04/24/2021. LPA also interviewed an additional five residents (R4, R5, R6, R7,R8) who stated they did not know of any residents with pressure injuries, and they do not have pressure injures. LPA reviewed documentation from Pacific Pace and Hospice, along with R1’s medical records that documented R1’s wound(s) prior to being admitted to facility. Interview with overseeing wound care physician stated that R1 did not develop any pressure injuries while in care at facility. Also, no documented evidence was discovered that indicated R1 developed pressure injuries while in care at the facility. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. Regarding Allegation: Staff are not preventing the spread of infection. It is alleged that facility did not prevent the spread of infection, and that bodily fluids on the floor of resident’s room was being stepped on by staff, and taken to other rooms of facility. Assistant Administrator S1 stated that they have an Infection Control Plan. LPA reviewed Infection Control Plan, and all five of five staff stated that they follow the Infection Control Plan to prevent infection. LPA observed a large bin in a secured area where all bio hazard material is place for disposal. Five of five staff stated there are specific procedures to prevent the spread of infection, and denied walking, or seeing others walk, or step into bio hazard liquids. Two of two residents who are currently receiving wound care stated, all bio hazard material is disposed in a proper manner. Residents (R4, R5, R6, R7, R8) stated that facility does everything they can to prevent the spread of infection. LPA toured facility with Assistant Administrator and did not see any infectious material or fluids anywhere in facility rooms, or common areas. (continued on 9099C) LPA observed large container in locked closet where all bio hazard material is placed for proper disposal by contractor, Allegiance Specialty Pharmacy. LPA observed a sign on the container stating “BIO-HAZARD”. R1’s Hospice physician could not collaborate the allegation. No documented evidence of any other resident, staff, or visitor being infected was discovered during the investigation. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was no supportive evidence to indicate that facility failed to take appropriate precautions to prevent the spread of infection. Regarding Allegation: Staff are retaining a resident that requires a higher level of care. It is alleged that facility retained a resident that required a higher level of care due to severity of wounds. Assistant Administrator (S1) stated facility does not retain residents that require a higher level of care. S1 stated R1 entered the facility at a Level 2, and the facility can care for residents up to Level 4. When R1 arrived at the facility on 09/28/2020, the facility and Pacific Pace provided care for resident’s needs. On 10/01/2020, a referral was provided for Mission Hospice to provide wound care to R1. Five of five staff interviewed stated they have not seen or know of any residents that require a higher level of care residing at facility. Five of seven residents stated that they are happy with the care they receive, and that no other residents require a higher level of care. Two residents stated that one resident is loud and wished they had a room further away, but not sure resident requires higher level of care. LPA Interviewed R1’s Hospice physician on 05/01/2023, and medical records for R1 were requested at that time. On 5/15/2023, physician sent email with additional information on wound care provided to R1. On 5/22/2023, R1’s records from WelbeHealth were transmitted via secure email to LPA. Physician overseeing wound care for R1 communicated to LPA that Physician was aware of R1 wound(s) on 10/01/2020, and that appropriate treatment was provided. R1’s wound care physician identified maggot infestation on 10/07/2020, and provided appropriate treatment at that time. Facility contacted Pacific Pace regarding possible MRSA infection on 10/06/2022, and treatment was prescribed according to progress notes in R1’s file. LPA reviewed all medical records gathered from interviews, emails from physician, and medical records obtained from WelbeHealth in regard to the stage and/or diagnosis of R1’s wound(s). There was no corroborating evidence indicating the facility accepted and/or retained a resident with a prohibited health condition, that the maggot infestation was due to neglect on part of the facility, or that the facility failed to contact R1’s physician. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. (Continued on 9099C) Regarding Allegation: Staff does not ensure that resident receives adequate wound care. It is alleged that resident is not receiving proper wound care. Assistant Administrator stated that the facility, Pacific Pace, and Mission Hospice was providing resident with proper wound care. LPA reviewed facility progress notes for R1 dated 10/06/2020 to 03/21/2021, and documentation specified all care, including wound care, that was provided to R1. Four of four staff interviewed stated that most wound care is provided by outside agencies such as Home Health or Hospice, and facility ensured that R1 received proper wound care while at facility. Two of two residents that currently require wound care stated that they were receiving proper wound care, and they were satisfied with the services. Additional five residents (R4, R5, R6, R7,R8) stated they do not know anyone who receives wound care, and are unable to answer the question. R1’s physician stated that proper wound care was provided to R1, with the exception of when R1 refused wound care. According to email sent to LPA from R1’s physician, R1 was enrolled in Pacific Pace from 10/1/2020 to 4/24/2021. R1 received wound care from Mission Hospice on the following dates: 10/23/2020, 10/24/2020, 10/25/2020, 11/10/2020, 11/13/2020, 11/14/2020, 11/15/2020 11/17/2020, 11/20/2020, 11/21/2020, 11/22/2020, 11/24/2020, 11/26/2020, 11/30/2020, 12/1/2020, 12/4/2020, 12/5/2020, 12/6/2020, 12/8/2020. R1 began receiving wound care Monday through Friday from 12/20/2020 to 1/4/2021. R1 cancelled wound care on11/1/2020, and care was also cancelled due to hospital admissions on: 12/11//2020 to 12/20/2020; 2/18/2021 to 2/23/2021, and on 3/29/2021 to 4/5/2021. R1 adamantly refused SNF placement after hospitalization in December 2020. R1 was advised of the benefits of rehabilitation and wound care. Wound care was provided by WelbeHealth, and Pacific Pace on: 10/8/2020, 10/9/2020, 10/13/2020, 10/14/2020, 10/15/2020, 10/26/2020, 10/28/2020, 10/29/2020, 11/2/2020, 11/4/2020, 11/5/2020, 11/11/2020, 11/12/2020, 11/16/2020, 11/18/2020, 11/19/2020, 11/23/2020, and refused on 11/25/2020. Wound care was cancelled by R1 on the following dates: 10/16/2020, 10/19/2020, 10/21/2020, 11/9/2020. According to R1’s Preadmission Assessment dated 09/28/2020, R1 had a history of refusing showers and care services. Based on interviews conducted with facility staff, Hospice physician, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies noted nor any citations issued at this time. Exit interview conducted and a copy of this report provided to Assistant Administrator Alex Solorio along with appeal rights.the state’s words, verbatim · CDSS document, Jun 23, 2023 · control 28-AS-20201027140928

Allegation investigated: Staff did not notify resident's authorized representative that resident was missing

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solario (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters. Plan of Operation, Police Report #2023-34886, Communication text messages with Resident #1 (R1) authorized representative and facility staff, Special Incident Report, SOC 341, R1's Admission Agreement, Emergency ID, PrePlacement and Apprasial Needs and Service Plan. LPA Calderon interview Alexander Solorio, Staff #1-4 (S1,S2,S3,S4), interviewed telephonically R1 authorized representative, attempt to interview telephonically R1, and interviewed Residents #2-7(R2-R7). Continution 9099-C... Unsubstantiated Regarding the allegation: Staff did not notify resident's authorized representative that resident was missing. Interview with Alexander reported that R1's authorized representative was notified on 5/1/23 via telephone and Alexander provided police report number to LPA. Interviews with Staff #2-4 reported that police report was done by facility, R1 based on Physician Report is able to leave facility unattended and R1 authorized representative was notified. Interview with Resident R2, R3, R6 all stated they are able to leave the facility, and when a resident are not present at the facility they search for residents and call the police and file a report. LPA reviewed records. Facility submitted to Licensing a Special Incident Report (SIR) on 5/1/23 regarding incident involving R1. SIR states R1's authorized representative was contacted. SOC 341 was submitted by facility to Licensing on 5/1/23 stating R1 absent without official leave incident occurring on 4/30/23 at approximately 5pm. SOC 341 states R1's authorized representative was notified on 5/1/23 as well as police on 5/1/23. LPA Calderon called Pasadena Police Department was reported that report was made by Pasadena Villa Assisted Living at 5:40pm. LPA reviewed reports, reports were made in a timely manner to appropriate representatives. Based on LPA's interviews and record review investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator Alexander Solario.the state’s words, verbatim · CDSS document, Jun 6, 2023 · control 28-AS-20230530122313

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management continuation -annual visit at the facility using the CARE tool. . LPA Flores met with Silvia Bernal Med-Tech and explained the reason for the visit. During this visit the following CARE tool domains were reviewed: Planned activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Facility has planned activities posted on hallway, a library with reading material, and an activities director. On 4/22/23 - LPA Flores conducted a review of medication for 5 residents during initial annual visit. Resident #1(R1) did not have 4 medications listed. Resident #2(R2) was out of 1 medications listed on medication sheet. Resident #4(R4) was out of 3 prescribed medications and 1 medication was out of the original package. Per Med-Tech medications have not been provided for weeks, however the medication sheet is initial as provided. During facility's tour LPA observed resident's medication on top of bed frame in shared bedroom #4. On 5/27/23 LPA reviewed emergency disaster plan. Last fire drill was conducted on 12/20/22 for the morning staff, 2/22/23 for the evening staff, and 2/23/23 for the night staff. On 4/22/23 - During facility's tour LPA observed full bed rails for R3 and resident #5(R5) and half bed rails for R2, resident #4(R4) and resident #6(R6). R3,R4,and R5 did not have a physician's order request on file. On 4/22/23 - LPA was made aware facility handles P&I money for residents. On 5/27/23 LPA reviewed P&I money for R2,R6, resident #7(R7),#8(R8),#9(R9) and record of resident's safeguarded cash resources for R2 and R8 balance was not written in log, for R2 as it is written R2 should have a balance of $70.00 and there is no money available. Facility did not provided a copy of surety bond. Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Scarlett Munoz - Receptionist and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 27, 2023

Allegation investigated: Facility is retaining residents who require a higher level of care

***This is an amended report which supersedes the original report dated 5/16/23. The purpose of this report is to remove confidential information in reference to Residents 1 and 2. The amendments to the report do not affect or change the findings on this complaint.*** Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Facility is retaining residents who require a higher level of care." Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted prior visits to this facility on 10/27/21 and 12/14/21, in reference to the allegation listed above. During the course of the investigation, LPA interviewed the Assistant Administrator and Staff members 1 - 3 (S1 - S3). LPA reviewed and obtained copies of resident files in reference to Residents 1 and 2 (R1 and R2). Unsubstantiated The investigation revealed the following; Allegation: Facility is retaining residents who require a higher level of care. Based on interviews conducted and record reviews, the statements obtained along with the information collected did not corroborate with the allegation. According to the Assistant administrator, the majority of residents who were admitted to Pasadena Villa Senior Living around the time of licensure were referrals from Department of Health Services (DHS). A proper assessment was conducted by the Administrator on R1 and R2. According to the Physician's Report for R1, R1 was listed as unable to bathe self, able to dress/groom self w/minimum assistance, able to feed self, unable to care for own toileting needs and unable to store or administer own medications. In the Preplacement Appraisal for R1 it states; R1 is non-ambulatory, uses a wheelchair, is alert and oriented and R1 likes to stay in room and watch TV. R1 was not listed as someone who needed higher level of care. According to the Physician's Report for R2, R2 was listed as independent and able to leave facility unassisted. R2 was able to store own medications but needed minimal assistance. According to the notes from DHS, R2 did not require one-on-one supervision. In the Preplacement Appraisal for R2, it states; R2 is visually impaired and uses cane. R2 was described as someone who likes to hear the TV and radio. R2 was not listed as someone who needed higher level of care. Based on the information gathered, there is insufficient evidence to support this allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, May 16, 2023 · control 28-AS-20211021085901

Allegation investigated: Staff unlawfully evicted resident in care

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Maddison Aceves and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Staff unlawfully evicted resident in care". During today's visit, LPA interviewed the Assistant Administrator and Resident #1 (R1), via telephone. Also copies of the following documents were obtained and reviewed; • Physician’s Report • Unusual Incident/Injury Reports • Appraisal/Needs and Services Plan • Admission Agreement • Email chains between Clinical Psychologist, Assistant Administrator and Clinical Program Manager from ODR. Please see LIC 9099C for additional information. Substantiated The investigation revealed the following; Allegation: Staff unlawfully evicted resident in care. Based on interviews conducted, LPA discovered that R1 was unlawfully evicted from the facility and an eviction notice was never issued to R1. Statements obtained from the Assistant Administrator and R1 corroborated that R1 was not allowed back at the facility after being hospitalized on 5/2/23. R1 is no longer residing at Pasadena Villa Senior Living. During the course of the investigation, LPA discovered that on 5/2/23, R1 was placed on a 5150 hold due to having erratic behaviors and being a danger to himself and others. R1 was transported to Los Angeles Downtown Medical Center (LADMC) and admitted for a psychiatric evaluation. On 5/3/23, the Assistant Administrator received a call from LADMC, stating that they wanted to extend R1's stay for a total of 14 days. On 5/5/23, the Assistant Administrator learned that R1 was transferred to Beverly Community Hospital (BCH). The Assistant Administrator called BCH to obtain additional information and was told that R1 was ready to leave the hospital against medical advice and would possibly be returning back to Pasadena Villa Senior Living. According to the Assistant Administrator, on 5/8/23, R1 arrived at the facility but staff refused to let R1 stay at the facility or remove his belongings. R1's Clinical Psychologist and Executive Director / Kandice Vergara arranged a meeting with R1 and R1 was issued a check for $2,500 to help pay for R1's stay at a hotel/motel until R1's Clinical Program Manager at ODR (Office of Diversion and Reentry) would find R1 placement elsewhere, as R1 required higher level of care. On 5/9/23, R1's personal belongings were placed in a storage in Van Nuys. On 5/16/23, the Assistant Administrator received an email from the Clinical Program Manager at ODR, stating that R1 no longer wants to be part of the ODR program. During the telephone call with R1, LPA learned that R1 is currently renting a room and living by himself. Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, May 16, 2023 · control 28-AS-20230508090902

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: May 23, 2023

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. The requirement is not met as evidenced by: Based on interviews conducted, LPA discovered that R1 was unlawfully evicted from the facility and an eviction notice was never issued to R1. Statements obtained from the Assistant Administrator and R1 corroborated that R1 was not allowed back at the facility after being hospitalized on 5/2/23. R1 is no longer residing at Pasadena Villa Senior Living.the state’s words, verbatim · CDSS document, May 16, 2023

Plan of correction: The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87224. POC is due to CCL by the POC due date of 5/23/23.

