Prospect Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lydia Pabion, Administrator and explained the reason for the visit. Facility is licensed to serve 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. LPA observed the following today: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and but does have an Infection Control Plan. 2. Physical Plant and Environmental: Facility is a two-story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, a laundry room, front porch, and smoking area in the back. LPA inspected the carbon monoxide/smoke detectors in random rooms and are working probably. LPA tested the hot water temperature, and was tested between 105.4 –121.5 degrees F. which is not within the Title 22 regulation of 105.0 – 120.0 degrees F. All the cleaning supplies and chemicals are locked and inaccessible to residents. The facility has sufficient personal hygiene products for clients to use. All clients rooms are completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. One soap dispenser is in need of repair, room 105 is missing slip mat, some window screens need repair, and one shelf in storage room needs replacement. Small trash can first floor restroom needs repair. (Continued on 809C) (continued from 809) 3. Operational Requirements: The facility maintains a fire clearance approved by the fire department. Facility Has hospice waiver for four (4) The facility has shaded area with table and chairs for residents to utilize for outdoor activity. The last fire/disaster drill was conducted on 02/03/2026. LPA reviewed and verified facility liability insurance which expires on 12/18/2026 4. Staffing: The facility has sufficient staff, and the night supervision staff did receive planned emergency training. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Lydia Pabion certificate expires on 08/10/2027. All the direct care staff received Medication Management Training. The first aid training certificates for staff are current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and Residents personal rights are posted by the main entry. Visiting hours were posted at facility. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. 10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed five (5) residents' medication files, and all medications are administered according to Doctor’s orders. (continue on 809C) (continued from 809C) 11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Facility needs to update emergency disaster plan to include additional relocation location. 12. Residents with Special Health Needs: No residents have prohibited health conditions. Deficiencies observed during today’s visit. Technical Violations and advisory issued. An exit interview was held. A copy of this report, 809D technical violations, advisory, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 23, 2026

The state marks this report as 11 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provided medical attention to resident as needed. Staff did not follow resident’s care plan

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Jose De Leon and explained the reason for the visit. The investigation consisted of the following: On 8/5/25 LPA Flores conducted an initial complaint investigation visit, interviewed administrator and nurse and collected the following documents for Resident #1’s (R1) file and requested copies of physician’s report, needs and care plan, identification and emergency sheet, admission agreement, hospital discharge documents, medication sheets, and home health plan. On 8/28/25 LPA Flores conducted an unannounced subsequent complaint visit and interviewed 5 residents and 5 staff. On 9/18/25 LPA Flores contacted Home Health Agency. On 11/24/25 LPA Flores contacted R1 over the phone. On 12/5/25 LPA Flores delivered findings. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff did not provide medical attention to resident as needed. It is alleged R1 was in pain and medical assistance was not obtained. Interviews with 6 out of 6 residents stated facility staff assist them with obtaining medical care when needed. Interview with staff revealed 5 out of 5 staff stated that staff provide assistance to residents as soon as they require it. Per administrator and facility’s nurse, on 7/24/25 facility’s nurse provided pain medication to R1 once R1 complained of pain. Per facility’s nurse, R1 often has pain due to health-related conditions. Therefore, the plan is to provide pain medication as prescribed by physician. As soon as R1 continue to complain of pain, facility staff send the resident out to the hospital. Documents reviewed revealed, Home Health Visit notes dated 8/6/25, note R1 is to be provided Norco for pain as needed. Per July 2025 medication sheet, on 7/24/25 R1 was provided morning dose of Hydroco/APAP for pain, no additional doses were provided as R1 went out to the hospital. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not follow resident’s care plan. It is alleged R1 required catheter care and facility staff did not provided. Interviews with residents revealed 6 out of 6 residents stated facility follows care plan or assist with care as needed. Interviews with staff revealed 5 out of 5 staff stated they follow resident’s care plan, which is explained by the administrator to the caregivers. Documents reviewed revealed Home Health Notes dated 7/23/25, note R1 was provided care for foley catheter by home health nurse and will continue to provide care and consult with physician regarding care. July 2025 medication sheet, notes R1 was being provided with antibiotics from 7/21/25-7/24/25. Home Health After Visit Summary notes R1 was at the hospital between 7/24/25-7/28/25 changes to antibiotics were noted. Although R1 had a change in condition, facility staff were following R1’s home health agency plan of care and a nurse was providing care with catheter. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Jose De Leon and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 28-AS-20250728111411

Allegation investigated: Facility staff did not notify authorized representative of incident.

