Prestige Care Homes II

Allegation investigated: Staff do not ensure residents are being served food of quantity to meet residents needs Staff do not ensure there is the required amount of food in the home

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a complaint investigation and deliver complaint findings. LPA Valerio met with facility staff Cynthia Yuvienco, and explained the purpose of the visit. LPA Valerio contacted Administrator Vidan Barias, who designated staff to sign on her behalf The investigation consisted of resident interviews, staff interviews, observations of food supply, and record review of pictures and facility files. The reporting party alleged that Resident 1 (R1) is not being fed at the care home. The RP reported that on Easter they had provided R1 with a sandwich with Mayo on it and nothing else. RP reported that the fridge was empty. Continues on LIC 9099 - C... Unsubstantiated On 04/16/2026, LPA Valerio conducted an unannounced visit to interview residents and observe the facility. LPA Valerio observed R1 in the living room in R1's hospital chair. R1 was being fed by staff during lunch time. LPA Valerio observed the resident and other resident during lunch time. According to resident interviews conducted, the facility provided a lot of food, sometimes too much, and had no concerns with the food. According to staff interviews, the staff stated they always have food. According to Staff 1 (S1), S1 does not remember what S1 served on Easter Sunday, but S1 usually makes sandwiches. LPA asked what does S1 put in the sandwich. S1 stated S1 puts mayo, lettuce, tomato, and chicken. Sometimes S1 will put turkey, bacon, or roast beef depending on what they have from the store. S1 serves it with a salad and fruit or cut vegetables. LPA Valerio observed the following food on 04/16/2026. LPA Valerio observed two refrigerator/freezer and a pantry. The first fridge had the following 8 Marie calendar chicken pot pie, a family size bad of frozen mix vegetables, two frozen packs of hot dogs, 1 family size bag of chicken thighs, one frozen family size bag of breakfast sausage, 2 small bags of mixed vegetables, 1 big frozen ground beef roll, 3 gallons of juice, 2 gallons of milk, 2 large bunch of strawberries, 3 loaves of bread, 1 family size of hamburger buns, 1 family size of hot dogs, 2 - 5 dozen box of eggs, fresh cabbage, 1 bunch of carrots, 20 pudding cups, and condiments. The second fridge had two sections. The refrigerator had two dozen of eggs, a bag of avocados, a bag of cut potatoes, two boxes of butter, soda, 12 jars of yogurt, and 1 jar of pasta. The freezer had two family size mixed vegetables, 1 family size box of orange chicken, 1 family size frozen uncooked shrimp, multiple bags of frozen protein items, and 6 bags of frozen waffles. The pantry was observed to have the following: 3 large jugs of vinegar, 2 - 35 cans of coca cola soda, 24 pack of cup noodles, 4 gallons of juice, 1 large jar of mayo, over 20+ cans of canned food, 6 boxes of tru-blue saltine crackers, 3 boxes of breakfast cereal, bananas, chocolate chip cookies, 4 family size bags of pasta noodles, and 6 boxes of rice roni. Licensing Program Analyst (LPA) Christina Valerio received pictures from Administrator Vidan regarding the food plates that were provided to R1. The administrator stated the concern of R1 not eating was brought up so they started taking pictures and sending it to the case manager and the family. According to Administrator, R1 would eat full plates and snacks but would say R1 was hungry. Continues on LIC 9099, page 3 Picture 1 - The picture had 6 pieces of breaded chicken placed on the plate. Each chicken was the size of a silver dollar. There were also cut up boiled potatoes with seasoning and Cut up asparagus that appeared to be steamed or sauteed. Picture 2 - The protein appeared to be orange chicken (7 pieces), steamed vegetables, and rice pilaf. Picture 3 - 4 triangle pieces of a grilled sandwich filled with sliced cheese, mayo, sliced ham, and scrambled eggs. Flake cereal served with milk and sliced bananas. Picture 4 - Pancit noodles with vegetables, egg, and chicken served with a chocolate cake loaf. Picture 5 - Swedish meatball with peas, gravy, and mash potatoes served with a chocolate pudding cup. On 08/07/2026, LPA Valerio conducted an unannounced visit to conduct an annual required visit. During the annual visit, LPA Valerio observed the facility to have a minimum food supply to meet the requirements of two days of perishable food items and seven days of non-perishable food items. LPA Valerio observed watermelon, bananas, and oranges available for residents. LPA Valerio observed frozen ground beef, chicken, salmon, chicken patties, and lasagna trays in the freezer. LPA Valerio observed milk, juice, condiments, mixed salad bag, zucchini, bread, cheese slices, fruit jam, peanut butter, butter, macaroni salad, onions, tomatoes, and eggs in the refrigerator. Based on all the information collected by the Department, although the allegation may have happened or is valid, here is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held, and a copy of report was left at the facility with staff Cynthia.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 27-AS-20260410145112