Allegation investigated: Staff financially abused resident in care.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Administrator, Alex Solorio who assisted with today's visit. Regarding the allegation that staff financially abused resident in care, the investigation consisted of : review of resident #1's file, interviews with Administrator, Staff #1 and resident #1 - resident #7. Administrator and Staff #1 denied the allegation. Staff interviewed stated that on 4/18/23, resident #1 began stating that the facility owed him money. Staff interviewed stated that they showed resident #1 his P & I log, which showed that resident #1 had taken out all of his funds. Resident #1 became very upset, when he was told this. Staff stated that it was decided that the facility would give resident #1 additional funds in order to avoid behavioral issues and to de-escalate the situation. Staff stated that they asked resident #1 to sign a document stating that he has received his P & I money, and is up to date. LPA observed a copy of the document signed by resident #1, dated 4/18/23. The facility submitted a special incident report to Community Care Licensing on 4/18/23 for this incident. Residents interviewed were unable to corroborate the allegation. Resident #2 -resident #7 stated that they do receive their P & I funds. They stated that they are not being financially abused by staff. Unsubstantiated Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Resident Care Director, Maria "Luisa" Razo.the state’s words, verbatim · CDSS document, May 11, 2023 · control 28-AS-20230501100330

Allegation investigated: Facility staff mishandled residents' food items.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of Resident & Staff Rosters and conducted a tour of facility such as common areas, including the kitchen. LPA reviewed files for Resident #1 (R1) and requested copies of the following documents: Identification and Emergency Information Sheets, Physician Reports, Resident Personal Property and Valuables Sheet and Resident Appraisal. LPA also interviewed Staff #1 (S1) - Staff #3 (S3), and Resident #2 (R2) - Resident #6 (R6). Attempted to interview Resident #1 (R1) but unsuccessful due to R1 out of the facility for a few days for evaluation. *****CONTINUED ON LIC 9099-C***** Unsubstantiated The investigation revealed the following: in regards to the allegation "Facility staff mishandled residents' food items", it is alleged that resident had to remove all of the food stuffs, cold and frozen in the kitchen in less than 24 hours. S1 indicated that residents are allowed to bring their own refrigerator in their rooms to store their food at no extra charge However, S1 indicated that they only store food provided by the facility's contracted vendors in the kitchen's refrigerators/freezers. This is to avoid any food cross-contamination that may cause illnesses to the residents. S1 spoke to R1 on 4/27/2023 personally and explained to him that he has to take his food out of the kitchen storage due to food safety and handling requirements. According to S1 he offered R1 (3) options and agreed to hold R1's food temporarily. S1-S2 transferred R1's food to the big refrigerator in the facility's back storage area. And R1 was given 2-3 days to hold the food at no extra charge and R1 agreed. Other staff members interviewed stated that they do not keep outside food in the kitchen's refrigerator/freezer for safety and to prevent cross-contamination of food. Residents interviewed indicated they were not aware of the allegation. Residents stated that they never asked any kitchen staff to keep the food that they purchased outside. Residents stated that the facility provide enough meals to them daily and they only purchase snacks and fruits if they have extra money. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to the Administrator, Alexander Solorio.the state’s words, verbatim · CDSS document, May 5, 2023 · control 28-AS-20230428085434

Allegation investigated: Resident is not being provided mail.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters. LPA Interview Assistant Administrator Alexander Solario, Staff #1,#2 and #3 (S1,S2,S3), LPA attempt to interview via telephone R1 and interviewed Resident #2-8 (R2-R8). LPA Calderon along side with Assistant Administrator Alexander 'Alex' Solario toured areas were Mail is distributed. In regards to allegation: Resident is not being provided mail.LPA Calderon interview with staff Alex and S1-S3 all who denied the above allegation and stated mail is being distributed to residents daily when mail comes in. (Continuation on LIC9099C) Unsubstantiated Interview with residents R2, R4,R6-R8 all denied above allegation and stated their mail is received and is not open or altered with. Interview with R3 and R6 stated their mail isn't sent to the facility and the above allegation does not pertain to them. LPA Calderon observed with Alex two areas were mail is distributed, mail box is locked, and side door of the facility has a Security Code/ Amazon Key Business Box for packet drop off. LPA Calderon observed mail packets having labels placed and mail was sealed. Although the allegation 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 are unsubstantiated. Exit interview was conducted and a copy of today's report was provided to Alexander Solario, Assistant Administrator.the state’s words, verbatim · CDSS document, May 4, 2023 · control 28-AS-20230426130601

Allegation investigated: Staff failed to provide a safe and comfortable environment for resident.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, Special Incident Reports, Resident #1 (R1) and Resident #2 (R2) : Physican Report, Pre-Placement Apprasial and Apprasial Needs and Service Plan.R2's Behavior Contract, R2's Relocation, Meeting Notes with Case Manager regarding R1 and R2, R1 and Resident #3 (R3) room change refusal, R2's House Rule Agreement, R1 Court Hearing Documents towards R2. LPA Intervierw Assistant Administrator Alexander Solario, Staff #1,#2 and #3 (S1,S2,S3), LPA Interviewed R2's Case Manager and R2's Program Manager and interviewed residents: R1 and R3 , attempt to interview via telephone R2 and Resident #4- Resident #8 (R4, R5, R6,R7) and R8). Continuatuion on LIC 9099-D... Unsubstantiated Regarding allegation: Staff failed to provide a safe and comfortable environment for resident. LPA Calderon interview Assistant Administrator Alex, Staff #1- Staff #3 all denied the above allegation. Alexander and S1 stated to provide a comfortable and safe environment they were having meetings with the case manager to address issues with R1 and R2. S2 and S3 during interviews stated front office staff let us know about issues with R1 and R2 and we would increase supervision and do more rounds and were aware of issues occurring and facility was addressing the situation for residents to feel safe and comfortable. LPA Calderon interviewed Case Manager for R2 and stated Alex would communicate to discuss a plan for residents to be safe/comfortable and meetings were addressed to work on issues for residents. LPA interview with Program Manager stated Alex did have plan for residents to be in a safe and comfortable environment. LPA Calderon interviewed Residents: R3, R4-R7 all denied the above allegation and stated they feel safe and comfortable with the facilities environment, and staff assist when needed. LPA reviewed Special Incident Reports and Meeting Notes with Case Manager all indicated that Case Manager was involved and that facility was taking action for residents to be redirected when issues arised to provide a safe/ comfortable environment. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted and a copy of today's report was provided to Alexander Solario, Assistant Administrator.the state’s words, verbatim · CDSS document, May 4, 2023 · control 28-AS-20230424090141

Allegation investigated: Resident hit another resident with an object resulting in bruising.

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial 10-day complaint visit to investigate the above allegation. LPA met with Assistant Administrator Alex Solorio and discussed the purpose of today's visit. During this visit, LPA obtained a copy of the resident roster, staff roster, Reviewed Resident #1 (R1's) file and obtained relevant documentation: R1's Face Sheet, R1's Physician Report, R1's Appraisal, R1's Needs and Service Plan, Special Incident Reports (SIR's), SOC 341, Hospital Documentation and 30 Day Eviction Notice and Pasadena Police Department Report# PA2023-30741. Interviews were conducted with Assistant Administrator and Staff S 1 and S 2 from 1:15 to 2:20 PM. Interviews were conducted with Resident's R 1 and R 2 from 2:25 to 3:00 PM. In regards to the allegation Resident hit another resident with an object resulting in bruising, based on interviews conducted and information gathered it was revealed in interview with Assistant Administrator that Resident R 1 without warning grabbed a chair and threw it at Resident R 2. Stated that law enforcement was called and video footage showed R 1 throwing the chair. Stated that Staff S 1 was close by and ran to Unsubstantiated incident within seconds and he ran to the incident right away. Said R 1 was still aggressive throwing rocks at the facility window and also being aggressive to staff. Stated that R 1 was sent for a psych evaluation, law enforcement was called and SOC 341, SIR and eviction notice was submitted. Also moved R1 to a different location in the opposite side of the building from R 2. Also provided First Aid for R 2 who had a minor skin tear and didn't need any additional medical assistance. Staff S 1 stated that she was passing breakfast with her cart and was 4 rooms away and heard noise and looked and saw R 1 throw a chair at R 2. Said she dropped everything to go there within seconds and with her walkie talkie called for help and the Assistant Administrator arrived in less than a minute. Staff S 2 said she was with Assistant Administrator and heard caregiver asking for help. Said Assistant Administrator ran right away and First Aid was given and psych evaluation requested,. Interview was conducted with R 1 who stated he did throw a chair and staff helped right away and then he ran out .R 1 during course of interview also was saying random statements such as call Citibank and I will pay you 2 million dollars and that he lives in Burbank and gave a different last name. R 1 said you have the facts and ended the interview not wanting to speak anymore. R 2 stated that R 1 threw a chair at him after he called him loco when R 1 called him stupid. Stated that it hit him in the leg and the caregiver came fast to help him and that R 2 ran away and went outside throwing rocks. Said police were called. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conductedthe state’s words, verbatim · CDSS document, Apr 24, 2023 · control 28-AS-20230418170117

Type of visit: Required - 1 Year

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Tina Doan Caregiver and explained the reason for the visit. Maria Luisa Razo Activities Director arrived 30 minutes later. Facility is licensed to served 97 non-ambulatory residents over the age of 60, of which 30 may be bedridden, and has a hospice waiver for 30. The Facility is a single building located in a residential area and it consist of an office, a conference room, a medication room, a commercial kitchen, a dining room, a library, an activity room, 3 shower rooms, residents room, a courtyard, and a patio. LPA Flores conducted a tour of the facility with Tina Doan Caregiver and observed the following: Commercial kitchen's floors have stains, stove has grease and dust attached, warming trays have grease and burn leftovers, sink is dirty. Walking refrigerator has several moldy and rotten cabbages, a basket of brussel sprouts, and a tub of apples stored. A bag of oatmeal was observed in the pantry's floor and open without any covers or protection. Dining room and library's floor has crumbs under each table, and dry dirty stains in the floor throughout. Each resident's room has a working private toilet, sink and grab bars; sufficient lighting, furniture, and bedding supplies. Water temperature was tested in the following rooms #22, #28,#40,#44,#7,#14,#4 and tested between 97.1 - 121.6 degrees F., which is not within the required 105-120 degrees F. Shower room by room #23 was observed with grab bars and no skid mat available. Restroom by room #23 was observed in working condition water temperature was tested at 118.2 degrees F., and sink cabinet and drawers were observed with growing mold. Shower room by room #16 was occupied at the time of the visit and was not observed. Shower across from room #12 was observed with grab bars, no skid mat available. Laundry room was observed and the bottom of the back walk is peeling with water damage about 3 ft from the floor across the width of the wall. Large trash can adjacent to the laundry was observed with lid open twice, the trash can contained diapers and liners disposed. (CONTINUED LIC 809C) LPA conducted file review for 5 staff/ 5 residents and reviewed medication for 5 residents. Administrator does not have TB test on file and Med-Tech does not have medication training hours on shadowing completed or initial training signed, and a physician's report/TB is missing. During resident file review it was noticed that resident #5(R5) does not have a TB test on file and residents #1(R1) and #2(R2) do not have a signed admission agreement. Facility's outdoor area provides covered sitting area, no large bodies of water were observed. Facility has a sprinkle fire system throughout. Fire extinguishers were observed and last checked on 5/18/22. Local Ombudsman and Let Us Know posters were observed. Certificate # 60132006740 with expiration date 3/15/24 for Kandice Vergara was observed. A copy of liability insurance was provided to LPA . LPA Flores interviewed 4 staff and 4 residents. LPA was not able to complete the following domains during this visit and will return at a future time to finish the following: Planned Activities, Incidental Medical and Dental, Disaster Preparedness, and Resident with Special Health Needs. Exit interview was conducted with Maria Luisa Razo Activities Director and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 22, 2023

Allegation investigated: Staff are not cleaning resident's room. Staff are not doing resident's laundry timely. Staff do not provide resident with enough linens.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, laundry schedule, bedding schedule, Linen invoice and housekeeping schedule, toured various Resident bedrooms and linen storage, interviewed Staff #1 to #5 in the office and interviewed Residents #1 to # 7 in the office. In regards to the allegation: Staff are not cleaning resident's room. Interviews with 5 of 5 Staff indicate Resident's rooms are clean on a regular basis and on an as needed basis. Interviews with 7 of 7 Resident indicate that their rooms are clean on a regular basis and also on an as needed basis. Review of the Housekeeping schedule indicate Resident's rooms are cleaned on a regular basis. LPA toured various Resident bedrooms and observed the bedrooms to be clean. Continue to LIC9099C...... Unsubstantiated In regards to the allegation: Staff are not doing resident's laundry timely. Interviews with 7 of 7 Residents indicate that laundry is done at least once a week and on an as needed basis. Residents also stated that laundry is done timely. Interviews with Staff also indicate laundry services is done timely at least once a week and on an as needed basis. Review of the laundry schedule indicate Staff is scheduled to perform laundry services everyday. In regards to the allegation: Staff do not provide resident with enough linens. LPA toured the linen storage areas and observed the facility to have sufficient linen supplies such as bedsheets, blankets and towels. Interviews with 7 of 7 Residents indicate that they are provided enough linens. Interviews with 5 of 5 Staff also indicate Residents are provided with enough linens. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 28, 2023 · control 28-AS-20230320081049

Allegation investigated: Resident's room has no call light. Resident's needs are not being met by staff. Staff is not treating resident with dignity. Staff are retaliating against resident.

