Pasadena Villa Senior Living

Allegation investigated: Staff failed to prevent resident from AWOL’ing from facility.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Staff failed to prevent resident from AWOL’ing from facility.". 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 1/6/22, in reference to the allegation listed above. The investigation consisted of interviews of various persons to include the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Resident 2 (R2). LPA made multiple attempts to interview Resident 1 (R1) but was unsuccessful as calls were not returned and R1 no longer resides at this facility. During today's visit, LPA learned that R1 was hospitalized on 1/16/22, at Riverside Community Hospital and remains hospitalized. Per the Assistant Administrator, R1 will not be returning back to the facility. Copies of the following documents were obtained and reviewed in reference to R1; • Client Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Substantiated Report / LIC 624. The investigation revealed the following: Allegation: Staff failed to prevent resident from AWOL’ing from facility. Based on interviews conducted and record reviews, LPA learned that on 1/1/22, at approximately 8am, R1 eloped from the facility in her wheelchair. According to the Ring doorbell footage of the front door, R1 was last observed smoking outside (near the main entrance door), as she sat in her wheelchair. At the time of the incident, there were 2 caregivers and 1 med tech working at the facility and all were busy assisting residents and did not observe R1 leaving the facility. From the interviews conducted, LPA learned that on the weekends, the front desk staff does not begin their work shift until 9am and there is no staff monitoring the front desk area and resident traffic going in and out of the facility between the hours of 6:30am and 9am. Although the facility is equipped with a surveillance system, the facility needs to have staff supervision in the early hours to ensure residents are not leaving the facility without informing staff and/or without assistance. Per R1's Physician's Report, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1. All reporting parties were notified of the incident, including the Pasadena Police Department. Based on LPA’s observations and interviews which were conducted and record review, 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, Apr 7, 2022 · control 28-AS-20220104100438

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(c)(3) · Plan of correction due date: Apr 8, 2022

Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. The requirement is not met as evidenced by; On 1/1/22, at approximately 8am, R1 eloped from the facility in her wheelchair. From the interviews conducted, LPA learned that on the weekends, the front desk staff does not begin their work shift until 9am and there is no staff monitoring the front desk area and resident traffic going in and out of the facility between the hours of 6:30am and 9am. Per R1's Physician's Report, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee will submit a plan to CCL ensuring the safety measures the facility will implement ensuring residents are not leaving the facility without informing staff and/or without assistance. POC is due to CCL by 4/8/22.

Allegation investigated: Residents engaged in a physical altercation while in care

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Assistant Administrator, Alex Solorio who assisted with today's visit. Regarding the allegation that residents engaged in a physical altercation while in care, the investigation consisted of Interview(s) with Assistant Administrator, Staff #1, Staff #2, review of facility video surveillance of incident(s) on 3/24/22, review of Resident #1 and Resident #2's files, and Interview(s) with Resident #1 and Resident #2. The investigation revealed the following: On 3/24/22 Resident #1 and Resident #2 were involved in two separate physical altercation(s). LPA Reviewed video surveillance and observed that in both altercations, staff were present and broke up the altercation(s) right away. Resident(s) and Staff interviewed confirmed that staff who were present, immediately assisted in breaking up the altercation(s). Resident #1 and Resident #2 stated that they were not injured, and did not require medical attention. Unsubstantiated Assistant administrator stated that Resident #1 and Resident #2 have had a few previous altercations with each other, and have both been counseled by facility staff in regards to breaking house rules. Assistant Administrator stated that both residents have been issued eviction notices on 3/28/2022. Assistant administrator stated that Resident #1 is moving to another facility today. Based on LPA's observations and interviews, investigation revealed: 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 is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Admnistrator, Alex Solorio.the state’s words, verbatim · CDSS document, Mar 30, 2022 · control 28-AS-20220325103032

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted a site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. The facility is licensed to serve for a capacity of 97 Non-ambulatory residents (of which 30 may be bedridden) ages 60 and above. The facility has an approved Hospice Waiver on file for thirty (30) residents. Pasadena Villa Senior Living does not have an approved Dementia Care Plan in its plan of operation and does not accept/care for residents with dementia. During today's visit, LPA used the infection control domain to complete the Required - 1 Year inspection. Also, the physical plant was toured, medication and food supplies reviewed. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility consists of 49 bedrooms, 28 bathrooms, 4 shower rooms (2 Main and 2 Private), a main dining room, 1 common room, a library, a kitchen, a salon, a medication rooms and several offices. The facility has a covered patio in front of the facility, and 2 courtyards. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. No large bodies of water were observed. There are no security bars or weapons on the premises. The facility has central air and heating accommodations. LPA toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has a shared bathroom. The bathrooms were observed to be operational w/grab bars. Each resident has a call light button which is given to them upon admission. The call light button was tested in various rooms and is operable. The hot water temperature was tested throughout the facility. The kitchen was observed. There was a sufficient amount of perishable and non-perishable food supplies and perishable food was stored in covered containers at the appropriate temperatures. No pesticides or poisons were stored in the food areas. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The fire extinguishers were observed to be fully charged and in compliance. The facility has smoke detectors and carbon monoxide detectors in each resident room and in the hallways of the facility. A shaded area with chairs is provided to the residents. Medications are centrally stored in the locked medication room. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician. The following deficiencies were observed during today's visit; Between the hours of 11am - 1pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In room #43, it was measured at 102.8 degrees F. In room #12, it was measured at 123 degrees F. At 1:10pm, LPA discovered medication Trazadone HCL 50MG (Take 1 tablet by mouth once daily at bedtime) was missing from facility for Resident 1. Between the hours of 11am - 1pm, LPA toured the facility and observed missing skid mats in one of the main showers and also in the private shower. Between the hours of 11am - 1pm, LPA toured the facility and observed resident rooms #115, #24, #17 and #43 were unsanitary and in need of cleaning. Urine was observed in the shared bathroom of room #115 and stains, dirt, food particles and dust were observed in rooms #24, #17 and #43. At 11:15am, LPA observed the table located near the dining room patio area was in disrepair (broken pieces). At 11:30AM, LPA observed the plywood behind the fascia board located near the roof facing the side of the property (near the parking lot) was in disrepair. A large piece was broken and missing. At 11:25am, LPA observed broken furniture/appliance, wheelchair, wheelbarrow, pieces of wood and a plantoon boat located in the outdoor passageway, near the parking lot. The following deficiencies were observed to be in violation under California Code of Regulations Title 22. (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, Mar 29, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Mar 30, 2022