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required visit. LPA Valerio met with facility staff Cynthia Yuvienco, and explained the purpose of the visit. LPA Valerio contacted Administrator Vidan Barias, who designated staff to sign on her behalf. LPA Valerio and facility staff toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed common areas to be fully furnished and free from odors. Resident bedrooms were fully furnished with a bed, chair, night stand, light, and a dresser. LPA Valerio observed resident rooms to be free from odors. LPA Valerio observed resident bathroom to have a shower chair, hand rails, a skid matt, and hygiene supplies. LPA Valerio observed the closet space utilized for extra linens and supplies. LPA Valerio observed the pantry area to have non-perishable items enough for a minimum of seven days. LPA Valerio observed the two kitchen refrigerators to have perishable food items to last a minimum of two days. Staff was observed assisted resident with ADLS, cleaning up from lunch time, providing snacks to residents, and cleaning the facility laundry. The fire extinguisher was observed to be fully charged with a last inspection date of November 08, 2025. The date of the last fire drill was conducted on March 15, 2026. The exterior area was observed to have a walk way for residents and a sitting area for outdoor visits. No emergency exits were obstructed or blocked. LPA Valerio reviewed three resident and staff files. All files were observed current with required annual documentation. LPA Valerio requested the following annual documentation be sent: LIC 500, LIC 308, LIC 610, and copy of liability insurance. Per California Code of Regulation (CCR) - Title 22 - no deficiencies were cited. An exit interview was held with staff, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski and Office Technician Amy Jordan arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit. LPA Moleski reviewed a death report which described the death of a resident (R1) on 6/17/25. R1 was awake and alert around 6:30 a.m., but was found unresponsive shortly after taking their morning medications, according to the report. LPA Moleski reviewed R1's file and interviewed Barias. LPA Moleski counted out R1's overactive bladder medication and observed that there were not enough doses of the medications to account for the number of pills remaining in the bottle. LPA Moleski counted 59 pills remaining in the 200-count bottle, which should correspond with 141 recorded dosages. However, there were fewer than 141 doses recorded in R1's MARs, and even counting every day R1 was present in the facility, there were not enough possible doses between the date the bottle was opened, 4/1/25, and R1's date of death, 6/17/25, to account for 141 doses, presuming that prescription orders were followed. Vidan observed the medication count to ensure accuracy and agreed that there was a discrepancy. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 2, 2025

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on observation and record review, medications for R1 were mismanaged, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a schedule of forthcoming staff trainings on medication management. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit. LPA Moleski reviewed five resident files (R1-R5) and three staff files (S1-S3). R1's file contained hospital discharge paperwork from a stay dated 3/31/25 through 4/3/25. The discharge documents indicated R1 was admitted for a clogged catheter, and was diagnosed with sepsis and a UTI. LPA Moleski reviewed an after visit summary for R1 dated 4/6/25 for a hospital visit for a transient ischemic attack. LPA Moleski reviewed a third hospital visit summary dated 4/12/25 through 4/16/25. R1 was admitted due to acute respiratory failure. LPA Moleski reviewed incident report records received by the Community Care Licensing Division (CCLD) and observed that only the second visit, dated 4/6/25, was reported by facility staff. While reviewing resident files, LPA Moleski observed that start dates for medications were not recorded, which means an audit of medications to ensure accuracy of doses is not currently possible. LPA Moleski toured the facility with Barias and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 78 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 112 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguishers, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions. LPA Moleski interviewed one staff member (S1) and one resident (R2). This facility is hereby cited per 22 CCR Sections 87465(a) and 87211(a)(1). An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Resident suffered injuries due to staff neglect Staff did not follow hospice care plan for resident Staff did not notify resident's responsible party about resident's injuries Staff did not dispense medication to resident as prescribed by physician Staff spoke inappropriately to residents