Licensing Program Analyst (LPA) Ashley Calderon conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with Alexander Solorio and discussed the purpose of today's visit. During this visit, LPA obtained a copy of the resident roster, staff roster, Resident #1 (R1's) file and obtained relevant documentation: R1's FaceSheet, R1's Physician Report, R1's Medical Consent Form, Pre-Placement Appraisal Information, R1's Appraisal, R1's Care Plan, R1's Appraisal/Needs and Service Plan Special Incident Reports,R1's Medical Refusal, Email with R1's Psychiatric Social Worker and Clinical Program Manager, R1's Behavior Contract, R1's Call Button Pendant Agreement. Fire Alarm Notice. LPA toured common areas and R1's bedroom. LPA interviewed Assistant Administrator Alex, Staff #1-4 (S1-S4), attempt interview with Resident#1 and #6 (R1 andR6) and interviewed Resident #2-5 and #7 (R2-R5 and R7), attempt to interview R1's Psychiatric Social Worker and interviewed R1's Clinical Program Manager via telephonically. Continuation on LIC 9099-C... Unsubstantiated Regarding Allegation: Resident's room has no call light. LPA Calderon interviewed staff Alex, S1-S4 stated that residents usually who have restrictions and are bedridden are ones with call button pendants. Alex, S2 and S3 stated R1 has a call button pendant. LPA Calderon observation when touring facility, building is a one story building, does not have separate floors or units. LPA Calderon reviewed R1's call button pendant Agreement stated responsibilities when receiving a pendant. Regarding Allegation: Resident's needs are not being met by staff. LPA Calderom interview staff Alex, S1-S4 all denied above allegations stating residents are receiving services to met their needs. Staff provide laundry service, food service, transportation when needed and medical services when required. Staff all stated R1 at times refuses help by staff as R1 is independent. LPA interviewed R2-R5 and R7 all denied allegation and stated they are assisted by staff to met their needs like staff clean, do laundry and provide meals. Regarding Allegation: Staff is not treating resident with dignity. LPA Calderon interviewed staff Alex and S1-S4 all denied allegation stating all residents are treated with dignity and respect and are do not treated any different. LPA Calderon interviewed R2-R5 and R7 and denied above allegation stating staff treat them with dignity and respect and have not observed staff treating residents disrespectfully. Regarding Allegation: Staff are retaliating against resident. LPA Calderon interviewed Staff Alex, S1-S4 all denied above allegation stating they do not retaliate and they respect and treat residents the same, staff talk calm and talk with residents. LPA interviewed R2-R5 and R7 stating staff do not retaliate against them or other residents. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted and a copy of this report was provided to Alexander Solorio/Assistant Administratorthe state’s words, verbatim · CDSS document, Mar 27, 2023 · control 28-AS-20230324105203

Allegation investigated: Staff do not provide adequate food service to resident Staff are not meeting resident's dietary needs Staff do not assist resident with toileting needs Staff do not respond to resident's calls for assistance Staff do not provide water to resident

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegations. LPA met with Alexander Solorio and discussed the purpose of today's visit. During this visit, LPA obtained a copy of the resident roster, staff roster, menus and shift-to-shift reports/notes. LPA reviewed Resident #1 (R-1's) file and obtained relevant documentation. LPA interviewed the Assistant Administrator, Staff #1 (S-1) through Staff #3 (S-3) and Resident #1 (R-1) through Resident #7 (R-7). LPA also conducted a tour of the kitchen. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff do not provide adequate food service to resident. Staff interviews revealed that staff provide adequate food service to residents. Staff indicated they follow a menu and also provide alternative food items for residents. Staff interviews revealed they have only received complaints from R-1 about R-1’s food. Per Staff interviews, R-1 alleges that the food provided has pepper in which R-1 alleges to be allergic to. Per Staff, R-1 requests to have baked chicken, baked potato, rice and bread for R-1’s meal and when R-1 does not like it, R-1 throws it away. Interviewed staff indicated that R-1’s meals are prepared as per R-1’s request (with no pepper/no chili). Per Staff, R-1 is also offered fruits/snacks daily. Interviews Residents indicated the staff provide adequate food service including snacks and do not have any concerns. Interviewed Residents indicated that the food portions and options are adequate. Interviews do not corroborate this allegation. Allegation: Staff are not meeting resident's dietary needs Staff interviews revealed that staff meet residents’ dietary needs. Per interviewed staff, kitchen staff are aware of the Residents dietary needs. Staff interviews revealed that there is a board in the kitchen which reflects Residents dietary needs (diabetic, no/low salt, food allergies, preference, ect). LPA toured the kitchen and observed this board posted. Per Staff interviews and R-1’s file review, R-1 is not on a special diet. However, per staff interviews, they have R-1 noted as having a “preference of no pepper/chili pepper or any pepper” noted. Interviewed Residents indicated staff are meeting residents’ dietary needs. (4) out of (7) interviewed Residents are on a diabetic diet. Interviewed Residents indicated they do not have any concerns in regards to their diets. Interviews do not corroborate this allegation. Allegation: Staff do not assist resident with toileting needs Staff interviews revealed that staff assist/meet residents’ toileting needs. Interviewed staff indicated they conduct rounds every (2) hours and check if residents need assistance with toileting needs and/or incontinence care. Staff indicated they have a list of Residents that require assistance with incontinence needs and do not have a log of when the rounds are conducted. Staff interviews revealed they have only received complaints from R-1 about R-1’s alleging that R-1’s toileting needs are not being met. Per staff interviews, R-1 “refuses to be touched” and staff attempt to assist R-1 as much as possible. (6) out of (7) interviewed Residents indicated staff conduct rounds often and provide assistance/incontinence care every (2) hours. Interviewed Residents indicated they do not have concerns with staff meeting their toileting needs. Interviews do not corroborate this allegation. **Refer to LIC 9099C for the continuation of this report.** Allegation: Staff do not respond to resident's calls for assistance Staff interviews revealed that staff respond to Residents calls in a timely manner. Interviewed Staff indicated they have not received any concerns/complaints from anyone in regards to staff not responding to residents calls for assistance. (6) out of (7) interviewed Residents indicated staff respond to their calls in a timely manner. Interviewed Residents indicated they do not have concerns with staff not responding to their calls. Interviews do not corroborate this allegation. Allegation: Staff do not provide water to resident Staff interviews revealed that staff provide water to residents. Staff interviews revealed they have only received complaints from R-1 about R-1’s not receiving hot water. Per Staff interviews, R-1 is provided with hot water as per R-1’s request. Per Staff interviews, R-1 only consumes hot water and when it cools off, R-1 requests hot water which is provided to R-1. Interviewed staff have not received concerns/complaints from other Residents in regards to staff not providing residents with water. (6) out of (7) interviewed Residents indicated staff provide Residents with water. Interviewed Residents indicated they do not have concerns with staff not providing residents with water. Interviews do not corroborate this allegation. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted, Appeal Rights and a copy of this report was provided to Alexander Solorio/Assistant Administratorthe state’s words, verbatim · CDSS document, Mar 23, 2023 · control 28-AS-20230317151530

Allegation investigated: Staff had inappropriate interactions with resident in care

Licensing Program Analyst (LPA) Alberto Lopez conducted an initial complaint visit for the above stated allegation. LPA met with Assistant Administrator Alex Solorio and explained the reason for the visit. The investigation consisted of: LPA conducted an interview with Assistant Administrator Alex Solorio S1 and 4 additional staff S2-S5 LPA also interviewed Residents 1-7 (R1-R7) LPA also obtained copies of Staff and Client Rosters, sign in sheets for 02/2023 and 03/2023. LPA attempted to interview Visitor (V1). LPA also collect copiy of incident report 03/11/2023 and R1 physician’s report. (Continued on 9099C) Unfounded (Continued from 9099) Regarding Allegation: Staff had inappropriate interactions with resident in care. It is alleged that R1 had inappropriate relations with a visitor (V1). Administrator S1 stated that the alleged staff is not a staff at facility and not a volunteer but is rather a visitor of resident (R1). Assistant Administrator (S1) stated that V1 was introduced as R1’s girlfriend. R1 refused to discuss this allegation with LPA. Seven (7) out of 7 residents did not corroborate the allegation and some expressed shock that LPA would ask such a question. Several residents stated that all staff are very nice and do not know of any residents having inappropriate interactions with staff. LPA interviewed five (5) staff, and all stated they are unaware of any inappropriate interactions between staff and residents. Several staff stated they knew V1 to be girlfriend of R1 and that is how R1 introduced V1. LPA attempted to interview W1 and was unsuccessful. The investigation revealed that V1 is not an employee or volunteer at this facility. This agency has investigated the complaint alleging, Staff had inappropriate interactions with resident in care. We have found that the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened and/or are without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Assistant Administrator Alex Solorio. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 21, 2023 · control 28-AS-20230313152725

Allegation investigated: Staff are retaliating against resident for complaining. Staff do not ensure residents are prohibited from smoking when oxygen is in use. Staff does not ensure resident is accorded privacy during phone calls.

Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit in reference to the above allegations. LPA met with Assistant Administrator Alexander Solorio. The investigation consisted of the following: A tour of the interior and exterior physical plant was conducted. The physical plant tour focused on observation of rooms in which there are resident smokers and/or there is Oxygen in use. Staff (S1- S5) and residents (R1 - R10) were interviewed. The following documents pertaining to R1 were reviewed and obtained: Identification and Emergency Information, Preplacement Appraisal Information, Functional Capability Assessment, Resident Appraisal, Care Plan, Appraisal/Needs and Services Plan, Physician Report, House Rules, and Admission Agreement. Resident resident roster, and LIC 500 Personnel Report. Resident (R2's) Behavior Contract, resident rosterm and LIC 500 Personnel Report were also obtained. See LIC 9099C for report continuation. Unsubstantiated Allegation: Staff are retaliating against resident for complaining. It is alleged that facility staff are retaliating/harassing resident (R1) because on 3/17/2023 the resident was provided a 2nd copy of the House Rules after filing a previous complaint with Community Care Licensing. According to staff interviews conducted, the findings indicate that the resident has history of smoking cigarettes in the room and during a prior CCL visit conducted by another LPA it was noted that R1's room had a strong marijuana odor. All staff denied the allegation, but confirmed the No Smoking policy has been addressed with the resident in a non-retaliatory manner. A total of 10 residents were interviewed. Two (2) out of the 10 residents stated that administration staff have retaliated against them in instances in which they complain about other residents, and/or when they complain about staffing not doing their job after daytime hours. The facility House Rules state "In order to promote a healthy environment in the facility, we have established a "No Smoking" policy in ALL INDOOR common areas and rooms. Smoking is however, permitted in the designated smoking areas only. The "No Smoking" policy includes all elevators, hallways, stairwells, public restrooms, courtyards, and patios." Therefore, there is in insufficient evidence to corroborate the allegation. Allegation: Staff do not ensure residents are prohibited from smoking when oxygen is in use. It is alleged that there is a resident that lights up cigarettes in its room and there is oxygen tanks in the room. The findings revealed that resident (R2) has been observed by staff and residents smoking inside the room, in which there in oxygen in use. According to Assistant Administrator, R2 has been observed lighting a cigarette in the room and walking out of the room to go smoke in the outdoor designated smoking area. Three (3) out 10 residents stated they have observed R2 smoke in the room where oxygen is in use. The residents confirmed that R2 has been addressed regarding the No Smoking policy and Oxygen Use. Staff stated that when and if they observe any resident smoking indoors they are immediately reminded that smoking is prohibited indoors. In addition, staff are trained to watch out for indoor smoking by residents. Per staff interviews, on 2/2/2023 resident (R2) was issued a Behavior Contract that discussed House Rules, No Smoking policy, and smoking area escort assistance. Staff are closely watching the resident to ensure no indoor smoking is being done. See next page. Allegation: Staff does not ensure resident is accorded privacy during phone calls. It is alleged that on 3/17/2023, the Assistant Administrator attempted to eavesdrop on R1's phone conversation, and was overheard asking hospice staff to tell him if the resident was making a call to Community Care Licensing. A total of five (5) staff were interviewed. All denied the allegation by stating that residents are always accorded privacy while they are using their phones in their rooms, lobby areas, and when they use the facility wireless telephone. Three (3) out of 10 residents stated that Administrator and staff seem to target specific residents. For instance, a resident stated that staff do not knock at the door or announce themselves and enter while they are talking on the phone. Another resident stated that Administrator seems to eavesdrop only on certain people. However, the majority of the residents stated that they are afforded privacy by facility staff, and that Administrator does not eavesdrop, but rather stops by the resident rooms to see how they are doing. LPA observed a wireless facility phone in the lobby area, and another phone located in the private marketing office that can be used by residents. There is insufficient evidence to support the allegation. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 Exit interview was conducted with Assistant Administrator Alexander Solorio. A copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 21, 2023 · control 28-AS-20230317135930

Allegation investigated: Staff failed to intervene in confrontation between residents. Staff does not ensure resident's privacy is protected. Staff threatened resident with eviction.