Maintenance and Operation. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by; Between the hours of 11am - 1pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In room #43, it was measured at 102.8 degrees F. In room #12, it was measured at 123 degrees F. This poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2022

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Mar 30, 2022

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by; At 1:10pm, LPA discovered medication Trazadone HCL 50MG (Take 1 tablet by mouth once daily at bedtime) was missing from facility for Resident 1. This poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Apr 1, 2022

Maintenance and Operation. Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by; Between the hours of 11am - 1pm, LPA toured the facility and observed missing skid mats in one of the main showers and also in the private shower. This poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Apr 1, 2022

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 met as evidenced by; Between the hours of 11am - 1pm, LPA toured the facility and observed resident rooms #115, #24, #17 and #43 were unsanitary and in need of cleaning. Urine was observed in the shared bathroom of room #115 and stains, dirt, food particles and dust were observed in rooms #24, #17 and #43. This poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Apr 12, 2022

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 met as evidenced by; At 11:15am, LPA observed the table located near the dining room patio area was in disrepair (broken pieces). At 11:30AM, LPA observed the plywood behind the fascia board located near the roof facing the side of the property (near the parking lot) was in disrepair. A large piece was broken and missing. This poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2022

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Apr 12, 2022

Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: At 11:25am, LPA observed broken furniture/appliance, wheelchair, wheelbarrow, pieces of wood and a plantoon boat located in the outdoor passageway, near the parking lot. This poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 29, 2022

Allegation investigated: Resident eloped from facility.

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 / Rocio Rosas 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 "Resident eloped from facility". During today's visit, LPA interviewed the Assistant Administrator / Alexander Solorio and Responsible Party / Family Member of Resident #1 (R1). LPA was unable to interview R1 as R1 does not reside at this facility and is staying with family. Also, copies of the following documents were obtained and reviewed in reference to R1; • Client Face Sheet • Preplacement Appraisal Information • Resident Appraisal • Physician's Report • Functional Capability Assessment • Unusual Incident/Injury Report / LIC 624 • Medication Release Form • Consent for Emergency Medical Treatment • Admission Agreement • Discharge Instructions from LAC+USC • R1's Exit Form from facility • Resident Roster Sheet. (Please see LIC 9099C for additional information) Substantiated The investigation revealed the following; Allegation: Resident eloped from facility. Based on interviews conducted and record reviews, LPA discovered that R1 was discharged from LAC-USC on 3/7/22 and transferred to Pasadena Villa Senior Living (PVSL). R1 was admitted to PVSL on 3/7/22, at approximately 2:45pm (Note: R1 was not a resident of PVSL prior to 3/7/22). Shortly after being admitted to PVSL, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. A missing person's report was filed with the Pasadena Police Department on the evening of 3/8/22 and R1 was found by Officers a few blocks away from the facility on the morning of 3/9/22, at approximately 9:30am. R1 has not returned to PVSL and is currently staying with family. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. R1 eloping from the facility poses an immediate health and safety risk to R1. Based on LPA’s observations and interviews which were conducted and record review, 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 investigation revealed the following; Allegation: Facility did not report resident missing. Based on interviews conducted and record reviews, LPA discovered that R1 was discharged from LAC-USC on 3/7/22 and transferred to Pasadena Villa Senior Living (PVSL). R1 was admitted to PVSL on 3/7/22, at approximately 2:45pm (Note: R1 was not a resident of PVSL prior to 3/7/22). Shortly after being admitted to PVSL, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. On 3/7/22, the Responsible Party / Family Member of R1 was notified by the Assistant Administrator that R1 had eloped from the facility. There was a discussion between the Responsible Party / Family Member and the Assistant Administrator that only one person would need to file the missing person’s report and the Responsible Party / Family Member stated that she would be filing the missing person’s report for R1. A missing person's report was filed with the Pasadena Police Department on the evening of 3/8/22 and R1 was found by Officers a few blocks away from the facility on the morning of 3/9/22, at approximately 9:30am. R1 has not returned to PVSL and is currently staying with family. Based on interviews conducted, LPA learned that there was an understanding between Facility Staff and the Responsible Party / Family Member of R1 on who would be filing the missing person's report to Law Enforcement therefore facility is not in violation for not reporting R1 missing to Law Enforcement. 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, Mar 11, 2022 · control 28-AS-20220309172035

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(c)(3) · Plan of correction due date: Mar 12, 2022

Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. The requirement is not met as evidenced by; On 3/7/22, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 11, 2022

Plan of correction: Licensee will submit a plan to CCL ensuring the safety measures the facility will implement (effective 3/11/22) to ensure residents who are listed as not able to leave the facility unassisted, do not elope from the facility. The plan must not violate the personal rights of residents. POC is due to CCL by 3/12/22.

Allegation investigated: Illigal Eviction

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced subsequent complaint investigation visit to facility and was greeted by Assistant Administrator Alex Solorio. Initial visit was conducted on 02/23/22 The investigation consisted of asking for and obtaining copies of resident rooster, staff roster, Appraisal needs for R1, and services plan dated 02/10/2022 for R1. Copy of 30-day eviction notice, copy of proof of service, SSI Notice of Change in Payment, Admission Agreement, copies of invoices from 09/01/2021 to 02/02/2021, SIR dated 11/24/2021, SOC 341 dated 12/09/2021. LPA Interviewed Assistance Administrator Alex Solorio, Business office staff Kevin Arutyunyan and R1. LPA interview case worker from Brilliant corners Trinidad Martinez and he stated he was aware of resident and has contingency plan if resident needs to leave. R1 admitted that RI has not paid to due to being robbed (no police report filed) and dental expenses. RI stated mother has mailed a check for balance due to facility on 2/23/2022. (continued on 9909C) Unsubstantiated (Continued from 9099) R1 stated she applied for rental relief on 02/11/22. Facility has followed proper procedures to evict resident. During this subsequent visit, Administrator stated that they received personal check dated 2/22/2022 for amount of $3,317.85 from resident’s mother which brings resident up to date on her back rent. Facility stated that resident paid rent for March 2022 and is up to date. NOTE: Due to resident paying her back rent and current month, LPA asked facility to rescind eviction notice and copy of that notice was obtained by LPA. 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. A copy of this report and appeal rights were left with the Administrator Alex Solorio whose signature on this form confirm receipt of this document.the state’s words, verbatim · CDSS document, Mar 8, 2022 · control 28-AS-20220217154432