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Barias, three staff members (S1-S3), five residents (R2-R6), a former resident’s responsible party (R1’s RP) and a former resident’s hospice nurse (R1’s RN). LPA Moleski received a death report for a resident (R1) of this facility dated 11/5/24. R1 was on hospice care and died of apparent natural causes, according to the death report. R1’s admission agreement was dated 10/25/24. [continued 9099-C] Substantiated LPA Moleski reviewed a note from visiting hospice staff on 10/26/24 which indicated that there was no discoloration or bruising on R1 at that time. LPA Moleski reviewed daily progress notes for R1, which were recorded by facility staff. A note on 10/25/24, R1’s date of admission, indicated that R1 was "in pain very often and medicated as needed." A note on 10/27 indicated R1 didn't sleep well until 3:30 a.m., and R1 continued to ask for pain medication. A note on 10/28 indicated R1 slept in short intervals and "keeps moving." A note on 10/29 indicated R1 was "very restless" overnight and didn't go to sleep. R1 was found on the floor around 4:30 a.m., although R1’s bed was set "all the way low." A note on 10/30 indicated the R1 was "very restless," and "went on floor." Staff put R1 back to bed, but "[R1] goes on floor again." A note on 10/31 indicated that R1 "was on floor around 10:30 p.m." R1 was put back to bed with a Hoyer lift. A note on 11/2 indicated R1 was "restless always." A second note on this same date indicated that R1 was "restless," but went to sleep later. A note on 11/3 indicated that R1 was "very restless." The author of the note wrote that staff put pillows by the side rails of the bed, but R1 threw them on the floor. R1 was "hitting [R1's] head on rails" and hitting their feet on the walls. A skin tear was noted on R1's feet and arms. A note on 11/4 indicated that R1 slept for a while, but then was very restless. The author said they were "watching [R1] alway" [sic] and "holding [R1's] hands." A second note on the same date indicated that R1 was restless for a short time, but after taking their medication, R1 went to sleep. The Community Care Licensing Division (CCLD) did not receive any incident reports regarding the falls as described above, or regarding the injuries suffered by R1. In an interview, R1’s RP said they were not notified of the injuries, and discovered them when visiting R1. In an interview, Barias said that R1’s RP was not notified of the injuries, and that she herself was not notified by her staff of the injuries. R1’s hospice nurse said the hospice agency was not notified of the injuries, and they discovered the injuries when visiting R1. LPA Moleski reviewed R1’s hospice care plan, dated 10/21/24. Admission instructions indicate that both R1 and caregivers were provided 24-hour contact phone numbers for the agency. A note in the care plan indicates that both the patient and caregivers were instructed on how and when to call hospice, and to do so on an as needed basis. The care plan identified R1 as a fall risk, and instructed staff to conduct a fall risk assessment if there is a fall and to notify the hospice agency. LPA Moleski did not observe any fall risk assessments documented in R1’s file. [continued on 9099-C] LPA Moleski reviewed notes taken by R1’s hospice nurse. The notes indicate that, during a visit on 11/4/24, R1’s RN discovered “several abrasions to right knee and bilateral feet and skin tears and abrasions to left forearm.” According to the note, R1’s RN was told by facility staff that R1 was agitated during the night and was found on the floor. LPA Moleski visited this facility on 11/12/24, after R1 had already died. During the visit, R1’s bed had already been removed, so it was not available for inspection. In an interview, Barias said that R1 was very restless, and their injuries were caused by R1 hitting the side rails on their bed. Barias said that R1 also slid down to the floor from bed. Barias said her staff had put a mattress below the bed, and they also put blankets and pillows on the bed rails to prevent further injuries. Barias said the protective padding was put in place after R1’s first incident of falling on 10/31/24. In an interview, S1 said that R1 was able to remove the blankets and pillows from the rails after staff added them. S1 said that R1 continually banged their hands into the rails, suffering swollen hands, and R1 also kicked the wall next to their bed with their feet. S1 said R1 also scratched themselves on the arms, removing the skin. S2 said that staff could not control R1’s behavior, even after giving R1 their PRN medication, and R1 continued to hit the rails. S2 said that staff used pillows and other padding to cover the rails, but R1 also kicked the wall adjacent to their bed, and suffered a scrape on their foot as a result. S2 said that R1’s hands and fingers were purple from striking the rails, and R1 also hit their head into the rails. S3 said that R1 wasn’t eating, was waving their arms around, and was scratching themselves on the arms. S3 said that when they observed this behavior, they put a pillow on R1’s