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation for the allegations listed above. LPA met with Assistant Administrator, Alex Solorio, and explained the purpose of the visit. The investigation consisted of the following: LPA obtained the staff roster, resident roster, and reviewed 2 resident files. Copies of Resident #1's (R-1) documents were obtained. LPA interviewed the Assistant Administrator, 4 Staff, and 6 Residents. The investigation revealed the following: Allegation - Staff failed to intervene in confrontation between residents. It is alleged that Resident #1 (R-1) had a confrontation with Resident #2 (R-2) and staff did not intervene. LPA interviewed the Assistant Administrator Solorio and 4 Staff. Unsubstantiated Staff who witnessed the incident, stated that R-1 wanted to talk to R-2’s roommate. Staff stated that R-1 became upset because R-2 was trying to prevent R-1 from having interaction with the roommate and verbally threatened R-2. Staff immediately intervened, told R-1 to step away, and tried to de-escalate the situation. Later that day, R-2 felt threatened again as R-1 attempted to visit the roommate and contacted the police without informing staff. Per Mr. Solorio, after the confrontation that occurred on 3/5/23, he contacted R-1's case worker to inform of the incident. They held a meeting with R-1 and placed resident on a behavior contract on 3/10/23. Staff interviewed stated they will intervene in any altercations between residents immediately upon hearing or seeing it occur. They want to make sure all residents are safe. 6 out of 6 residents interviewed have seen staff intervene whenever there are any altercations between residents. Based on information gathered, there is insufficient evidence to show that staff failed to intervene in confrontations between residents. Allegation - Staff does not ensure resident's privacy is protected. It is alleged that staff allow residents to enter another resident's room without their permission. Staff interviewed stated they ensure residents are accorded privacy. They will knock and asked for permission before coming in. They are constantly monitoring residents to make sure they are safe and their privacy are respected. If they see a resident going to the wrong room, they will redirect the resident. However, they stated the residents are respectful and have seen them knock on the room door and ask for permission before they entered. 5 out of the 6 residents have not had anyone enter their room unattended and feels their privacy is protected here. Allegation - Staff threatened resident with eviction. Per the Assistant Administrator, he has not threatened any residents with an eviction notice. He will explain to residents that certain behaviors and breaking the house rules could lead them to an eviction. Staff interviewed have not threatened to evict residents either. 5 out of the 6 residents interviewed have never been issued an eviction letter nor been threatened with one. One stated an eviction was issued due to not fully paying the rent. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Assistant Administrator Solorio. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 16, 2023 · control 28-AS-20230310104544

Allegation investigated: Resident call buttons are in disrepair. Staff are not meeting residents laundry needs. Staff are not meeting residents showering needs. Facility dryer is in disrepair. Staff are not meeting residents bedding needs.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander 'Alex' Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, Resident #1 (R1) Physician Report, R1's Needs and Appraisal Plan, R1's Admission Agreement,R1's Care Plan, R1's Special Incident Reports (SIR), R1's Call Light Pendant Agreement,facilties laundry Schedule and Shower/Bedding Schedule.LPA interviewed Assistant Administartor and Staff #1- #4 (S1-S4) . LPA Calderon attempt to interview R1, interviewed Resident #2-#5 (R2-5). LPA toured along side with Luisa Razo laundry room and LPA tested residents call buttons. Continuation on LIC9099D... Unsubstantiated In regards to allegation: Resident call buttons are in disrepair. LPA Calderon interview staff, Alex and S2-S4 all denied above allegation stated some resident's have pendants for call buttons and in addition staff do rounds to check on residents. LPA Calderon interview residents R2-R4, all denied above allegation and stated call button are pendants and work. LPA observed and tested resident call button pendants and were functional and operable. LPA also observed a purchase of new pendants that will be distributed to residents once activated. LPA reviewed R1's documentation on Pendant Agreement / Responsibility. In regards to allegation: Staff are not meeting residents laundry needs.LPA interviewed S1 and S2 who do not work in the laundry services and laundry services are not part of their job duties. LPA interviewed Alex, S3 and S4 all who denied above allegation and stated laundry is done weekly, there is a laundry schedule and laundry if needed more if residents are soiled staff will assist. LPA interview resident R2-R4 all denied above allegation and stated their laundry needs are met and staff do laundry service for residents.LPA collected and reviewed Laundry Schedule, residents received laundry services once a week on schedules days and LPA toured laundry room and observed laundry being done for residents in care. In regards to allegation:Staff are not meeting residents showering needs. LPA Calderon interviewed staff Alex, S4 and S3 denied above allegation and stated resident's have shower days twice a week or as needed if requested based on solid incidents. Alex stated upon second shower of the week refusal facility documents refusal and resident's sign documentation. LPA Calderon interviewed resident R2-R4 and all denied allegation stating they take showers, they receive towels and have scheduled shower days if assistance is needed. LPA Calderon observed and reviewed Shower Schedule, residents are scheduled to receive showers twice a week. LPA reviewed R1's SIRs on shower incidents, R1 refused shower and LPA reviewed facility documentation on R1's shower refusals. In regards to allegation:Facility dryer is in disrepair. LPA Calderon interviewed staff Alex and S1-S4 all denied above allegation and stated dryer machines are operable. S1 stated during interview S1 checks on laundry machines regularly for any needed repairs and facility is scheduled to receive new commercial washer and dryers. LPA interviewed resident R2-R4, all denied above allegation stating machines work, staff does laundry for residents.LPA observed laundry room, laundry machines were in use and functioning. Dryer machine was running and operable. Laundry room is used by staff only. Continuation on LIC 9099D. In regards to allegation: Staff are not meeting residents bedding need. LPA interview staff Alex and S3 and S4 all denied above allegation stated resident receive clean linen and bed sheet change based on shower schedule days and as needed. Interview with S1 and S2 stated job functions do not involve bedding services but machines are clean and operable to do laundry for linen. LPA interviewed resident R2-R4 all denied above allegation stated bed sheets are changed, and when requested for new cleaned staff provided bedding services. LPA reviewed Shower / Bedding Schedule. Residents are scheduled to receive showers twice a week and on scheduled shower days cleaning of bedding is scheduled for the same day. LPA Calderon reviewed R1's SIR on bedding incidents and SIR's state staff providing sheet change for R1's bed. Based on LPA's interviews and record review, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 14, 2023 · control 28-AS-20230306153126

Allegation investigated: Staff not assisting resident with ADLs. Staff did not observe changes in resident's health.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced visit at the facility for the purpose of investigating and deliver findings to the above-mentioned allegations. LPA Pena met with Assistant Administrator Alexander Solorio and explained the purpose for the visit. During the initial visit on 9/29/2020, Licensing Program Analyst (LPA) Renee Arterberry conducted an unannounced 24 Hour Health and Wellness Check telephonically and virtually (via FaceTime) with Alexander Solorio facility administrator and facility nurse Marisol Cruz, employees of the facility. LPA Arterberry interviewed S1-S2, reviewed the facility file for R1, obtained copies of the following documents: Identification Page/Face Sheet, Pre-Appraisal Assessment, Medication Administration Record (MAR), Admission Agreement, Medical Assessment, Unusual Incident Reports (SIR) and hospice documents. LPA Arterberry also toured the physical plant: kitchen, dining room, and medication room. During the subsequent visit on 2/17/2023, Licensing Program Analyst (LPA) Bennette Pena conducted a tour of the physical plant and obtained copies of the following documents: current resident/staff roster and R1's files such as: Face sheet, Physician's Report, Admission's Agreement, Resident Appraisal, Hospice Health Information, Incident Reports and Medication Administration Records (MARs) for Aug 2020-Oct 2020. LPA also interviewed Resident #2 (R2) - Resident #6 (R6), Staff #1 (S1), Staff #3 (S3), Staff #4 (S4) and telephonically interviewed Staff #2 (S2). During today’s visit, Licensing Program Analyst (LPA) Bennette Pena obtained additional documents for R1 such as: National Rehab Center Discharge Instructions (dated 8/11/2020), Plan of Care (POC) Summaries (dated 9/09/2020, 9/24/2020), Physician’s medication order (dated 10/02/2020) and Huntington Hospital Discharge Instructions (dated 10/02/2020). *****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Regarding allegation: "Staff not assisting resident with ADLs." It is alleged that R1 was weak and in severe discomfort, has been in pain for 8 days and constipated for 3 days with a pain level of 10 out of 10 and nausea level 8 out of 10. Based on documents reviewed, on 9/23/2020 R1 was admitted at Huntington Hospital and assessed by EMS. EMS observed R1’s “urine in the Foley to be dark in color and cloudy”. LPA reviewed R1’s Medication Administration Record (MAR) for Sep 2020 and it revealed that R1’s medication Zofran was not administered, and pain medication Morphine was last given on 9/20/2020 & 9/21/2020, two (2) days prior to R1’s hospitalization. Hospice communication log revealed that on 9/21/2020, Hospice RN reported the following: R1’s Foley catheter was not changed the night before, Foley was leaking around and Foley drainage slightly cloudy. (5) out of (6) residents interviewed indicated that they are independent in many ways, and they only need assistance with medication. Interviews conducted with staff members indicated that the Med-Tech and Caregivers were trained to clean and drain the Foley catheter bag. Staff also revealed that the facility’s daily notes and log were communicated verbally. Regarding allegation: “Staff did not observe changes in resident's health.” It is alleged that R1 started experiencing pain two (2) days after a Foley catheter was placed. But facility staff do not check on R1 enough and that he has been in pain for 8 days and constipated for 3 days with a pain level of 10 out of 10 and nausea level 8 out of 10. Based on documents reviewed, on 8/11/2020, R1 was admitted for care at the facility per admission agreement. Then R1 was admitted on 9/23/2020 at Huntington Hospital and assessed in by EMS, “urine in the Foley to be dark in color and cloudy”, “weak and in severe discomfort, with a pain level of 10 out of 10 and nausea level 8 out of 10.” EMS observed “rigidity, pain, distension, and tenderness in all four quadrants” of R1. (5) out of (6) residents interviewed indicated that they are able to do daily living activities on their own and they only need assistance with medication. Interviews with the staff revealed that there were enough staff per shift to check on residents and the facility’s daily notes and log were only communicated verbally. Based on LPA’s interviews, and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to the facility failed to observe changes in resident’s health which resulted in resident experiencing severe pain and discomfort while in care. Refer to LIC 421IM*** At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date. An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.the state’s words, verbatim · CDSS document, Mar 10, 2023 · control 28-AS-20200925154403

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87459(a)(5)(B) · Plan of correction due date: Mar 13, 2023

87459 Functional Capabilities ...(a) The facility shall assess ....personal assistance and care ... to perform specified activities of daily living...(5) Continence, including: (B) Whether assistive devices...catheter are used. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that R1's need for personal assistance and care was not met as R1 was observed in by EMS, “urine in the foley to be dark in color and cloudy” which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2023

Plan of correction: The Administrator will implement a Restricted Health Condition Care Plan in place and have a licensed professional provide training to all staff on catheter care and assistance. Proof of staff training including topics covered, duration and the name and signatures of staff and the licensed professional, shall be submitted to LPA Bennette Pena by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 13, 2023

87466 Observation of the Resident..The licensee shall ensure...observed for changes in physical, mental, ...functioning ....appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that the condition that the resident was observed in by EMS, “urine in the foley to be dark in color and cloudy”, “EMS observed rigidity, pain, distension, and tenderness in all four quadrants” and “R1 was weak and in severe discomfort with a pain level 10 out of 10 and nausea level 8 out of 10" which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2023

Plan of correction: Administrator to provide an in-service training on Observation of the Resident regulations. Administrator will submit a copy of the training sign-in log with staff names and signatures, date, duration of training, name of trainer and curriculum used to LPA Bennette Pena by POC due date.

Allegation investigated: Facility staff did not provide resident adequate supervision resulting in resident wandering away from the facility.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters, Resident #1's (R#1) Physician's Report, Appraisal/Needs and Services Plan and Preplacement Appraisal Information. LPA also interviewed Staff #1, #2 in the office and attempted to interviewed R#1 but R#1 is currently out of state and was not available to be interviewed. In regards to the allegation: Facility staff did not provide resident adequate supervision resulting in resident wandering away from the facility. Interviews with Staff #1 and #2 indicate R#1 is able to leave the facility unassisted and does not have wandering behaviors. Review of R#1's record indicate R#1 does not have wandering behaviors and is able to leave the facility unassisted. Continue to LIC9099C..... Unsubstantiated Based on LPA's interviews and record review, the investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2023 · control 28-AS-20230227093847

Allegation investigated: Staff did not provide adequate supervision to resident resulting in resident wandering away from facility.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander "Alex" Solorio (Assistant Administrator) and explained the purpose of the visit. On 3/1/23, LPA Calderon called Pasadena Police Department to request documentation of an incident report, Deputy Veronica stated no report provided only incident number given: Incident number: #2314334. During today's visit on 3/2/23, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R1) Admission Agreement, Physician Report, Face Sheet, Hospital Report and Unusual Incident Report. LPA interviewed Alex Solario, Staff #1 (S1) and attempt interview R1. Continuation on LIC9099-C... Unsubstantiated In regards to the allegation: Staff did not provide adequate supervision to resident resulting in resident wandering away from facility. LPA Calderon interviewed Alex Solorio whom stated R1 is able to leave the facility unassisted and received care by the Hospital. LPA interviewed S1 who stated they knew R1 was going to the community and R1 is able to leave the facility. LPA attempt to interview R1, unsuccessful as R1 was out in the community for the day. LPA reviewed R1's Physician Report which states :Yes R1 Able To Leave Facility Unassisted. Based on LPA's interviews, record review and observations, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 28-AS-20230223095854

Allegation investigated: Resident developed multiple pressure injuries Staff are not preventing the spread of infection Staff are retaining a resident that requires a higher level of care Staff does not ensure that resident receives adequate wound care