Allegation investigated: Facility does not meet the American Disabilities Act Standards for wheelchairs

Licensing Program Analyst (LPA) Christine Wong conducted an initial 10 days complaint visit to investigate the above allegation. LPA met with Assistant Administrator- Alexander Solorio and explained the reason of the visit and he also assisted LPA with the visit. The investigation consisted of the following: On today's visit, LPA interviewed the four (4) staff, seven (7) residents and toured the front door and two fire doors in the back which lead to the patio. LPA also obtained the copy of resident and staff roster. The investigation revealed of the following: Allegtation " Facility does not meet the American Disabilities Act Standards for wheelchairs." (See LIC 9099C for continuation) Substantiated LPA observed all the doors in the facility does meet the Americans Disabilities Act Standard for wheelchairs. However, LPA interviewed seven (7) residents and four (4) residents reported sometimes their wheelchair did get stuck when they went through the door due to one side of the door was not wide enough for them to go through. The residents reported especially the two fire doors in the back which lead to the patio, the doors are very heavy and sometimes its difficult for the residents to push it while they are on the wheelchair. LPA also interviewed staff and reported they did receive suggestions and complaints from residents about the two fire doors in the back which is not an easy access for the residents to go through especially on the wheelchair. Residents sometimes required assistance from staff to open the door for them. LPA also observed the two fire doors in the back and required to open the left side of the door first then the right side and the doors are heavy to push it. Based on the statements and interviews from residents and staff and LPA's observation, 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 interviewed was conducted. The Plan of Corrections were reviewed and developed with the Assistant Administrator- Alexander Solario. A copy of this report, LIC9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 16, 2022 · control 28-AS-20220214123417

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(14) · Plan of correction due date: Mar 2, 2022

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...following personal right (14)To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility. The requirement is not met as evidenced by LPA's observation and interviews by residents and reported the doors are not easy access for the residents use wheelchairs to go through which pose an potential risk for residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2022

Plan of correction: The Executive Director will come up a plan for how to make the doors to be easy access for the residents who use the wheelchair to go through. The Executive will send the plan to LPA by POC due date.

Allegation investigated: Staff restrained resident to a bed. Staff are threatening resident’s life. Staff are attempting to steal resident’s money.

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 "Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money". During today's visit, LPA interviewed the Assistant Administrator, Resident #2 (R2) and Staff #1 (S1). LPA was unable to interview Resident #1 (R1) as R1 expired on 1/28/22. Also, copies of the following documents were obtained and reviewed in reference to R1; • Resident Face Sheet • Appraisal/Needs and Services Plan • Physician's Report • Unusual Incident/Injury Report / LIC 624 • Hospice Records (Please see LIC 9099C for additional information) Unsubstantiated The investigation revealed the following; Allegations: Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money. Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 had been receiving hospice services since 4/2/21. During R1's stay at Pasadena Villa Senior Living, R1 shared a room with R2 until 1/6/22. Staff began noticing the rapid deterioration in R1's mental state and moved R1 to a private room on 1/6/22. R1 was often observed by staff and his roommate to be disoriented and paranoid. Per statements obtained, R1 would hallucinate and accuse staff (no staff in particular) of strapping him down to his bed, trying to kill him and stealing his money. R1 also accused R2 of trying to kill him and stealing his money. On 12/12/21, Officers Woolford and Goretti, from the Pasadena Police Department responded to Pasadena Villa Senior Living in regards to a call made by R1, stating that "Staff is trying to 187 him". Upon arriving at the facility, the Officers contacted R1 who stated that yesterday morning, a male staff member strapped him down to his bed, they were trying to kill him and take his social security income by throwing him in a river in Long Beach. R1 stated that he was still strapped down to the bed. The Officers inspected R1's bed in person and observed that R1 was not strapped down to his bed and there was no obvious sign of injury. The Officers found no crime had occurred and ended their visit. On 1/28/22, R1 expired while receiving hospice services through Comfort Choice Hospice. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations of "Staff restrained resident to a bed, Staff are threatening resident’s life and Staff are attempting to steal resident’s money". 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, Feb 1, 2022 · control 28-AS-20220124153310

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 2/1/22, LPA discovered that the facility failed to update R1's Appraisal/Needs and Services Plan as required by Title 22 Regulations. Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 was observed by staff and R2 (roommate) to be disoriented and paranoid. Due to a decline in health, R1 was often observed to be hallucinating. As a result, R1 was transferred to a private room on 1/6/22. After reviewing the Appraisal/Needs and Services Plan for R1 dated 10/12/21, LPA discovered that the changes in R1's physical, medical, mental, and social condition was not updated on the Appraisal/Needs and Services Plan. This poses a potential health and safety risk to R1. 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, Feb 1, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Feb 8, 2022

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidenced by; Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 was observed by staff and R2 (roommate) to be disoriented and paranoid. Due to a decline in health, R1 was often observed to be hallucinating. This poses a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Feb 1, 2022

Plan of correction: Licensee will review Title 22 Regulations, Section 87463 on Reappraisals 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: Resident is being financially abused while in care

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint investigation toward the above allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason of the visit and he also assisted LPA with the visit. The investigation consisted of the following: LPA interviewed five residents (R1-R5), assistant administrator and three staff (S1-S3) and obtained copy of resident roster, Resident#1 (R1) face sheet, preplacement appraisal information and case assessment/evaluation and contact information for Pasadena Police Department. The investigation revelaled of the following: Allegation "Resident is being financially abused while in care." LPA interviewed Resident#1 (R1) and stated that the debit card was missing and got stolen in the facility. (See LIC 9099C for continuation) Unsubstantiated R1 also stated that approximately $2000 was withdrawn by someone, and due to the pin number was on the back of the card and the bank was not able to reimburse the money back to R1. LPA asked R1 for the copy of the bank statement and R1 said no access on it and no record for the bank statement. In addition, R1 does not remember what date the money was withdrawn which before or after the hotel trip with family. LPA interviewed residents and staff and both denied seeing any suspicious people went into R1's room or around the hallway. The residents all felt safe living in the facility and they never lost or got stolen for any costly items in the facility. The staff also reported R1's room is always locked. Administrator also stated that the police officer came but they were not able to open up the case for R1 due to R1 was not able to provide the details of bank statement and the inconsistent statement for R1. The police officer will open up the case when R1 is willing to provide the statement but till now, R1 still has not provided any bank statement to the police officer. Based on LPA's interviews conducted and record review, the incident of resident is being financially abused while in care, there is insufficient 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. An exit interview was conducted and a copy of this report and appeal right was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2021 · control 28-AS-20211214122415