bed rail, and also put a recliner up against R1’s bed, effectively restraining R1. S3 said that staff were supposed to call R1’s nurse if they became agitated, but they didn’t speak with the nurses because of their lack of English proficiency. In an interview, R1’s RN said that staff should have immediately called the hospice agency to report R1’s behavior. After R1’s RN discovered R1’s injuries on the morning of 11/4/24, R1 received an increase in prescribed medications through the hospice agency. No additional unusual incidents or injuries were noted in R1’s ongoing notes from that time until the time of R1’s death on the night of 11/5/24. In an interview, R1’s RP said that R1 suffered many bruises because they frequently tried to crawl out of bed. R1’s RP said that staff had put a mat on the floor to prevent injury from falls. R1’s RP was not aware of R1’s habit of hitting their bed rails with their hands. R1’s RP said that staff also placed barriers up to prevent R1 from leaving bed, such as a wheelchair placed against the bed, and additional rails on the lower portion of the bed. The use of de facto restraints by staff will be addressed in a follow-up case management report. [continued 9099-C] Based on the above interviews, although some preventative measures were taken by staff to prevent R1’s injury, they were not effective, as R1 was able to remove the blankets and pillows from their bed rails and continued to engage in self-injurious behavior as a result. Additionally, despite suffering numerous falls prior to 11/4/24, fall risk assessments were not documented, and R1’s hospice agency was not notified for follow-up, as required by R1’s hospice care plan. According to a note written by R1’s hospice nurse dated 11/4/24, R1 had been medicated immediately prior to the nurse’s visit, and while reviewing medication logs and doses, inconsistencies were discovered. In an interview, Barias said that, on 11/4/24, a staff member, S1, gave R1 two doses of an antipsychotic medication within two hours, when R1’s medication order indicated it should only be given every four hours. LPA Moleski reviewed R1’s medication administration records (MARs) and confirmed Barias’ statement. R1 was given a 1-millileter dose of the medication at 8 a.m. on 11/4/24, and a second 1-millileter dose at 10 a.m., according to the MARs. R1 was later given 1 milliliter of the same medication at 2 p.m., then 1.5 milliliters at 6 p.m. and 10 p.m. LPA Moleski reviewed R1’s prescription orders. LPA Moleski reviewed a prescription dated 10/21/24, which indicated that R1 could have a maximum of 1 milliliter of the medication every four hours as needed. LPA Moleski reviewed an approved medication list which included the same prescription as of 10/28/24. A new prescription for the same medication was authorized by a hospice agency physician as of 11/4/24 at 11:05 a.m. for a maximum of 1.5 milliliters every four hours as needed. In an interview, S1 admitted that they had given the medication a second time on the morning of 11/4/24 within two hours, rather than four, but said they thought it was the only way to calm R1 down. LPA Moleski reviewed daily progress notes for a resident (R2). A note on 10/23 indicated that R2 was going to the bathroom "too many times." A note on 10/31 states that R2 "stole the raisins and ate half." Another note that same date stated that R2 "try to take stuff fr pantry room, I told him you not suppose to open that, you ask if you want something" [sic]. In an interview, Barias said an incident occurred on 11/4/24 wherein R2 had gone to the bathroom without assistance and was “messing it up.” Barias said they were notified by R1’s hospice agency that a staff member (S1) was yelling at R2 because of this. Barias was not present during this incident, but said S1’s voice is “too loud.” [continued on 9099-C] In an interview, R2 said that S1 is “bossy” and has a “staccato” way of speaking to R2. R2 said that S1 often sends R2 out of the kitchen, except at mealtimes. R2 described S1 as commanding. In an interview, S1 described their own voice as “not that sweet” and “loud.” S1 said that they were not expecting a nurse to be present on 11/4/24 to “observe my attitude.” In an interview, R1’s RP, who was also present on 11/4/24, said the staff member was yelling at R2, and asking R2 why they had made such a mess. R1’s RN, who was present on 11/4/24, confirmed they had also overheard the incident. The department has determined the following as it relates to the allegations that a resident suffered injuries due to staff neglect, that staff did not follow a hospice care plan for a resident, that staff did not notify a resident’s responsible party about a resident’s injuries, that staff did not dispense medication to a resident as prescribed by their physician, and that staff spoke inappropriately to residents: Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87464(f)(1), 87633(a)(4), 87211(a)(1), 87465(a)(4), and 87468.1(a)(1). An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.the state’s words, verbatim · CDSS document, Feb 11, 2025 · control 27-AS-20241105091209