**** This amended report supersedes report dated 03/02/2023. It was created to add additional interview responses of staff and residents on 9099C. The additional revision did not change any other aspects of the report and all aspects including the findings remain the same. *** Licensing Program Analyst (LPA) Alberto Lopez made unannounced subsequent visit to investigate the above allegations. LPA Lopez met with Assistant Administrator Alex Solorio and discussed the purpose of the visit. Initial 10 day visit was conducted telephonically by LPA Joe Katrdzhyan on 10/27/2020 The investigations consisted of reviewing and obtaining relevant medical documentation from R1 and interviews with staff and residents. Regarding allegation: Resident developed multiple pressure injuries. Assistant Administrator S1 stated that resident arrived to the facility with pressure injuries and was receiving wound care from Pacific Pace and Mission Hospice at the time. 5/5 staff (S1-S5) stated that no (CONTINUE ON 9099C) Unsubstantiated resident has developed a pressure injury while in care. LPA interviewed 2 residents with current wounds and 2/2 residents (R2-R3) stated they arrived at facility with wounds and did not develop them at the facility. LPA also interviewed additional 5 residents (R4-R8). R4–R8 stated they do not know any residents with pressure injuries, and they do not have any. LPA reviewed documentation from Pacific Pace and Hospice along with R1 medical records and it documented R1 wound(s) prior to being admitted to facility. Regarding Allegation: Staff are not preventing the spread of infection. Assistant administrator S1 stated that they have an infection control plan. LPA reviewed infection control plan and all staff 5/5 stated they follow the plan to prevent infection. LPA observed a large bin in a secured area where all biohazard material is place for disposal. 5/5 stated they are specific procedures to prevent the spread of infection and denied ever walking or seeing others walk or step in biohazard infectious liquids. 2 of 2 of residents who currently received wound care stated that all biohazard material is disposed in proper manner. R4-R8 stated that facility does everything they can to prevent infection spread. LPA took tour of facility with assistant administrator and did not notice any infectious material or fluids anywhere in the facility rooms or common areas. LPA observed large container in locked closet where all biohazard material is placed for proper disposal by contractor Allegiance Specialty Pharmacy. LPA observed a sign on the container with “BIO-HAZARD” on it. Regarding Allegation: Staff are retaining a resident that requires a higher level of care. Assistant Administrator (S1) stated that facility does not retain residents that require higher level of care. S1 stated R1 came in at level 2 and the facility can care for residents up to level 4. When R1 arrived the facility, the facility along with Pacific Pace and Hospice provided all of resident’s needs. 5/5 staff interviewed stated they have not seen or know of any residents that require higher level of care residing at facility. 5 of 7 residents stated that they are happy with the care they receive and know of no other residents that requires higher level of care. 2 residents stated that one resident is loud and wish they had a room further away, but not sure resident requires higher level of care. Regarding Allegation: Staff does not ensure that resident receives adequate wound care. Assistant Administrator stated that facility, Pacific Pace and Mission Hospice was providing resident with proper wound care. LPA reviewed facility progress notes for R1 dated from 10/06/2020 to 03/21/2021 and it documented all care including wound care provided to R1. 5/5 staff interviewed stated that mostly all wound care is done by outside agencies like home health or Hospice and that facility ensured that R1 received proper wound care while at facility. 2/2 current residents that require wound care stated they are getting proper wound care and happy with the services. The other 5 residents R4-R8 stated they do not know anyone who receives wound care and unable to answer this question. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies noted nor any citations issued at this time. Exit interview conducted and a copy of this report provided to Assistant Administrator Alex Solorio along with appeal rights.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 28-AS-20201027140928

Allegation investigated: Facility is not able to meet the needs of residents due to inadequate staffing. Staff failed to meet resident’s toileting needs in a timely manner. Facility staff are not competent on how to use a hoyer lift. Facility is unsanitary. Facility staff failed to keep the facility in a comfortable temperature for residents.

Licensing Program Analyst (LPA) V. Maldonado made an subsequent unannounced visit at the facility for the purpose of invstigating the above-mentioned allegations. LPA Maldonado met with Assistant Administrator Alexander Solorio and explained the purpose for the visit. On 07/23/20, LPA. Joe Katrdzhyan made an initial visit that was conducted telephonically with Exective Director Kandice Vergara, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures. During that visit, LPA Katrdzhyan requested the following documents for Resident# 1 (R1): Pre-placement Appraisal Information, Functional Capability Assessment, Physician's Report, Appraisal/Needs and Services Plan, Physician's order for a hoyer lift, Staff training conducted on the use of a hoyer lift, Resident Roster and Staff Roster. (Report Continued on LIC9099-C...) Unsubstantiated During today's visit, LPA conducted a tour of the physical plant with Alexander and obtained a copy of the resident/staff roster, staff training conducted on the use of a hoyer lift and the following documents for Residents# 1-8, (R1-R8): Facesheet, Physician's Report, Needs and Services Plan. LPA also requested the following for R1: Physician's order for a hoyer lift and incident reports for R1 for the months of July-August 2020, and interviewed Staff# 1-4 (S1-S4) and R2-R8. The investigation revealed the following: Regarding allegation: Facility is not able to meet the needs of residents due to inadequate staffing. It is alleged that the facility is short staffed to operate safely, with only 2 caregivers for 42 residents. Per interviews conducted, (4) of (4) staff state there are 2 caregivers per shift, with the majority of the residents being independent and requiring minimal assistance with their Activities of Daily Living (ADL). (6) of (8) residents stated that all of their needs are being met. After review of the documents obtained for R1-R8, none of the residents require a 1:1 assistance/supervision. This allegation is unsubstantiated. Regarding allegation: Staff failed to meet resident’s toileting needs in a timely manner. It is alleged that R1 waited for 3 hours to be removed from the commode (toilet) after taking staff 2.5 hours to be taken to the commode. (4) of (4) state that residents are assisted within 5-10 minutes of their requests, and residents who require toileting assistance are regularly checked on every 2 hours. (1) of (8) residents state that they require assistance with toileting and are assisted timely. This allegation is unsubstantiated. Regarding allegation: Facility staff are not competent on how to use a hoyer lift. It is alleged that there is a hoyer lift in the facility, but staff do not know how to use it. (4) of (4) staff state that training was provided via videos and in-person by the assistant administrator and is currently being used for 2 residents. (6) of (8) residents state they do not require transfer with a hoyer and staff assist them by lifting them between 2 caregivers. All residents denied being hurt by transfer or being concerned with the staff training on assistance with transferring them. This allegation is unsubstantiated. Regarding allegation: Facility is unsanitary. It is alleged that a resident observed urine on the floor and the facility smelled like feces. LPA conducted a tour of the physical plant and common areas and observed housekeeping cleaning the hallways and rooms. LPA did not smell or observe urine or feces. (4) of (4) staff state the facility is cleaned daily and as needed. (6) of (8) residents denied the allegation and stated the facility is kept clean and sanitary. This allegation is denied. (Report Continued on LIC9099-C...) Regarding allegation: Facility staff failed to keep the facility in a comfortable temperature for residents. It is alleged that one side of the building is 20 degrees cooler than the other side and the AC is kept running all night making it really cold. LPA observed the electrical room where the thermostats are located and observed 11 thermostats, all set to 76*F. (4) of (4) staff state that if residents have concerns about the temperature, the staff will adjust it to accommodate the residents. (6) of (8) residents denied the allegation and stated that if they have concerns about the temperature, staff will adjust it to accommodate them. This allegation is unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Feb 16, 2023 · control 28-AS-20200714152111

Allegation investigated: Facility does not ensure that food of good quality is being served to residents in care.

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander "Alex" Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R1) Admission Agreement, Alex will send LPA Calderon an email on R1 shower and housekeeping refusal. LPA obtained facility laundry schedule for residents, residents shower schedule, food menu, food alternative slips, Staff #1, Staff #2 and Staff #6 (S1, S2 and S6) food handler training certifications. LPA Calderon alongside with Alex toured kitchen/cafeteria, three resident showers, residents rooms: Room 1,Room 33, Room 39,Room 40, and Room 46 and laundry room. LPA Interviewed Staff #1- #5 (S1-S5), attempt interview Staff #7 (S7) and interviewed Residents #2-6 (R2-R6). Continue to LIC9099C.... Substantiated Allegation: Facility does not ensure that food of good quality is being served to residents in care. LPA Calderon along side with Assistant Administrator Alexander Solorio and S2 observed old rotten, molded / fungus and discoloration vegetables and fruits in storage room, being in unsanitary condition for residents to consume. Based on LPA Calderon interviews conducted with R2, R3, R5 the statements obtained were consistent and corroborated with the allegation that facility is not ensuring the food quality residents are being served. Based on LPA’s observations and interviews which were conducted: the preponderance of evidence standard has been met, therefore the above allegation are found to be Substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8, Article 6 ), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Alexander Solorio along with the Appeals Rights.the state’s words, verbatim · CDSS document, Feb 14, 2023 · control 28-AS-20230207105455

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Feb 15, 2023

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. The requirement is not met as evidenced by: Based on interviews conducted: LPA observed food quality for perishable foods (vegetables and fruits) containing bacteria, fungus and mold. Food in unsanitary conditions for residents in care.the state’s words, verbatim · CDSS document, Feb 14, 2023

Plan of correction: Assistant Administrator immediately notified kitchen staff to remove unsanitary food items and develop a plan to maintain good quality, fresh food for residents in care. Administrator will provide in-service food training on food handling will provide LPA with in servicie training. Will obtain Quality food check log. Assistant Administrator will submit proof of correction to CCL by the POC due date.

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

Allegation investigated: Resident sustained an injury while in care and staff did not seek timely attention. Staff failed to provide a safe environment for resident. Staff failed to meet resident's medical needs.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Alexander Solorio (Assistant Administrator) and explained the purpose of the visit. During today's visit, LPA obtained a copy of the Staff/Resident rosters, Resident #1's (R#1) Physician's report, tree cutting invoice, Medication log and Hospital records. Toured the patio area with Staff #1. Interview Staff #1 to #4 in the office and interviewed Residents #2 to #7 in the office. In regards to the allegation: Resident sustained an injury while in care and staff did not seek timely attention. It was alleged that a tree branch located in the patio area fell on R#1 but Staff did not seek timely attention. On 01/23/23 a tree branch fell on R#1 and Staff was made aware of the incident. Staff immediately assisted R#1 and called the paramedics. Paramedics arrived a few minutes later and transported R#1 to the hospital. Per hospital records, R#1 did not sustain serious injury. Continue to LIC9099C.... Unsubstantiated In regards to the allegation: Staff failed to provide a safe environment for resident. It was alleged the a tree located in the patio area of the facility was not properly maintained which resulted in a tree branch falling on R#1. Interviews with 4 of 4 Staff indicate they did not notice the patio tree to be in bad condition. Interviews with 6 of 6 Resident indicate they did not notice the patio tree to be in bad condition and feels safe in the facility. Staff and Residents also indicate they are not aware of the condition of the tree until the tree was cut down which revealed rotting inside the tree. LPA toured the patio area and observed the tree was removed. In regards to the allegation: Staff failed to meet resident's medical needs. It was alleged that R#1 was diagnosed with a new medical condition prior to returning from the hospital and facility failed to assist R#1 with obtaining medications for the new diagnosis. Review of R#1's Physician report and hospital records does not indicate a diagnosis of any new medical conditions therefore new medications were not needed. Interviews with 6 of 6 Residents indicate their medical needs are met. Based on LPA's interviews, record review and observations, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 10, 2023 · control 28-AS-20230208131648

Allegation investigated: Facility staff are not maintaining activation switches for handicap doors.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with the Assistant Administrator, Alex Solorio. The purpose of the visit was explained. LPA Chan toured the facility, obtained the staff and resident rosters. Interviews were held with the Assistant Administrator, 4 Staff, and 5 Residents. Regarding allegation - Facility staff are not maintaining activation switches for handicap door, alleging that it took 2 weeks to repair the buttons to automatically open the door to re-enter from the smoking area. The Assistant Administrator indicated that the switch from the back door to go in and out to the smoking area was not working from Thursday due to a power outage. The switch was re-programmed today and is now functional. During that period of disrepair, the doors were either propped open or staff assisted those in wheelchairs in opening the door. Substantiated Maintenance staff confirmed that the activation switch was not working properly early December due to it not being programmed, but started working again about 1.5 weeks ago. Both Assistant Administrator and maintenance staff indicated that the maintenance staff was trained to reprogram the switch if it is in disrepair. LPA tested the door switch during the visit and observed it to be working properly after maintenance fixed it today. 2 of the staff interviewed stated that the button to open the back door going out to the smoking area was not working for a few days last week. LPA interviewed a total of 5 residents, some wheelchair bound and some not. 4 out of the 5 residents indicated that the push button door switch was not working for about a week this month. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with Assistant Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 20, 2022 · control 28-AS-20221212144247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 23, 2022

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews conducted, the back door switch to the smoking area was in disrepair which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2022

Plan of correction: The Administrator shall ensure that the automatic door switch is in good repair at all times. This POC is due on 12/23/22. ***This POC has been cleared as of today.***

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, the following concern was observed; At 9:30am, LPA was greeted by Staff #1 (S1) inside the facility (by the front door) and S1 was observed not wearing a face covering/mask, while working inside the facility. Also, upon entering the facility and walking inside the office area, LPA observed the Assistant Administrator / Alexander Solorio and Staff #2 also not wearing a face covering/mask, while working inside the facility. During today's visit, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care. The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 21, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(c)(1)(F) · Plan of correction due date: Oct 22, 2022

Infection Control Requirements. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by: At 9:30am, LPA was greeted by Staff #1 (S1) inside the facility (by the front door) and S1 was observed not wearing a face covering/mask, while working inside the facility. Also, upon entering the facility and walking inside the office area, LPA observed the Assistant Administrator / Alexander Solorio and Staff #2 also not wearing a face covering/mask, while working inside the facility. During today's visit, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2022

Plan of correction: Administrator will ensure that all facility staff are following Pasadena Public Health and CCLD requirements by conducting an in-service training with all staff on the importance of wearing a face covering/mask and also on the importance of COVID screening for all visitors, staff and residents. Administrator will submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Allegation investigated: Facility does not have hot water for bathing and hygiene. Facility does not serve food of the quality necessary to meet the needs of the residents. Meals are not being planned with consideration of resident's religious practices. Meals are served cold.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 07/16/2020, LPA Katrdzhyan conducted telephone interviews with the Executive Director and Resident Care Director. On today's visit, LPA Mora obtained a copy of the resident and staff rosters, menu, alternate menu, conducted a tour of the facility, and interviewed the Assistant Administrator, Staff 1 – Staff 2 (S1–S2), and Resident 1 – Resident 7 (R1-R7). The investigation revealed the following: regarding the allegation "facility does not have hot water for bathing and hygiene" it is alleged that residents have reported to the facility that they do not have hot water in their rooms and showers, but nothing has been done. (CONTINUED TO LIC 9099C) Unsubstantiated Assistant Administrator and staff interviewed could not corroborate with the allegation and stated that if they are made aware of any water temperature issues, it is quickly addressed by the maintenance staff. Residents interviewed could not corroborate with the allegation and stated that they do have warm water in their restrooms and the community bathrooms. LPA toured the facility and observed that bedrooms have a restroom and the facility have community bathrooms for residents to shower. LPA measured the water temperature in 7 resident restrooms and 1 community bathroom, and all measured within required water temperature which is between 105 degrees F and 120 degrees F. Regarding the allegation "facility does not serve food of the quality necessary to meet the needs of the residents" it is alleged that the food is bland and catered to individuals that have special dietary restrictions due to health issues and that food does not have salt, butter, or flavor and is often unrecognizable. Assistant Administrator and staff interviewed could not corroborate with the allegation and stated that they follow the recipes of a nutritionist. They also stated that salt, pepper, and other condiments are provided on the side for the residents to adjust the flavor of the food to their liking. Residents interviewed could not corroborate with the allegation and stated that the food is good and confirmed that condiments are available if requested. Regarding the allegation "meals are not being planned with consideration of resident's religious practices" it is alleged that the facility is aware of the residents religious practices, but still serve foods that the residents are not allowed to eat. Assistant Administrator and staff interviewed could not corroborate with the allegation and stated that they have a list of residents with dietary restrictions and they provide these residents with an alternate menu. Residents interviewed could not corroborate with the allegation and stated that the facility does provide an alternate menu. Regarding the allegation "meals are served cold." it is alleged that food was being delivered to the residents bedroom late and cold. Assistant Administrator and staff interviewed could not corroborate with the allegation and stated that during Covid-19 they were serving and delivering 10 plates at a time to prevent delivering cold food. Residents interviewed could not corroborate with the allegation and stated that they receive their food in a reasonable hot temperature. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2022 · control 28-AS-20200709092002

Allegation investigated: Staff do not assist residents with showers. Staff do not provide residents with housekeeping services. Facility does not meet resident's dietary needs. Facility is not providing laundry services to residents on a regular basis. Staff is not ensuring the facility is free of odor from incontinent residents.