Allegation investigated: Facility staff did not prevent residents from engaging in a physical 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 "Facility staff did not prevent residents from engaging in a physical altercation". 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 10/27/21, in reference to the allegation listed above. During the course of the investigation, LPA conducted interviews of various persons to include the Assistant Administrator, Staff members 1 - 3 (S1 - S3) and Residents 1 - 4 (R1 - R4). LPA also reviewed the surveillance video regarding the incident involving Residents 1 and 2 (R1) and (R2). The investigation revealed the following; The incident involving R1 and R2 occurred on 10/20/21, at approximately 2:30pm. Based on interviews conducted, R2, who is visually impaired was observed by witnesses yelling in the lobby, near her room. Unsubstantiated R1, who resides a couple of doors down from R2 was observed by witnesses coming out of her room (in her wheelchair) telling R2 that there is no one in the lobby and to stop yelling. According to witnesses, the incident escalates quickly and that is when R2 approaches R1 and slaps R1 in the face. Based on interviews conducted, the majority of the statements obtained stated that the incident could not have been prevented by staff. S1, who is the facility housekeeper observed the verbal exchange between R1 and R2 and before he was able to walk over and notify staff, R2 approached R1 and slapped R1 in the face. R1 did not sustain and injuries as a result of the incident. R1 still resides at this facility. R2 no longer resides at this facility as R2's placement agency (DHS) transferred R2 to another facility on 12/6/21. During the visit conducted on 10/27/21, LPA reviewed the surveillance footage of the incident involving R1 and R2 with the assistance of the Assistance Administrator. Based on LPA’s observations, the incident took about one minute and thirty seconds from the time the two residents were observed exchanging words in the hallway leading to R2 slapping R1. In the video, R2 is observed in the hallway by herself, standing in front of her room (with her back facing the camera). A few seconds later R1 is observed coming out of her room in her wheelchair and both residents are then observed exchanging words. S1 (Housekeeper) is observed arriving at the scene and assessing the situation and as the two residents are getting loud, S1 is observed walking away to inform staff about the two residents arguing. As S1 is observed walking away, R2 is observed walking towards R1 (while R1 is sitting in her wheelchair) and R2 slaps R1 in the face. Shortly after staff is observed arriving at the scene to de-escalate the situation. Based on LPA's observations and interviews conducted, the incident involving R1 and R2 escalated quickly and there was insufficient time for staff to intervene and prevent the incident from happening. 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, Dec 14, 2021 · control 28-AS-20211021085901

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

Allegation investigated: Staff took away resident's personal property Resident is unable to communicate with family members Staff unable to meet resident's needs while in care Staff emotionally abused resident while in care

Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Alex Solorio and explained the reason for the visit. The initial complaint visit was conducted by LPA Rivas on 5/13/20. The investigation consisted of the following: LPA Rivas interviewed one staff member, Resident #1 (R1), and R1's Service Coordinator. LPA Vasallo obtained R1's records including face sheet, physician's report dated 3/20/20, and medication list. LPA Vasallo also interviewed six residents and two staff. The investigation revealed the following: Allegation Staff took away resident's personal property. It's alleged staff took R1's cellphone. R1 was interviewed and indicated staff took his/her cellphone. Staff interviewed denied the allegation. Staff indicated R1 would misplace his/her belongings and would find it a short time later. Staff confirmed R1 had a "flip phone" and would use it often. Residents interviewed did not corroborate the allegation. None of the residents indicated staff take any belongings. Continued on 9099C. Unsubstantiated R1's Service Coordinator indicated he/she communicated with R1 often over the phone. R1 moved out of the facility on 4/25/20 and never had a roommate. There were no witnesses to the alleged incident. Therefore, the allegation is unsubstantiated. Allegation: Resident is unable to communicate with family members. It's alleged that at the beginning of the COVID-19 pandemic, R1 had no way to communicate with family. R1 was interviewed and indicated he/she was able to call his/her brother and sister. However, R1 did not want to provide contact information for the family to verify. Staff interviewed denied the allegation. Staff indicated facility purchased a cellphone and iPad so residents could communicate with family at the time when visits were not allowed due to the COVID-19 pandemic. Facility had a receipt for a cellphone dated 4/4/20. Staff report this cellphone was for residents to use. Residents also had access to the landline. During the visit, LPA also observed the iPad that residents can use to communicate with family. Residents interviewed confirmed facility has a cellphone and landline they can use to call friends and family. Residents also confirmed there is an iPad accessible to them also. Based on the information obtained, the allegation is unsubstantiated. Allegation: Staff unable to meet resident's needs while in care. It's alleged R1's diaper was not changed often enough. Staff interviewed denied the allegation. Staff indicated on several occasions R1 did not want staff to care for him/her. Staff report that R1 would yell at staff and would tell staff to leave the room. Residents interviewed did not corroborate the allegation. Residents did not have anything negative to report regarding staff. R1 moved out on 4/25/20 after only living at the facility for 1 month. There is no evidence that R1 suffered any adverse affects from not having diapers changed. Based on the information obtained, the allegation is unsubstantiated. Allegation: Staff emotionally abused resident while in care. The details of this allegation are unclear. R1 was interviewed and did not provide any details about the allegation. Staff interviewed denied the allegation. Residents interviewed did not corroborate the allegation. Residents did not report anything negative about the staff. The allegation is vague and there was no evidence to prove the allegation. Therefore, the 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.the state’s words, verbatim · CDSS document, Dec 2, 2021 · control 28-AS-20200506135045

Allegation investigated: Staff neglected resident. Staff did not notice a change in resident's condition.