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 13, 2025

87464(f)(1): “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(c).” This requirement was not met as evidenced by: Based on interview and record review, a resident was not provided appropriate and/or effective assistance necessary to prevent self-inflicted injuries, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to provide a written acknowledgement of this requirement, and a written outline of care for terminally ill residents by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(a)(4) · Plan of correction due date: Feb 13, 2025

87633(a)(4): “(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill … when all of the following conditions are met: … all hospice care plans are fully implemented by the licensee …” This requirement was not met as evidenced by: Based on interview and record review, fall assessments were not documented or provided to R1’s hospice agency, and other unusual behaviors requiring immediate attention were not reported immediately to the hospice agency, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to conduct a staff training regarding communications to be made to hospice agencies. Licensee agrees to provide LPA Moleski with a schedule for training by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 12, 2025

“The licensee shall assist residents with self-administered medications as needed.” This requirement was not met as evidenced by: Based on interviews and record review, a resident was given more medication that permitted by their physician on 11/4/24, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to conduct a staff training regarding medication procedures. Licensee agrees to provide LPA Moleski with a schedule for training by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 12, 2025

87468.1(a)(1): “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 was not met as evidenced by: Based on interviews and record review, a R2 was not accorded dignity in their relationships with staff, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to conduct a staff training regarding personal rights. Licensee agrees to provide LPA Moleski with a schedule for training by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 25, 2025

87211(a)(1): “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 requirement was not met as evidenced by: Based on interviews and record review, CCLD and R1’s RP were not notified of R1’s various injuries and other concerning behaviors, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to conduct a staff training regarding reporting requirements by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on a complaint investigation. During the course of that investigation, LPA Moleski discovered other deficiencies unrelated to the complaint allegations, which will be addressed in this case management report. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit. LPA Moleski reviewed a resident’s (R1’s) medication administration records (MARs) as part of the previously mentioned complaint investigation. LPA Moleski observed that dosage amounts were not recorded for multiple doses of a PRN antipsychotic and a PRN opioid narcotic. Dosages are missing for one or more administrations of one or both of these medications on 10/26, 10/27, 10/28, 10/29, 10/30, and 10/31. Per 22 CCR Section 87465(b-d), PRN medications may only be given to a resident if their physician has stated in writing their ability to determine their need for PRN medications and communicate their symptoms. If that resident has deficits in either area, then a record including dosages must be maintained for all PRN medication administrations. LPA Moleski reviewed R1’s file and did not observe any documentation from R1’s physician regarding their ability to determine their need for PRN medications and communicate their symptoms. R1 was admitted to this facility as of 10/25/24, according to their admission agreement. However, R1’s LIC 602 examination was dated 10/31/24, after R1 was already admitted. The LIC 602 was not signed by R1’s physician until 11/1/24. Per 22 CCR Section 87458(a), medical assessments must be obtained “prior to a person’s acceptance as a resident.” [continued on 809-C] Based on multiple interviews with staff and other witnesses, and based on review of facility records, R1 suffered from restlessness and agitation between at least 10/31/24 and their death on 11/5/24. In an interview, a staff member (S3) admitted to moving a recliner up against R1’s bed in order to prevent R1 from slipping out. In an interview, R1’s responsible party said they had also observed a wheelchair moved up against R1’s bed, and additional lower railings in order to prevent R1 from getting up out of bed. 22 CCR Section 87608(a)(1) includes among postural supports devices which are used to prevent a resident from falling out of bed. Section 87608(a)(2) states that residents must be able to release any such device quickly, and Section 87608(a)(3) states that there must be written orders for the use of any such device from the resident’s physician. Section 87608(a)(5)(B) prohibits full-length bed rails, except for residents receiving hospice care, and when their hospice care plan specifies the need for full rails. LPA Moleski reviewed R1’s hospice care plan and did not observe any indication that R1 was approved to have full rails installed on their bed. This facility is hereby cited per 22 CCR Sections 87608(a), 87465(b), and 87458(a). An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.the state’s words, verbatim · CDSS document, Feb 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a) · Plan of correction due date: Feb 13, 2025