***This complaint report LIC9099 supersedes LIC9099 dated 07/13/22.*** Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Assistant Administrator Alexander Solorio and explained the purpose of the visit. During today's investigation, LPA obtained and reviewed a copy of the Staff/Resident rosters, laundry schedule, shower schedule and food menu. LPA toured the facility with Staff #1. Interviewed Residents #1 to #6 in various locations of the facility and interviewed Staff #1 to #6 in the office. In regards to the allegation: Staff do not assist residents with showers. Interviews with 6 of 6 Residents who need shower assistance indicate that they are receiving shower assistance at least twice a week. Interviews with caregiving staff who provide assistance with shower indicate that showers are provided twice a week and as need. A review of the shower schedule clearly outline Residents in need of shower assistance and on which days of the week services are provided. Continue to LIC9099C....... Unsubstantiated ***This complaint report LIC9099C supersedes LIC9099C dated 07/13/22.*** In regards to the allegation: Staff do not provide residents with housekeeping services. Interviews with 6 of 6 Residents indicate Staff is providing housekeeping services daily and full cleaning services on a weekly basis. Interviews with housekeeping Staff indicate they clean the facility and Resident bedrooms on a daily basis. In regards to the allegation: Facility does not meet resident's dietary needs. LPA observed sufficient food supplies to meet the needs of Residents. Review of the food menu indicate nutritious meals are provided 3 times a day. Interviews with kitchen staff indicate Residents are receiving 3 meals a day based on the posted menu. Kitchen staff is aware of Residents on modified diets and are providing the proper modified meals. Interviews with Resident indicate they are receiving 3 nutritious meals a day and of good portions. Resident mentioned on this complaint regarding a modified diet revealed during an interview that they are not on a modified diet. In regards to the allegation: Facility is not providing laundry services to residents on a regular basis. Interviews with 6 of 6 Resident indicate that laundry services are provided on a weekly basis. Interviews with Staff indicated laundry services is provided on a weekly basis. Review of the laundry schedule clearly outlines laundry services provided to Residents and on which date it is provided. In regards to the allegation: Staff is not ensuring the facility is free of odor from incontinent residents. Interviews with Residents indicate that they do not notice odors in the facility as housekeeping Staff is cleaning on a daily basis. Interviews with Staff indicate that there are odors at times but Staff immediately cleans and removes the source of the odor. LPA toured the facility including resident bedrooms receiving incontinence care and did not notice a smell of urine or any other type of odors. Based on LPA record review, observations and interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 23, 2022 · control 28-AS-20220706122455

Allegation investigated: Facility has pests Licensee does not maintain facility clean and sanitary at all times Licensee does not provide resident with basic laundry service

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Assistant Administrator Alexander Solorio, Staff 1-3 (S1-3), Residents 1-6 (R1-6). LPA attempted to conduct an interview with R7 but they were out of the facility. LPA called R7 to attempt to conduct a telephone interview but did not receive a call back. LPA obtained copies of Staff and Resident Rosters, Pest Control Invoices for July - September 2022, laundry schedule, and shower schedule. LPA conducted a tour of the facility with Assistant Administrator which included observations of a random selection of resident rooms, facility bathrooms, Activity room and outside patio areas. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Facility has pests, it is alleged that the facility has roaches. Interviews conducted with Assistant Administrator and S1-3 revealed that there are no roaches in the facility. Staff also stated that the facility is serviced monthly by a pest control company. Assistant Administrator stated that he has not been approached by any facility resident reporting that they have seen roaches and stated that the facility residents are very vocal and know when, where and to who they can report any concerns regarding anything at the facility. Interviews conducted with 4 out of 6 residents revealed that they have not seen any roaches at the facility. LPA toured the facility including resident rooms and did not observe any roaches or any other pest and or rodents during the tour. LPA observed the facility to be clean during the tour. Based on statements gathered from interviews conducted with staff, facility residents, LPA record review and observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Licensee does not maintain facility clean and sanitary at all times, it is alleged that all three showers at the facility are always filthy, and are not cleaned regularly. Showers are supposed to be cleaned twice a day but is allegedly this is not happening. It is also alleged that housekeeping duties which include resident rooms being cleaned, floors swept and mopped on a schedule are not being performed due to the facility being short staffed. Interviews with 6 of 7 residents indicate facility staff are providing housekeeping services daily and full cleaning services on a weekly basis. 6 out of 7 residents stated that the showers are cleaned regularly and they see staff cleaning the showers more that twice a day. Interviews with housekeeping staff indicate they clean the facility including all three showers and Resident bedrooms on a daily basis. Staff also stated that resident rooms and showers are also cleaned as needed so it might be more than a couple of times a day depending on the need for service. Assistant Administrator and S1-3 stated that they believe that there are enough staff on schedule to care for all facility residents. 6 out of 7 residents stated that they are satisfied with the services and do not have any concerns regarding the facility not being cleaned on a daily basis. LPA observed the facility and all three showers to be clean during the tour. Based on statements gathered from interviews conducted with staff, facility residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegation. For allegation, Licensee does not provide resident with basic laundry service, it is alleged that facility staff did not follow laundry schedule and did not ensure that R7's laundry was done. Interviews with 6 of 7 residents indicate they do not have any concerns regarding the laundry schedule/ service and stated that their laundry is done weekly as scheduled and their bed linens and sheets are cleaned twice a week. 6 out of 7 residents stated that they are satisfied with the laundry and linen services and do not have any concerns. Assistant Administrator and S1-3 stated that residents laundry service is conducted on a weekly schedule and resident's bed linens are cleaned twice a week on the same day as the resident's shower schedule and as needed depending on if a resident has had an accident that requires an immediate change of soiled linens and also stated that the same applies for laundry service. Based on statements gathered from interviews conducted with staff, facility residents, LPA record review and observations, there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Sep 13, 2022 · control 28-AS-20220909160319

Allegation investigated: Staff did not safeguard resident's funds

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of: LPA conducted interviews with Assistant Administrator Alexander Solorio, Staff 1-3 (S1-3), Residents 1-6 (R1-6). LPA obtained copies of Staff and Resident Rosters. LPA reviewed a sample number of a total of five (5) resident's Record of Client's/ Resident's Safeguarded Cash Resources and collected copies of LIC405 for each one. (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff did not safeguard resident's funds, it is alleged that R6 put money away and kept it by their bedside on 8/18/22 and on 8/23/22 the money was missing from the place that they last remember the money was placed. R6 is suspicious that the money might have been taken by a facility caregiver and declined to state the name. Interviews conducted with Assistant Administrator and S1-3 revealed that there have been no reports from any facility resident reporting missing money from their rooms and denied seeing any suspicious behavior from either residents or staff. Staff denied seeing resident go into R6's room or hang around anywhere near the hallway next to R6's room. Assistant Assistant Administrator Solorio stated that R6 is a very vocal resident and they have not reported to him that they were missing any money from their room. Assistant Administrator stated that R6 rarely comes out of their room, does not have a roommate, is very alert and reports any concerns they have to him. Assistant Administrator and S1-3 deny that any facility staff have ever taken any money or anything else from any facility resident and stated that staff go in there when the resident needs assistance, when they need to clean, deliver food and collect clothes/ bed linens for laundry service. Interviews conducted with 5 out of 6 residents revealed that they do not have any concerns regarding their belongings and have not had anything taken from their rooms. 5 out of 6 residents stated that staff go into their rooms to clean and assist them when they need help and stated that they feel safe living at the facility. Interview with R6 revealed that they believe that the money was taken by another facility resident and not by a facility staff. R6 stated that they do not know which resident but have heard someone around their door but when they call out no one answers. LPA review of R6's Record of Client's/ Resident's Safeguarded Cash Resources (LIC405) did not reveal any discrepancies and LPA observed that the balance is accurate and observed the dates and signatures from staff and resident when money is withdrawn. LPA review of 4 additional LIC405's did not reveal any discrepancies. Based on statements gathered from interviews conducted with staff, facility residents and LPA record review, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Assistant Administrator Alexander Solorio.the state’s words, verbatim · CDSS document, Sep 13, 2022 · control 28-AS-20220906150311

Allegation investigated: Facility door is too cumbersome for residents in wheelchairs to open. Residents soiled linen is not changed timely.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Facility door is too cumbersome for residents in wheelchairs to open and Residents soiled linen is not changed timely." During today's visit, LPA interviewed the Assistant Administrator, Staff members 1 and 2 (S1 & S2) and Residents 1 - 6 (R1 - R6). Also, a random selection of resident rooms were toured. The investigation revealed the following; Allegation: Facility door is too cumbersome for residents in wheelchairs to open. The details of this allegation states that the fire doors that exit to the back patio (where residents take breaks) are too heavy for residents in wheelchairs to open. (please see LIC 9099C for additional information) Substantiated Based on interviews conducted the statements obtained were consistent and corroborated with the allegation. Residents and staff interviewed confirmed that the fire doors that exit to the back patio (where residents take breaks) are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time. Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true. Allegation: Residents soiled linen is not changed timely. Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains. Based on majority of the interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true. Based on LPA’s observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator along with the Appeals Rights. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. During the interview of Resident 1 (R1), R1 was not able to identify the date & time of the incident in order for LPA to review the surveillance camera at the facility and see the details surrounding the incident. According to the Assistant Administrator, he was informed of the incident from R1 and offered to call R1's insurance company to have it replaced but R1 refused as she handles her own concerns. The Assistant Administrator offered to give R1 a loaner wheelchair but R1 refused. The Assistant Administrator was unsure if the incident occurred at the facility as R1 did not provide a date and time of the incident. According to R1, R1 was hospitalized about a month ago and the hospital replaced her old wheelchair by giving her a new one. During today's visit, LPA observed R1 using a new wheelchair. Based on the information gathered, there is insufficient evidence to support this allegation to be true. Allegation: Trash in resident rooms are not being emptied often. The details of this allegation states that Residents soiled diapers are not emptied often from the trash container inside of resident’s room. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with this allegation. Residents and Staff interviewed confirmed that trash is emptied in resident rooms regularly, which is once a day or as needed. Soiled diapers are not disposed in trash bins located in resident rooms and are disposed in the big trash bins located in the hallways, which are emptied during each shift. During today's visit, LPA toured a random selection of resident rooms and did not observe trash and or diapers in the bins located in resident rooms. LPA did not observe an overflow of trash anywhere. Based on interviews conducted and LPA's observation, there is insufficient evidence to support this allegation to be true Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220816120208

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(14) · Plan of correction due date: Sep 15, 2022

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities... To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. The requirement is not met as evidenced by; Residents and staff interviewed confirmed that the fire doors that exit to the back patio are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time.the state’s words, verbatim · CDSS document, Aug 25, 2022

Plan of correction: Administrator will develop a plan and make corrections to the exit doors making them easily accessible for residents in wheelchairs and submit proof of correction to CCL by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 1, 2022

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The requirement is not met as evidenced by: Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains.the state’s words, verbatim · CDSS document, Aug 25, 2022

Plan of correction: Administrator will develop a plan ensuring all resident beds have required bed linens and are washed regularly and submit plan of correction to CCL by the POC due date.