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent complaint visit to the facility and was greeted by Assistant Administrator Alexander Solorio and explained the reason for the visit. The purpose of the visit is to deliver the findings for the above allegations. Initial visit was conducted on 12/17/2020 and interview was conducted with Wellness Nurse / Marisol Cruz Riquelme telephonically due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). Subsequent visits were conducted on 7/21/21 and 9/9/21 in which staff and resident's were interviewed. Investigation consisted of interviews with staff, residents, hospice agency representative, social worker for Resident 1, and review of Hospice Documentation. In regards to the allegation Staff neglected resident, based on interviews conducted and information gathered it was revealed that Resident 1 was admitted to the facility on 12/01/20. Hospice agency began service on 12/02/20 for Resident 1 which included a Plan of Care formulated to oversee activities of daily living (ADL's). A Certified Home Health Aide was assigned 2x weekly to perform ADL's care and assistance. Hospice Representative interviewed stated that the facility acted professionally and performed their job duties Unsubstantiated well in regards to Resident 1. Interviews conducted with clients who said staff act quickly for residents and call 911 right away and staff does a good job helping all individuals with medication, food and arranging transportation. Stated that staff help residents to get their needs met with showering and changing diapers. Staff interviewed stated that there was a Care Plan and they would do changes for showers and medication management. Hospice would do wound care. Stated that when Resident 1 did not look well staff reacted immediately to get help. Social Worker for Resident 1 did confirm that Resident was at facility for 6 days and then went to the hospital. Stated that she did communicate with the facility on the health status of Resident 1. It should be noted that Hospice was overseeing Resident 1 from 12/2/20 to 12/07/20. Resident 1 entered hospital on 12/7/20 and did not return to the facility. 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. In regards to the allegation Staff did not notice a change in resident's condition, based on interviews conducted and information gathered Resident 1 had a Plan of Care from Hospice between 12/02/20 and 12/07/20 in which all ADL's were overseen with 2x weekly performing Care and Assistance as assigned by RN Supervisor Plan of Care. Hospice Agency representative stated that facility carried out their job duties professionally and did a good job. Interviews conducted with clients who said staff act quickly for residents and call 911 right away and staff does a good job helping all individuals with medication, food and arranging transportation. Stated that staff help residents to get their needs met with showering and changing diapers. Staff interviewed stated that there was a Care Plan and they would do changes for showers and medication management. Staff acted immediately when Resident 1 was not looking well and called 911. Social Worker for Resident 1 did confirm that Resident was at facility for 6 days and then went to the hospital. Stated that she did communicate with the facility on the health status of Resident 1. 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.the state’s words, verbatim · CDSS document, Nov 23, 2021 · control 28-AS-20201210170802

Allegation investigated: Staff not administering medication in a timely manner.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit regarding the above allegation. LPA met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: On 04/14/21, LPA Joe Katrdzhyan conducted an initial complaint investigation via telephone due to the situation surrounding the Coronavirus Disease 2019 (COVID-19). Today's visit: LPA Luis Mora obtained copies of staff & client rosters, call light & response time in-service training signing in sheet, and medication records for Resident #1 - Resident #7 (R1-R7). LPA also interviewed Resident #1 - Resident #7 (R1-R7) and Staff #1 - #5 (S1-S5), and toured facility. The investigation revealed the following: it's alleged that staff are not administering the medication in a timely manner. Based on interviews conducted with residents, 7 out of 7 stated that they get their medication on time and have had no issues receiving their medication. (CONTINUED TO LIC 9099C) Unsubstantiated Based on interviews conducted with staff, 2 out of 5 stated that they have a schedule to administer the medication and they follow that schedule timely. The other 3 staff interviewed do not administer medication. LPA also reviewed medication records for R1 - R7 and observed proper documentation. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with residents and staff, and review of medication 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 violations did or did not occur, therefore the allegation are UNSUBSTANTIATED. Exit interview was held with Assistant Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2021 · control 28-AS-20210407154550

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, LPA met with Assistant Administrator / Alexander Solorio who assisted with the visit. The purpose of today's visit is to review the files of Resident 1 -5 (R1 - R5). Due to time constraints, LPA had to terminate visit and will return on a later date to complete the 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, Oct 19, 2021

Allegation investigated: Facility made false claims regarding employee training. Staff have not received required training.

Licensing Program Analysts (LPAs) Luis Mora and Joe Katrdzhyan conducted an unannounced complaint visit regarding the above allegations. LPAs met with Assistant Administrator Alexander Solorio and explained the reason for the visit. The investigation consisted of the following: LPAs obtained copies of Staff & Client Rosters, Staff #1 - #5 (S1-S5) New Hire Initial Training Record sheet and Hands-on Training Record sheet. LPA Mora interviewed Assistant Administrator Alexander Solorio and S1 - S5. The investigation revealed the following: in regards to the allegation "facility made false claims regarding employee training.", it is alleged that the assistant administrator Alexander Solorio signed caregivers training certificates, however, the caregivers never actually received the training. LPA Mora observed CPR/First Aid certificates for S1 - S5. (CONTINUED ON LIC 9099C) Unsubstantiated LPA Mora also observed that S1 - S5 completed 40 hours of initial training which included Orientation, Building and Fire Safety, Dementia Care, Medication Policies and Procedures, Personal Care/Universal Precautions/ Postural Supports, Restricted Conditions, Hospice/Psychosocial Need/Direct Care. These trainings are listed on the New Hire Initial Training Record and Hands-on Training Record and signed by the Assistant Administrator Alexander Solorio. Per interviews with caregivers, 5 out of 5 confirmed that they completed these training at the beginning of their employment. Therefore, there was insufficient evidence to corroborate with the allegation. In regards to the allegation "staff have not received required training.", it is alleged that the training that the caregivers receive at the facility is merely shadowing a day or two and do not get computer, classroom or video training. Complainant stated that the new caregivers have mentioned that they do not know what they are doing and are feeling lost in their job. LPA Mora observed that on the New Hire Initial Training Record sheet, the method of training used was a combination of media and shadowing. Per interviews with caregivers, 5 out 5 confirmed that they received training via media for about 3-4 days and then shadowing for 3 days. Furthermore, none of the caregivers indicated that they felt lost at their job and stated that they received proper training and continue to get refresher and new training every 3 months. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff and review of staff training 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 was held with Assistant Administrator Alexander Solorio and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 6, 2021 · control 28-AS-20201201103928