87608(a): “Postural supports may be used under the following conditions … [et seq.]” This requirement was not met as evidenced by: Based on interview and record review, R1 was restricted from leaving their bed with devices not approved for use by their physician or hospice agency, and which did not permit quick release by the resident, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to conduct a staff training regarding the use of restraints. Licensee agrees to provide LPA with a training schedule by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(b) · Plan of correction due date: Feb 25, 2025

87465(b): “If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.” This requirement was not met as evidenced by: Based on record review, R1 did not have the necessary physician’s authorization to receive assistance with PRN medications from facility staff, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to review this Section and provide a written acknowledgement of its requirements by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Feb 25, 2025

87458(a): “Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.” This requirement was not met as evidenced by: Based on record review, R1 was examined for their medical assessment after already being admitted to this facility, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee agrees to review this Section and provide a written acknowledgement of its requirements by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation. During the course of the investigation, LPAs Moleski and Williams observed unrelated deficiencies. LPAs Moleski and Williams met with facility administrator Vidan Barias and explained the purpose of the visit. Upon arrival to this facility, LPAs Moleski and Williams observed a paper bag located next to the dining room table with a sign on it which read "old meds." Inside the bag were many bottles of medications, which were out and accessible to residents in care. Additionally, located immediately next to the table on a cabinet were a bottle full of stool softener pills and a daily pill dispenser, containing approximately four weeks' worth of pills. A staff member (S1) said the daily pill dispenser was theirs. While reviewing a resident's file (R1), LPA Moleski observed that R1 was bedridden, according to two LIC 602s, dated 10/17/24 and 10/31/24. This facility's fire clearance does not permit the acceptance or retention of bedridden residents. While touring this facility, LPA observed a laundry room left open and unlocked which contained laundry detergent, insecticide, and two pairs of garden shears. A cabinet inside the laundry room was also left unlocked, and it contained a bleach cleaning solution. This facility is hereby cited per 22 CCR Sections 87465(h)(2), 87202(a)(2), and 87309(a). An immediate civil penalty in the amount of $500 is hereby assessed due to a violation of fire clearance. This facility was previously cited per Sections 87465(h)(2) and 87309(a) during an annual inspection on 7/2/24. As these are repeat violations, civil penalties in the amount of $250 for each citation are hereby assessed, for a grand total of $1,000 between all three civil penalties. An exit interview was held with Barias. Appeal rights and a copy of this report were left with Barias.the state’s words, verbatim · CDSS document, Nov 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Nov 13, 2024

"(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance ... (2) Bedridden persons." This requirement was not met as evidenced by: Based on record review, the licensee admitted and retained a bedridden resident, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: Licensee agrees to submit a written statement acknowledging fire clearance requirements and affirming that they will be adhered to in the future. Licensee said they will provide this by Friday. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Nov 13, 2024

"(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement was not met as evidenced by: Based on observation, the licensee left medications out unlocked and accessible to residents in care, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: Licensee agrees to conduct a staff training by Friday and will provide LPA Moleski with a sign-in sheet afterward. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Nov 13, 2024

"(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients." This requirement was not met as evidenced by: Based on observation, cleaning solutions, insecticide, and shears were left unlocked and accessible to residents in care, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Nov 12, 2024

Plan of correction: Licensee agrees to conduct a staff training by Friday and will provide LPA Moleski with a sign-in sheet afterward. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski and Investigator (Inv.) Tim Balarie arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Vidan Barias and explained the purpose of the visit. LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Moleski observed that R2 has a foley catheter, according to an appraisal dated 3/30/24. LPA Moleski did not observe the required record of care for a restricted health condition. Barias could not provide a record of care regarding R2's foley catheter. LPA Moleski toured the facility with Barias and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 106 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed fully-charged and up-to-date fire extinguishers and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski, Inv. Balarie, and Barias observed a resident (R2) who had medications unsecured in their room. LPA Moleski, Inv. Balarie, and Barias observed multiple cleaning solutions left unlocked in the laundry room. LPA Moleski and Inv. Balarie observed cleaning solutions under the sink in an unlocked cabinet in a resident bathroom. LPA Moleski interviewed two staff members (S1-S2) and two residents (R1-R2).This facility is being cited per 22 CCR Sections 87465(h)(2), 87309(a), and 87611(b). An exit interview was held with Barias. Appeal rights and a copy of this report was left with Barias.the state’s words, verbatim · CDSS document, Jul 2, 2024