Allegation investigated: Staff did not meet the needs of the resident which resulted in hospitalization. Staff did not take the resident to the doctor. Staff did not arrange for transportation.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #2 (S2: Receptionist/Activities Director, Maddison Aceves). LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA Ceniceros later met with Asst. Administrator (A2: Alexander Solorio); as Administrator (A1: Kandice Vergara) was unavailable. The purpose of today's visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 04/29/21 (via telephone) with Administrator (A1: Kandice Vergara) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 12:30 p.m. - 1:15 p.m. Asst. Administrator, Staff #2. LPA/RA did not interview Resident #1 as the resident no longer resides at the facility effective 03/25/21. Unsubstantiated Regarding Allegation #1: this investigation revealed that Asst. Administrator Solorio was unaware of Resident #1 becoming ill health upon moving out of the facility on 03/25/21 that later required a 7-day hospitalization. Resident #1 (R1) was receiving home health care by (American Home Health) twice a week (based on R1's home health agency agreement, dated 11/18/20 thru 03/25/21). The facility also has a House Doctor and Nurse Practitioner who visit the facility once a month or as needed to provide medical care for any change of conditions with the residents. Resident #1 was a participant of the Enriched Residential Care (ERC) housing program and had an assigned Case Manager through the Department of Housing for Health (DHH) and would schedule all the resident's medical, dental, optical, podiatry appointments and then inform facility staff. Witness #1 (W1: Carmen Zavala, DHH Case Manager) confirmed that Resident #1's needs were being met by facility staff; however, Resident #1 was inpatient and very demanding. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff did not meet the needs of the resident which resulted in hospitalization is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed that Resident #1 had an involved Case Manager through the Department of Housing for Health (DHH). Asst. Administrator Solorio stated that the facility staff together with Resident #1's DHH Case Manager were doing everything with doctors appointments through virtual visits or FaceTime; and, appointments that could be moved to the following month (i.e., optometrist, dental, optical, podiatry) were being re-scheduled due to the COVID-19 pandemic. Resident #1 (R1) was receiving home health care twice a week and attended all appointments. (LPA/RA Ceniceros observed doctors' appointments for Physician on 08/20/20, Dental on 01/14/21 and 03/04/21, Internal Medicine on 03/22/21, and e-mails, dated 11/05/20 and 04/22/21.) Witness #1 (W1: Carmen Zavala, DHH Case Manager) confirmed that Resident #1 would attend all scheduled doctors' appointments. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Staff did not take the resident to the doctor is found to be UNSUBSTANTIATED. Regarding Allegation #3: this investigation revealed that the facility (together with Resident #1's DHH Case Manager) worked together to get Resident #1 transportation services through Access, effective 01/11/21. Asst. Administrator Solorio stated that R1 would refuse to be transported to appointments and requested for the DHH Case Manager to accompany the resident. Witness #1 (W1: Carmen Zavala, DHH Case Manager) confirmed that she would communicate to facility staff whenever the agency (ERC) scheduled Resident #1's medical/dental/optical/podiatry appointments; so transportation was provided to Resident #1. (LPA/RA reviewed R1's documentation: dental appt. on 03/04/21; LAC+USC Medical Center ED visit on 04/25/20). Witness #1 (W1: DHH Case Manager, Carmen Zavala) confirmed that Resident #1 at times did not want to travel to doctors' appointment; therefore, W1 would accompany the resident from time to time. (LPA/RA Ceniceros reviewed e-mails (dated 08/20/20, 11/05/20, 02/26/21, 03/18/21) between facility staff and DHH Case Manager in regards to scheduling Resident #1's transportation to and from appointments. Facility staff would escort Resident #1 to the physician's and dental appointments located around the corner from the facility; therefore, no transportation would be needed at that time. Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff did not arrange for transportation is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator, Alexander Solorio.the state’s words, verbatim · CDSS document, Aug 18, 2022 · control 28-AS-20210422132803

Allegation investigated: Financial abuse. Facility staff failed to report incidents to agencies.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #2 (S2: Receptionist/Activities Director, Maddison Aceves). LPA/RA spoke to S2 prior to entering the facility to conduct a risk assessment. S2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. LPA/RA Ceniceros later met with Asst. Administrator (A2: Alexander Solorio); as Administrator (A1: Kandice Vergara) was unavailable. The purpose of today's visit is to conduct a subsequent visit and to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Joe Katrdzhyan on 03/16/21 (via telephone) with Administrator (A1: Kandice Vergara) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 8:30 a.m. - 10:00 a.m.) Asst. Administrator, Business Office Unsubstantiated Manager (S1: Kevin Arutyunyan), Staff #2, and Resident #3. LPA/RA did not interview Resident #1 who moved on 09/16/21, Resident #2 moved on 04/24/21, and Resident #4 moved on 10/25/21. LPA/RA Ceniceros reviewed (between 10:00 a.m. - 10:45 a.m.) pertinent documents: Admissions Agreement, Emergency I.D. & Information; Record of Resident's Safeguarded Cash Resources, Billing Statements, and March 2021 Invoices for Residents #1, #2, #3, #4. Regarding Allegation #1: this investigation revealed that Residents #1, #2, #3, and #4 were a participants of the Pacific PACE Program. Facility would bill Pacific Pace $60 per day for Residents #1, #3, #4 and $33 per day for Resident #2. Pacific PACE would pay a portion of the residents' rent and the residents would pay the remaining balance. (LPA/RA reviewed Resident #1, #2, #3, and #4 Admission Agreement for the rent amount and March 2021 Invoices that documented Resident #1, #2, #3, and #4 "outstanding" balances.) Interviews conducted with facility staff corroborated that Pacific PACE pays for the level of care for Resident #1, #2, #3, and #4; and, the residents pay for their room and board from the money they receive from SSI. In an attempt to change the payee to the facility, Residents #1 #2, #3, and #4 refused to do so. Pacific PACE was being billed each month; however, the facility had been receiving late payments from Pacific PACE and no payments from Residents #1, #2, #3, and #4 which accumulated to an "outstanding" balance. The facility was willing to take a loss from not collecting the "outstanding" balances from Residents #1, #2, #3, and #4 as an agreement that the facility become the payee for Residents #1, #2, #3, and #4. Resident #1's personal funds were going elsewhere (family), but never paid the rent. Resident #2 had own card with funds and spent money on personal items, but nothing towards the rent. Resident #3 had own card with funds and spent majority of money on personal items, but nothing towards the rent. Resident #4 had own own card with funds and spent the money on personal items, but nothing towards the rent. (LPA/RA reviewed Invoice #0324B (dated 03/01/21) documented Resident #1 owed $6,701.42; Invoice #0320B (dated 03/01/21) documented Resident #2 owed $6,523.17; Invoice #0321B (dated 03/01/21) documented Resident #3 owed $5,701.42; Invoice #0329B (dated 03/01/21) documented Resident #4 owed $5,450.35). Based on the evidence gathered and interviews conducted and records reviewed, LPA/RA Ceniceros did not observe financial abuse from the facility to Residents #1, #2, #3, and #4. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of FINANCIAL ABUSE: Financial Abuse is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed that Residents #1, #2, #3, and #4 are participants of the Pacific PACE Program who pays for the level of care for Residents #1, #2, #3, and #4. Pacific PACE Program began; however, Residents #1, #2, #3, and #4 did not have an assigned social worker; therefore, facility staff would make notifications regarding these residents thru a direct line to Pacific PACE and left a message and followed up with an e-mail regarding the incident. (LPA/RA Ceniceros reviewed e-mails (dated 03/01/21, 03/08/21, and 03/24/21 from (former) Staff #3 (S3: Business Office Manager, Gretel De San Diego) to the agency regarding Residents #1, #2, #3, and #4 "outstanding" balances, effective 03/01/21. (LPA/RA reviewed Invoice #0324B (dated 03/01/21) documented Resident #1 owed $6,701.42; Invoice #0320B (dated 03/01/21) documented Resident #2 owed $6,523.17; Invoice #0321B (dated 03/01/21) documented Resident #3 owed $5,701.42; Invoice #0329B (dated 03/01/21) documented Resident #4 owed $5,450.35). Based on the evidence gathered and interviews conducted and records reviewed, LPA/RA Ceniceros observed documentation of communication (via e-mail) between the facility and agency. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of REPORTING REQUIREMENTS: Facility staff failed to report incidents to agencies is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator, Alexander Solorio.the state’s words, verbatim · CDSS document, Aug 18, 2022 · control 28-AS-20210308152714

Allegation investigated: Staff did not assist residents with medications as needed. Centrally stored medications are not kept in a safe and locked place. Unqualified staff administer injections to residents.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, conducted a tour, and interviewed the Administrator, Med-tech 1 (M1), Med-tech 2 (M2), and Resident 1 – Resident 7 (R1-R7). The investigation revealed the following: regarding the allegation "staff did not assist residents with medications", it is alleged that the facility's licensed vocational nurse (LVN) ignores residents who are sufferring and in needs of medications. Example of medications include pain and nausea medications. No specific names of residents were provided. (CONTINUED TO LIC 9099C) Unsubstantiated Interviews conducted with assistant administrator and med-techs revealed that medications are given in a timely manner and the med-techs administer medications at 8am, 12pm, 5pm, and 8pm. The med-techs do not refuse to give medication to residents. However, there are times when it is not time to give the second dose and they advise the residents to wait. The med-techs strictly follow the doctor's orders to avoid overdosing the residents. Medications like narcotics can't be given constantly and need be to given hours apart per doctor's orders. Interviews conducted with residents revealed that they receive their medication on time and med-techs do not refuse to give them their medications. The investigation revealed the following: regarding the allegation "centrally stored medications are not kept in a safe and locked place.", it is alleged that the facility's LVN leaves bags of medications on the floor in her office. Interviews conducted with assistant administrator and med-techs revealed that the LVN, who no longer works here, would organize the new medications and place the old medications on the floor in her office to discard. The medication was never left unattended and when the LVN stepped out of the office she would locked the door. Once she was done organizing then she would store and lock the new medication and properly discard the old medication. No resident had access to her office. Interview conducted with residents revealed that they have not observed medication unattended and that they keep it safe and locked in the medication room. The investigation revealed the following: regarding the allegation "unqualified staff administer injections to residents.", it is alleged that the facility's LVN instructed med-techs who are not qualified to administer injections to inject residents. Interviews conducted with assistant administrator and med-techs revealed that during the time that the LVN worked at this facility there was no residents that required injections. There were only residents that self-administer insulin pens. However, the med-techs do not directly administer the insulin pen on the residents. They provide the insulin pen to the resident and the resident injects themselves while the med-tech observes them and assist once they are done. Currently the facility has only one resident that requires a behavioral injection. Interview with this resident revealed that a doctor or licensed nurse comes to the facility to inject him. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2022 · control 28-AS-20201005141056

Allegation investigated: Facility is retaliating against resident for making complaints. Facility not meeting the needs of resident.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, conducted a tour, and interviewed the Administrator, Staff 1 – Staff 2 (S1–S2), and Resident 1 – Resident 7 (R1-R7). The investigation revealed the following: regarding the allegations "facility is retaliating against resident for making complaints" and "facility not meeting the needs of resident", it is alleged that a staff retaliated against this resident by turning off the air conditioner or increasing the heat of the air conditioner in this resident's room. The resident requested for the air conditioner to be turned on at a cold temperature. (CONTINUED TO LIC 9099C) Unsubstantiated Interviews with the assistant administrator and staff revealed that this resident wanted the temperature to be set at 66 degrees or lower. The facility has a total of 11 thermostats and there are a total of 11 air conditioner units. Each air conditioner unit is shared among 6-8 rooms. The other residents that shared the air conditioner with the resident in question complained that it was too cold. The facility adjusted the temperature per Title 22 which states "the facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature." The resident in question was given a fan to maintain cool, but did not like it. The facility also offered to move the resident to another room with less occupied rooms around that room because this will allow them to set the thermostat in that area to the resident's desired temperature, but the resident refused to move. The resident also accused the facility of turning off the air conditioner, but staff explained that the thermostats are set a specific temperature and once the room reaches the temperature then the air conditioner turns off automatically. The air conditioner will turn back on once the temperature starts to increase. Interviews conducted with residents revealed that they don't have a problem with the temperature and confirm that their rooms are at a comfortable temperature at all times. They also stated that if it gets too cold or hot then facility takes action immediately. LPA toured the facility and 7 random rooms, and confirmed a comfortable temperature in all areas. LPA also observed the 11 thermostats and confirmed that the temperature is set at 78 degrees. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2022 · control 28-AS-20210412151359

Allegation investigated: Resident has access to marijuana while in care. Resident has access to alcohol while in care.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Staff / Maddison Aceves and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Resident has access to marijuana while in care and Resident has access to alcohol while in care". During today's visit, LPA interviewed the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Residents 1 - 3 (R1 - R3). Interview of S1 was conducted via telephone. Also, copies of the following documents were obtained and reviewed in reference to R1; • Resident Identification and Emergency Information Sheet • Physician's Report • Facility Internal Incident/Accident Reports • Thirty Day Termination Warning • House Rules (Please see LIC 9099C for additional information) Unsubstantiated The investigation revealed the following; Allegations: Resident has access to marijuana while in care and Resident has access to alcohol while in care. On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 was on shift and conducting a walk through of the facility and checking on residents when S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 reminded R1 of the facility house rules and asked R1 to dispose the marijuana. S1 than confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. On 7/18/22, R1 called the Pasadena Police Department and reported theft regarding the marijuana. The Pasadena Police Department made a visit to the facility and spoke with R1 and S1 and reminded R1 of the facility house rules and asked R1 not to smoke or sell marijuana inside the facility. No further action was taken by the Pasadena Police Department. Based on interviews conducted and documents reviewed, LPA learned that R1 had concerns related to substance abuse around the time of admission (in 2020), but had been doing better until recently. LPA reviewed the Physician's Report for R1 and discovered that R1 is independent and able to leave the facility unassisted. R1 is also able to store and administer own medications and manage cash resources. During the interview of R1, R1 admitted to purchasing marijuana from marijuana dispensaries while being out in the community and occasionally using it inside the facility and selling it to residents. R1 also stated that facility staff have given him multiple verbal warnings and discussed the facility house rules explaining that the use and sell of marijuana is prohibited. On 6/30/22, R1 was issued a "Thirty Day Termination Warning' for breaking facility house rules by continuing to use marijuana inside the facility. As a result of the latest incident which occurred on 7/17/22, the Assistant Administrator stated that R1 will be issued a "30 Day Eviction Notice" on 7/28/22, for failing to comply with facility house rules and nonpayment of rent. Based on the information gathered, there is insufficient evidence to support these allegations to be true. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2022 · control 28-AS-20220719101626

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. During a complaint investigation conducted on 7/27/22, LPA discovered that the facility failed to report an Unusual Incident/Injury Report to Community Care Licensing (CCL) as required by Title 22 Regulations / Reporting Requirements. On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 was on shift and conducting a walk through of the facility and checking on residents when S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. The Pasadena Police Department was involved and conducted a visit on 7/18/22. During today's visit, LPA requested the Assistant Administrator to complete an Unusual Incident/Injury Report and submit a copy to CCL no later than the end of business day on 7/27/22. The following deficiency was observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted and a copy of this report was provided along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jul 27, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) · Plan of correction due date: Jul 27, 2022

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by; On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. The Pasadena Police Department was involved and conducted a visit on 7/18/22.the state’s words, verbatim · CDSS document, Jul 27, 2022

Plan of correction: Assistant Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how he will ensure that incidents are reported to the CCL office as required according to the Regulation. Also, an Unusual Incident/Injury Report must be submitted to CCL no later than the end of business day on 7/27/22, in reference to the incident involving R1.