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Joe Katrdzhyan and Luis Mora conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPAs met with Assistant Administrator / Alexander Solorio and were later joined by the Executive Director / Kandice Vergara-Williams who assisted with the visit. The purpose of today's visit is to review the file of Resident #1 and tour the physical plant to ensure residents are not smoking marijuana inside the facility. At 12:15PM, LPA Katrdzhyan toured the physical plant (inside/outside) with the assistance of the Executive Director and did not observe residents smoking marijuana inside the facility. Also, there was no odor of marijuana present inside/outside of the facility premises. After reviewing the file of R1, LPA Katrdzhyan observed that at the time of admission, facility staff did not conduct a proper assessment of R1 as the Care Assessment/Evaluation, Functional Assessment, Mental Status Questionnaire and the Resident Appraisal were incomplete. Most of the answers to the questions listed on the forms were left blank. Also, the Unusual Incident/Injury Reports were reviewed for R1 and it was determined that R1's behaviors changed between period April of 2021 through September of 2021 and facility staff did not update the Appraisal/Needs and Services Plan for R1 addressing the current changes. R1 had multiple incidents of not following the facility Guest Policy by sneaking unknown male individuals from the street into her room. R1 was involved in theft of using a card belonging to another resident and making unauthorized purchases. R1 was also involved in multiple incidents of selling drugs to other residents inside the facility and getting into physical and verbal altercations with other residents and staff. R1 is in the process of being evicted from the facility for being non-compliant with facility house rules. 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 Executive Director along with the Appeals Rights.the state’s words, verbatim · CDSS document, Oct 6, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(1) · Plan of correction due date: Oct 15, 2021

Pre-Admission Appraisal - General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement is not met as evidenced by: After reviewing the file of R1, it was observed that at the time of admission, facility staff did not conduct a proper assessment of R1 as the Care Assessment/Evaluation, Functional Assessment, Mental Status Questionnaire and the Resident Appraisal were incomplete. Most of the answers to the questions listed on the forms were left blank. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: The Executive Director will review Title 22 Regulations, Section 87457 on Pre-Admission Appraisal 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: CCR87463(a) · Plan of correction due date: Oct 15, 2021

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidenced by: The Unusual Incident/Injury Reports were reviewed for R1 and it was determined that R1's behaviors changed between period April of 2021 through September of 2021 and facility staff did not update the Appraisal/Needs and Services Plan for R1 addressing the current changes. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2021

Plan of correction: The Executive Director shall update R1's Appraisal/Needs and Services Plan to indicate the changes in behaviors which led to the eviction. The Plan shall be submitted to CCL by the POC due date.

Allegation investigated: Resident was sexually abused while in care.

Licensing Program Analysts (LPAs) Joe Katrdzhyan and Luis Mora conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPAs 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 allegation of "Resident was sexually abused while in care". During today's visit, LPA conducted interviews of various persons to include the Assistant Administrator, Residents 1 through 3 (R1 - R3) and Staff #1. LPA attempted to interview Staff 2 via telephone but was unsuccessful. The investigation revealed the following; Allegation: Resident was sexually abused while in care. The details of this allegation states that on 9/9/21, R1 was sexually assaulted by R2, while she lay in her bed. (Please see LIC 9099C for additional information) Unsubstantiated Statements obtained from R1 by facility Staff, Law Enforcement and Community Care Licensing regarding the time/date and details of the alleged incident were inconsistent and changed during the course of the investigation. There were no witnesses to the alleged incident. R2 denied making sexual advances towards R1. From the interviews conducted, LPA learned that R1 has a history of making false allegations towards residents and staff. R1 and R2 used to be friends and have been observed by staff in the past hanging around in R1's room watching TV and talking. R1 is in the process of being evicted from the facility for being non-compliant with facility house rules. Pasadena Police Department also conducted an investigation regarding the alleged incident and it was determined that no crime had occurred. Based on interviews conducted, there is insufficient 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. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Sep 21, 2021 · control 28-AS-20210920110503

Allegation investigated: Marijuana is present on the facility grounds

Licensing Program Analysts (LPAs) Nune Margaryan and Joe Katrdzhyan conducted a subsequent visit to the facility to further investigate the above noted allegation. Upon arriving at the facility, LPAs met with Administrator Alexander Solorio and explained the purpose of this visit. The initial visit was conducted by LPAs Nune Margaryan and Tony Vasallo on 08/11/21. During the visit, LPAs obtained resident and staff roster, interviewed six (6) residents and six (6) staff. Resident #1's (R1) file was reviewed. On a later date additional phone interviews were conducted of three (3) staff. The following documents were also provided to LPA by email: House Rules; Memo-Subject: Reminder of Designated smoking areas and Consequences for violation Initial Training Records for staff; Non-Medical Medication: Polices, Procedures, Interaction of Drugs. MAR for Resident #1 (R1). (Please see LIC 9099C for additional information) Substantiated The investigation consisted of the following: Based on interviews conducted, LPA learned that residents are smoking marijuana at the facility and staff admitted that there have been complaints regarding marijuana smell coming from the facility. During the visit conducted on 08/11/21, LPAs toured the facility and observed a strong odor of marijuana coming from room 45B and the nearby hallway area. Per staff, all residents are required to follow the facility house rules. Based on LPA's observations and interviews which were conducted and documents reviewed 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) Exit interview conducted and report provided with Appeal rights. The investigation consisted of the following: On 08/17/21, LPA Nune Margaryan spoke with the Administrator and requested verification of training for all staff who provide medications assistance. Documents were received and reviewed by the LPA and it was confirmed that staff working on the day of the reported incident had completed the required training to assist residents with medications. Based on interviews conducted, statements obtained from Staff members #1 and 2 (S1 and S2) confirmed that R1 never requested pain medication on the date of the incident and R1 has a history of refusing medications. Statements obtained from residents did not present concerns of medications not being administered as prescribed. Although the allegation 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 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, Sep 1, 2021 · control 28-AS-20210803093535