Allegation investigated: Staff do not assist residents with showers. Staff do not provide residents with housekeeping services. Facility does not meet resident's dietary needs. Facility is not providing laundry services to residents on a regular basis. Staff is not ensuring the facility is free of odor from incontinent residents.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Assistant Administrator Alexander Solorio and explained the purpose of the visit. During today's investigation, LPA obtained and reviewed a copy of the Staff/Resident rosters, laundry schedule, shower schedule and food menu. LPA toured the facility with Staff #1. Interviewed Residents #1 to #6 in various locations of the facility and interviewed Staff #1 to #6 in the office. In regards to the allegation: Staff do not assist residents with showers. Interviews with 6 of 6 Residents who need shower assistance indicate that they are receiving shower assistance at least twice a week. Interviews with caregiving staff who provide assistance with shower indicate that showers are provided twice a week and as need. A review of the shower schedule clearly outline Residents in need of shower assistance and on which days of the week services are provided. Continue to LIC9099C....... Unsubstantiated In regards to the allegation: Staff do not provide residents with housekeeping services. Interviews with 6 of 6 Residents indicate Staff is providing housekeeping services daily and full cleaning services on a weekly basis. Interviews with housekeeping Staff indicate they clean the facility and Resident bedrooms on a daily basis. In regards to the allegation: Facility does not meet resident's dietary needs. LPA observed sufficient food supplies to meet the needs of Residents. Review of the food menu indicate nutritious meals are provided 3 times a day. Interviews with kitchen staff indicate Residents are receiving 3 meals a day based on the menu. Interviews with Resident indicate they are receiving 3 nutritious meals a day and of good portions. In regards to the allegation: Facility is not providing laundry services to residents on a regular basis. Interviews with 6 of 6 Resident indicate that laundry services are provided on a weekly basis. Interviews with Staff indicated laundry services is provided on a weekly basis. Review of the laundry schedule clearly outlines laundry services provided to Residents and on which date it is provided. In regards to the allegation: Staff is not ensuring the facility is free of odor from incontinent residents. Interviews with Residents indicate that they do not notice odors in the facility as housekeeping Staff is cleaning on a daily basis. Interviews with Staff indicate that there are odors at times but Staff immediately cleans and removes the source of the odor. Based on LPA record review, observations and interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Alexander Solorio and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 13, 2022 · control 28-AS-20220706122455

Allegation investigated: Residents engaged in altercation while in care.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio and was later joined by the Executive Director / Kandice Vergara who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Residents engaged in altercation while in care". During today's visit, LPA interviewed the Executive Director, Assistant Administrator, Staff 1 (S1) and Residents 1 and 2 (R1 and R2). LPA reviewed video surveillance of the incident. Also, a copy of the Unusual Incident/Injury Report was obtained involving R1 and R2. (Please see LIC 9099C for additional information) Unsubstantiated The investigation revealed the following; Allegation: Residents engaged in altercation while in care. On 6/27/22, at approximately 7:38am, there was an incident involving R1 and R2. According to the video surveillance, at 7:37am, R2 is observed exiting his room towards the patio walkway in his wheelchair. A few seconds later, R2 is observed getting up from his wheelchair and walking towards the small gate (near the exit) and closing it. At 7:38am, R1 is observed exiting her room and walking towards R2. (R1 and R2 are in separate rooms but share the same patio) It is unclear in the surveillance video what was said between both residents but a few seconds later, R1 is observed walking towards the wheelchair of R2 and pushing it out of the walkway. R2 is than observed walking towards his wheelchair and it appears as if there were more words exchanged between R1 and R2 and at which time R2 is observed moving his wheelchair towards the wall, standing next to it facing the street. R2 is than observed walking towards the sliding door of R1 and leaning on the wall (with his back towards the wall). Shortly after R2 is observed swinging his left arm towards R1. It is unclear if the swing was an attempt to hit R1 or if it made contact with R1 as R1 was inside the room and not visible in the surveillance video. S1 observed the situation after the incident had occurred and re-directed R2 back to his room. Interviews conducted of R1 and R2 confirmed that there was no physical altercation between both residents. Both residents denied hitting one another and stated the incident was a verbal argument. It was confirmed that there were no witnesses to the incident. On 6/28/22, R1 was moved to another room by facility staff to ensure both residents stay away from each other and to avoid future incidents. The Pasadena Police Department was involved and conducted interviews of R1 and R2 but no further action was taken. Based in the information gathered, there is insufficient evidence to support this allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 6, 2022 · control 28-AS-20220628090132

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Case Management / Technical Assistance visit to this facility. Present during the visit were Nurses, Sharon Evangelista and Casey Cortes from Pasadena Public Health (PPH). Upon arriving at the facility, LPA and PPH Nurses met with Staff / Maddison Aceves and were later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. The purpose of today's visit was explained. There are currently NO active cases of COVID at Pasadena Villa Senior Living. During today's visit, a tour of the physical plant (inside) was conducted. The following recommendations were made by the PPH Nurses; Sign placed on front door regarding visitation must clarify testing requirements for visitors. (Antigen test must be conducted 24 hours prior to visitation or a PCR / Blood test must be conducted 48 hours prior to visitation) Place signs on resident doors located in yellow zone asking residents to "Keep resident doors closed". Place Droplet & Contact Precaution signs on resident doors located in yellow zone. Dispose/disregard face shields which are NOT all plastic. Place hand sanitizer in TV / Activity room. Conduct in-service training with staff on the importance of following instructions listed on labels of cleaning solutions, when disinfecting for COVID. Place sign in staff break room stating maximum capacity for staff should not exceed 2 staff members at one time. Place hand sanitizer and also alcohol wipes in staff break room. Remove outdated signs located in TV / Activity Room and also in staff break room. Use paper bags when storing reusable goggles. Provide separate trash bins (w/lid) inside resident rooms located in yellow zone. No deficiencies were observed at the time of this visit. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Jul 6, 2022

Allegation investigated: Staff not responding to resident's call light.

Licensing Program Analyst (LPA) Luis Mora conducted a subsequent unannounced complaint visit regarding the above allegation. LPA met with Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 03/11/2021, LPA Joe Katrdzhyan conducted an initial complaint investigation via telephone due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). On 10/20/2021, LPA Luis Mora conducted a subsequent complaint visit and obtained copies of staff & resident rosters, call light & response time in-service training. LPA also interviewed Resident 1 - Resident 7 (R1-R7), Administrator, and Staff 1 - 5 (S1-S5), and toured facility. On today’s visit 05/20/2022, LPA Luis Mora delivered findings. The investigation revealed the following: regarding the allegation “staff not responding to resident's call light” it is alleged that caregivers are not instructed to attend to the pendant or call light especially on the 10:30pm to 6:30 am shift. (CONTINUED TO LIC 9099C) Substantiated The investigation revealed the following: regarding the allegation “staff not responding to resident's call light” it is alleged that caregivers are not instructed to attend to the pendant or call light especially on the 10:30pm to 6:30 am shift. Interviews conducted with staff revealed that in early March 2021 there was a caregiver during the graveyard shift that was caught on camera sleeping or on their phone and not responding to the call light. A call light system & response time in-service training was conducted on 03/11/2021. The facility reduced the caregiver’s hours due to continued poor work performance; this resulted in the caregiver resigning on 05/05/2021. Interviews conducted with residents revealed that the staff are responding quickly to their call light and there is no longer an issue with the response time. During the tour the LPA pressed the call light in 3 random resident rooms and the response time was between 2-4 minutes. Based on LPA's interviews which were conducted, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, May 20, 2022 · control 28-AS-20210302110357

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: May 27, 2022

87415(a)(2) - Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available... to assist in caring for residents. (2)In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake.... This requirement was not met as evidenced by: LPA's interviews with staff revealed that there was a staff not responding to the call light. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, May 20, 2022

Plan of correction: Licensee will conduct an in-service training in rgards to the call light and submit POC to LPA by 05/27/2022. It has been confirmed that an in-service training has already been conducted on 03/11/2021 when this allegation was brought up. POC cleared.

Allegation investigated: Resident is smoking around an oxygen tank Facility doesn't have enough towels for residents

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegations of "Resident is smoking around an oxygen tank and Facility doesn't have enough towels for residents". During today's visit, LPA interviewed the Assistant Administrator / Alexander Solorio, Staff members 1 and 2 (S1 and S2) and Residents 1 through 5 (R1 - R5). LPA toured the facility and inspected the linen closets and laundry room. Also, a copy of the Behavior Contract for R1 was reviewed and obtained. (Please see LIC 9099C for additional information) Substantiated The investigation revealed the following; Allegation: Resident is smoking around an oxygen tank. The details of this allegation states that R1 lights up cigarettes and smokes inside her room. R1 uses an oxygen tank and should not be lighting up or smoking cigarettes inside her room. Based on interviews conducted, LPA learned that Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occasions, R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care as smoking is prohibited where oxygen is in use. The Assistant Administrator has become aware of this concern and has developed a Behavior Contract with R1 stating that R1 will follow the house rules of Pasadena Villa, R1 will smoke in the designated smoking area and request assistance from staff to be escorted to the smoking area. Failure to follow the Behavior Contract will result in loss of permanent housing and eviction for R1. R1 has agreed and signed the Behavior Contract dated 5/9/22. According to the Assistant Administrator, R1 has been following the Behavior Contract as of 5/9/22 and is no longer non-compliant. Based on interviews conducted and record review, there is sufficient evidence to support this allegation to be true. Allegation: Facility doesn't have enough towels for residents. Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents. From interviews conducted, LPA learned that some residents are left without bath towels while their dirty towels are in laundry and some residents have to use a bath robe or a blanket to dry themselves after a bath as the facility does not have an extra supply of bath towels. Based on interviews conducted and LPA's observation, there is sufficient evidence to support this allegation to be true. Based on LPA’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided along with the Appeals Rights. Based on interviews conducted the statements obtained were inconsistent and did not corroborate with the allegation. Clients and Staff interviewed confirmed that there is no concern with laundry not being done. Laundry is done regularly, which is once a week or as needed. Based on the information gathered, there is insufficient evidence to support the allegation to be true. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 18, 2022 · control 28-AS-20220511161940

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(C) · Plan of correction due date: May 18, 2022

Oxygen Administration - Gas and Liquid. Smoking shall be prohibited where oxygen is in use. This requirement is not being met as evidenced by: Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occassions, R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 18, 2022

Plan of correction: The Assistant Administrator has developed a Behavior Contract with R1 stating that R1 will follow the house rules of Pasadena Villa, R1 will smoke in the designated smoking area and request assistance from staff to be escorted to the smoking area. According to the Assistant Administrator, R1 has been following the Behavior Contract as of 5/9/22 and is no longer non-compliant. ***Citation was cleared at the time of visit and no further action is needed***

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: May 18, 2022

Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident... Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times... Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents.the state’s words, verbatim · CDSS document, May 18, 2022

Plan of correction: The Assistant Administrator purchased extra bath towels during the time of this visit and provided a copy of the receipt to the LPA. ***Citation was cleared at the time of visit and no further action is needed***

Allegation investigated: Lack of supervision resulting in a physical altercation between residents.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Lack of supervision resulting in a physical altercation between residents". Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted prior visits to this facility on 2/11/22 and 3/11/22, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Assistant Administrator / Alexander Solorio, Staff members 1 and 2 (S1 and S2) and Residents 1 and 2 (R1 and R2). Also, copies of the following documents were obtained and reviewed in reference to R1 and R2; • Client Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Report / LIC 624. (Please see LIC 9099C for additional information) Unsubstantiated The investigation revealed the following; Allegation: Lack of supervision resulting in a physical altercation between residents. According to the Unusual Incident/Injury Report submitted by the facility, on 2/1/22, at approximately 6:45pm, R1 and R2 were both in their room when an altercation occurred. R1 had initiated a conversation with R2 at which time R2 yelled at R1 stating "I don't like talking" and proceeded to physically attack R1. Based on record reviews and interviews conducted, LPA learned that on 2/1/22, R1 was moved into the same room as R2, due to both residents testing positive for COVID. Prior to the move, both residents were informed about temporarily rooming together and presented no concerns. The incident involving R1 and R2 happened shortly after on 2/1/22, while both residents were quarantining together in the red zone. Residents and Staff interviewed confirmed that staff were not present during the incident but upon hearing the commotion, immediately assisted in breaking up the altercation and separating both residents. R1 sustained a few scratches to his face and a swollen lip but refused medical attention. Staff assisted R1 by applying fist aid. Per the Assistant Administrator, there have been no prior incidents involving R1 and R2 and both residents are independent and do not require one to one supervision. This was an isolated incident. According to the Appraisal/Needs and Services Plan for R1, R1 is listed as emotionally stable and usually keeps to himself. According to the Appraisal/Needs and Services Plan for R2, R2 is listed as emotionally stable and likes to socialize with other residents. Residents and Staff interviewed confirmed that staff could not have done anything different to prevent the incident from happening. All reporting parties were notified of the incident, including the Pasadena Police Department. The Pasadena Police Department was involved and came out and spoke with both residents. R1 refused to press charges against R2. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2022 · control 28-AS-20220203121715