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 15, 2021

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. This requirement is not met as evidenced by: Based on interviews conducted, LPA learned that residents are smoking marijuana at the facility and staff admitted that there have been complaints regarding marijuana smell coming from the facility. During the visit conducted on 08/11/21, LPAs toured the facility and observed a strong odor of marijuana coming from room 45B and the nearby hallway area.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities 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 administer medications as prescribed There is a strong odor of marijuana present inside the facility Facility has inadequate staffing for the residents while in care

Licensing Program Analysts (LPAs) Joe Katrdzhyan and Nune Margaryan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff did not administer medications as prescribed, There is a strong odor of marijuana present inside the facility and Facility has inadequate staffing for the residents while in care". Upon arriving at the facility, LPAs met with Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 7/7/21, in reference to the allegations listed above. During the course of the investigation, LPA interviewed the Assistant Administrator and Receptionist / Jeanette Velasquez. LPA was unable to interview Resident #1 (R1) and Staff members #1 and 2 (S1 and S2) as R1 no longer resides at this facility and S1 and S2 are no longer employed at this facility (whereabouts are unknown at this time). During the visit conducted on 7/7/21, LPA toured the facility smoking and non-smoking areas. LPA also obtained and reviewed copies of the following documents in reference to the allegations listed above; • Written statement from S1 regarding the incident involving R1 • Hands-on Training Record for S1 Substantiated • New Hire Initial Training Record for S1 • R1 Information Sheet • Physician's Report for R1 • Preplacement Appraisal Information for R1 • Personnel Record for S1 • Staff and Resident. The investigation revealed the following; Allegations: "Staff did not administer medications as prescribed" and "Facility has inadequate staffing for the residents while in care". The details of these allegations state, R1 called 911 due to experiencing back pain. Once the Emergency Medical Services (EMS) arrived at the facility, S1 reported to EMS personnel that she was the only staff on duty with a census of 36 residents and she was not qualified to administer the necessary medications to R1. Based on interviews conducted and record reviews, the incident involving R1 took place on 6/27/21, between the hours of 10:35PM - 11:35PM. R1 called 911 because was she experiencing back pain and had not been provided her pain medications. After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1. In reference to the allegation of "Facility has inadequate staffing for the residents while in care", statements obtained confirmed that S1 was the only staff member on duty at the time of the incident and in charge of providing care and supervision to 36 residents. S2 was scheduled to be on duty with S1 but was a "no call, no show" leaving S1 alone at the facility. LPA learned that S1 failed to inform Management about S2 being a "no call, no show" in a timely manner in order to find a replacement. Based on interviews conducted and record reviews, there is sufficient evidence to support the allegations of "Staff did not administer medications as prescribed" and "Facility has inadequate staffing for the residents while in care". Allegation: "There is a strong odor of marijuana present inside the facility". During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been observed smoking marijuana in their rooms and the outside, near the courtyard area. Based on LPA's observation and interviews conducted, there is sufficient evidence to support the allegation of "There is a strong odor of marijuana present inside the facility". 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 state’s words, verbatim · CDSS document, Sep 1, 2021 · control 28-AS-20210706094631

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.2(a)(4) · Plan of correction due date: Sep 15, 2021

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, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will review Title 22 Regulations Section 87468.2 on Additional Personal Rights of Residents in Privately Operated Facilities 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: HSC 87468.2(a)(4) · Plan of correction due date: Sep 15, 2021

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, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: On 6/27/21, between the hours of 10:35PM - 11:35PM, S1 was the only staff member on duty at the time of the incident and in charge of providing care and supervision to 36 residents. S2 was scheduled to be on duty with S1 but was a "no call, no show" leaving S1 alone at the facility.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will review Title 22 Regulations Section 87468.2 on Additional Personal Rights of Residents in Privately Operated Facilities 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: HSC 87468.1(a)(2) · Plan of correction due date: Sep 15, 2021

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. This requirement is not met as evidenced by; During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been observed smoking marijuana in their rooms and the outside, near the courtyard area.the state’s words, verbatim · CDSS document, Sep 1, 2021

Plan of correction: Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities 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: Illegal eviction.

Licensing Program Analyst (LPA) Cynthia Chan conducted the initial investigation for the allegation on illegal eviction. LPA arrived unannounced and met with Gretel De Santiago, Administrator Assistant and explained the purpose of the visit. Michael Murphy, Human Resources Director assisted LPA with the visit. The investigation consisted of the following: LPA obtained a copy of the staff roster and resident roster. LPA requested copies of the documents from Resident #1’s (R1) file: 30-day eviction letter, Appraisal/Needs and Services Plan, House Rules, and Facility notes/Usual Incident Reports. LPA also interviewed Kandice Williams, the Executive Director, 3 Staff, and 2 Residents. (Continue on LIC9099C) Substantiated The investigation revealed the following: Based on record review, Resident #1 (R1) was initially served a 30-day eviction letter on 5/5/21 and another most recently on 7/9/21. Per Executive Director, R1 had a physical altercation with another resident which led to the eviction notice served on 7/9/21. LPA interviewed R1 who denied the physical altercation and stated that the eviction letter was never provided to her. However, the incident was verified by staff through the video footage and the eviction letter served on 7/9/21 was signed by R1. Although LPA received documentation of incidents pertaining to R1, the specific incident(s) that caused for eviction were not indicated on the eviction letter. In addition, R1’s Appraisal/Needs and Services Plan has not been updated since 11/23/2020 to address the current behaviors. R1 is still residing at the facility. Based on record review, 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 interviewed was conducted. The Plan of Corrections were reviewed and developed with the Executive Director. A copy of this report, LIC9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 11, 2021 · control 28-AS-20210806121901

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1568.683(a) · Plan of correction due date: Aug 18, 2021

1568.683 Eviction notices; reasons for eviction contents, service (a)... a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: The licensee did not ensure that the reasons for eviction for R1 was written on the eviction letter which poses a potential health, safety, and personal right risk to resident in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: The Executive Director shall review the Health and Safety Code 1568.683 on Evictions. A letter to rescind the eviction letter served on 7/9/21 shall be provided to R1 and verification to LPA by POC due date 8/18/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 18, 2021

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidenced by: The licensee did not ensure that the Appraisal/Needs and Services Plan for R1 has been updated to address current behaviors which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: The Executive Director shall update R1's Appraisal/Needs and Services Plan to indicate the behaviors which caused for the eviction. The Plan shall be submitted to LPA by POC due date 8/18/21.

Allegation investigated: Resident wandered away from the facility

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 allegation of "Resident wandered away from the facility". During today's visit, LPA interviewed the Assistant Administrator and reviewed the file of Resident #1 (R1). LPA obtained copies of the following documents in reference to R1; • Physician's Report • Unusual Incident/Injury Report • Resident Information Sheet • Medical Reports The investigation revealed the following; Based on the interview conducted and file review, LPA discovered that on 7/27/21, at approximately 1PM, R1 left the facility through the side gate, located in the parking lot. Once facility staff discovered R1 went missing, Substantiated a missing person's report was filed through the Pasadena Police Department and the brother of R1 was notified. On 7/30/21, facility staff received a call from Huntington Hospital stating R1 was found in the parking lot of Target and taken to Huntington Hospital. As of 8/3/21, R1 remains hospitalized. According to the Physician's Report dated: 9/1/2020, R1 is not able to manage own treatment, medication and equipment. R1 is listed as non-ambulatory and needs assistance with most of his activities of daily living. The treating physician has also indicated that R1 is not able to leave the facility unassisted. LPA discovered that this was the second incident involving R1 leaving the facility unassisted, without staff supervision. This presents an immediate health and safety concern for R1 as the facility was not able to provide care and supervision to meet the needs of R1. Based on LPA’s interview 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, Aug 3, 2021 · control 28-AS-20210728115738

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 4, 2021

Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2 Health and Safety Code section 1569.2(c) provides: "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by; On 7/27/21, at approximately 1PM, R1 left the facility through the side gate, located in the parking lot. Per the Physician's Report dated: 9/1/2020, R1 is not able to manage own treatment, medication and equipment. R1 is listed as non-ambulatory and needs assistance with most of his activities of daily living and R1 is not able to leave the facility unassisted. This presents an immediate health and safety concern for R1 as the facility was not able to provide care and supervision to meet the needs of R1.the state’s words, verbatim · CDSS document, Aug 3, 2021

Plan of correction: Administrator shall conduct an in-service training to staff on Basic Services and provide a copy of the materials discussed along with names and signatures of staff in attendance. Administrator will also develop a written plan detailing how staff will ensure care and supervision is being provided as necessary to meet the needs of residents in care. POC must be submitted to CCL by the POC due date of 8/4/21.

Allegation investigated: Facility is not ensuring resident obtains necessary medical equipment. Resident's call light is not functioning.

Licensing Program Analyst (LPA) Nicole Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer was met by assistant administrator Alex Solorio and explained the purpose of today's visit. The investigation consisted of the following: On 5/26/21, LPA Spencer conducted a health & safety check and obtained copies of the staff and resident roster. On 7/30/21, LPA Spencer interviewed the assistant administrator, staff #1-2 (S1-S2), and residents #1-3 (R1-R3). R4 was not at the facility and was unable to be reached by phone after several attempts. LPA Spencer collected copies R4's face sheet, physician's report, call light pendant acknowledgement form, hospital bed order form, and discharge papers. The investigation revealed the following: regarding allegation facility is not ensuring resident obtains necessary medical equipment, it was alleged the the facility did not ensure that a resident was provided with a hospital bed. ***Narrative continued on LIC9099C. Unsubstantiated On today's visit on 7/30/21, LPA observed that R4's room had a hospital bed with half rails. LPA reviewed the hospital bed order form showing that the hospital bed was ordered on 4/30/21 and arrived to the facility on 5/3/21. The administrator stated that the bed was assembled but had full rails so it had to be adjusted/replaced with half rails. All staff interviewed stated that the facility provides accommodations for hospital beds and that no residents have complained about not receiving necessary medical equipment. R1-R3 stated that they use hospital beds and they have no issues with the facility obtaining necessary medical equipment for residents. Regarding the allegation that resident's call light is not functioning, LPA observed that R4's room had a functioning call light. LPA reviewed call light pendant acknowledgement forms that showed that R4 received a replacement call light on 5/26/21 and 6/2/21. Per interview with assistant administrator, each resident receives a call light pendant. If the call light stops working or residents misplace it, it is replaced by the facility once staff are made aware and the resident signs for the replacement. Assistant administrator stated that R4 has received 3-4 call light pendant replacements due to being misplaced or not functioning. All staff interviewed stated that call light pendants are replaced right away if they're not functioning. R1-R3 stated that they have a functioning call light and demonstrated that they were functional. Based on observations, interviews, and record reviews, 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. An exit interview was conducted, and a copy of report was provided to Assistant Administrator.the state’s words, verbatim · CDSS document, Jul 30, 2021 · control 28-AS-20210525125201

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegation of "Illegal eviction". Upon arriving at the facility, LPA met with HR Representative / Michael Murphy and was later joined by the Assistant Administrator / Alexander Solorio who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 5/21/21, in reference to the allegation listed above. On 6/2/21, LPA Linda M Almaraz conducted a complaint investigation at this facility regarding the same allegation (Illegal eviction), involving the same resident, Resident #1 (R1). During the course of the investigation, LPA Almaraz discovered that the facility had served R1 a 30 day eviction notice for refusing medication and verbally abusing staff. The 30 day eviction notice was served to R1 on 5/13/21. The eviction notice stated the resident had yelled at staff several times from 7/2020 though 5/2021 and had been calling staff "incompetent, liar and lazy" while expressing dissatisfaction with their care. During file review, it was Unsubstantiated discovered that R1's Appraisal/Needs and Service Plan had not been updated since the initial one conducted on 7/9/2020, to reflect the R1's non-compliance with medication. Based on the investigation conducted by LPA Almaraz, there was no evidence found to support that R1 had been verbally abusive by yelling at staff and R1 has the right to refuse medication. The allegation of Illegal Eviction was Substantiated by LPA Almaraz on 6/2/21 and deficiencies were issued under California Code of Regulations Title 22. Please refer to Complaint #28-AS-20210526164252, dated: 5/26/21 for additional information. This concludes the investigation on "Illegal eviction" based on the findings delivered by LPA Almaraz. 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 7, 2021 · control 28-AS-20210514091631