*This report is a corrected version of report dated 8/5/25 to change finding and substantiated one of the allegations and add additional information.* Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Janice Somera and explained the reason for the visit. The investigation consisted of the following: LPA requested staff/resident rosters. On 5/27/25 LPA Flores interviewed the administrator, 3 staff, 5 residents, reviewed file for resident #1-#2(R1-R2) and requested copies of medical assessment, needs and care plan, admission agreement, information and emergency information sheet, power of attorney, and incident reports. On 7/22/25, 7/28/25, and 7/31/25 LPA attempted to contact South Pasadena Police officer. On 7/31/25 LPA interviewed 1 staff over the phone. On 8/5/25 LPA delivered findings. On 8/7/25 LPA interviewed South Pasadena Police Department officer. On 8/11/25 LPA Flores interviewed R1's responsible party. On 8/29/25 LPA received a copy of police report. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Facility staff did not notify authorized representative of incident. It is alleged facility staff did not notified R1’s responsible party regarding incidents that occurred on 5/7/25 and 6/11/25. Interviews with residents revealed facility staff notify their responsible party when necessary. Interviews with staff revealed Administrator or LVN are responsible for notifying responsible parties when incidents take place. Per administrator, on 5/8/25 administrator contacted R1’s responsible party via telephone at least three times and was unable to leave a voice message. Interview with R1’s responsible party revealed upon visiting R1 at the facility on 5/8/25, administrator stated to them that they had attempted to notify them of the bruise but had not been able to reach them. Regarding the incident on 6/11/25 responsible party called around 3:15pm and was asked to call police officer for details regarding an incident. Incident report dated 5/8/25 notes administrator notified responsible party. Incident report dated: 6/11/25 does not note responsible party was notified. Per police report reviewed, South Pasadena Police officer responded to a battery assault at the facility at 12: 32pm. Facility staff failed to notify R1’s responsible party of the incident that took place on 6/11/25 and requested to call police officer for details of the incident. Therefore, the allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident. It is alleged that on 5/7/25, R1 was attacked by roommate resulting in an injury. Interviews conducted with residents revealed 4 out of 5 residents stated not have observed R2 having aggressive behaviors, hearing an argument, loud noises, or being hurt by R2 at the facility. 1 out of 5 residents stated R2 hit resident with an open hand in the face seven times the evening of 5/7/25. Interviews with staff determined staff did not observe or hear loud noises that indicate the incident was happening. Staff stated that on 5/8/25 LVN noted the bruise around the eye when providing eye drops in the morning. Per staff, R2 has not shown aggressive behavior in the last six months, other than the one incident they observed in the dining room on 6/11/25. Documents reviewed revealed; incident report dated 5/8/25 notes R1 was observed with a bruise in the eye and R1 stated that it was due to R2 hitting R1. R1 was provided with first aid assistance, and R2 was transferred to a different room. Incident report dated: 6/11/25 notes R2 was walking behind R1 in the dining room and pulled R1’s hair causing R1 to fall. The administrator contacted South Pasadena Police Department and police report was created. R2’s physician’s report does not note aggressive behaviors. Incident report review does not show a history of aggressive behavior’s observed of R2 in the last 2 years. Review of police report and video, it was observed that R2 drags R1 to the floor causing R1 to hit the side of the head against the rail and two staff respond to assist R1. Although R1 had a bruise on 5/8/25 it is unsure if R2 caused the bruise, and the incident on 6/11/25 did occur. However, The facility took action once the first incident happened and moved R2 to a different room. During the second incident Administrator contacted South Pasadena Police Department and sought care for R1 and R2. Therefore, the allegations is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 30, 2025 · control 28-AS-20250523163423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Sep 5, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the ...g: (2) Occurrences, ...outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents... This requirement is not met as evidence by: Based on interviews and record review administrator failed to inform responsible party of incidents which poses a potential threat to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2025

Plan of correction: Administrator will certify in writing that will ensure responsible parties are notify of any incidents and will update phone numbers, obtain other means to contact responsible party and submit a copy of certification to the department by POC due date 9/5/25.

Allegation investigated: Lack of staff supervision resulting in resident eloping from the facility.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced and met with the administrator, Lydia Pabion. The purpose of the visit was explained. LPA obtained a copy of the staff roster, resident roster, and documents on Resident #1 (R1). LPA interviewed the administrator, 3 Staff, and 5 Residents. R1 was not available for the interview today. The investigation revealed the following: Allegation - Lack of staff supervision resulting in resident eloping from the facility. It is alleged that Resident #1 (R1) was found by law enforcement and was in the hospital for dehydration. According to staff interviews, R1 was not in the facility around 7 pm on 8/5/25. Substantiated The facility staff searched the entire building and drove around the streets but could not find R1. Staff contacted the police to file a report the same day. The administrator noted that R1 was found by the police on 8/6/25 approximately 4pm and is temporarily in a rehabilitation facility. Based on information gathered, R1 had gone missing in the past while out with another resident. Staff had not observed any changes in R1 and stated that R1 usually does not leave the facility. Staff are aware that R1 cannot leave the facility unassisted and did not know why R1 left without informing anyone. LPA reviewed R1’s physician’s report, and it indicated that the resident is not able to leave the facility unassisted. Residents interviewed stated that the staff monitor who enters and leaves the premises. Four (4) residents who can leave the facility will sign out when or if they do, and one, who cannot leave the facility unassisted, only goes out in the community with a staff member. Based on interviews 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 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 28-AS-20250808152943

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 16, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record review, R1 who cannot leave the facility unassisted, eloped from the facility which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The Licensee will provide a written plan explaining how the facility will ensure that residents who cannot leave the facility unassisted are supervised as required.

Allegation investigated: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident. Facility staff did not notify authorized representative of incident.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met Lydia Pabion with and explained the reason for the visit. The investigation consisted of the following: LPA requested staff/resident rosters. On 5/27/25 LPA Flores interviewed the administrator, 3 staff, 5 residents, reviewed file for resident #1-#2(R1-R2) and requested copies of medical assessment, needs and care plan, admission agreement, information and emergency information sheet, power of attorney, and incident reports. On 7/22/25, 7/28/25, and 7/31/25 LPA attempted to contact South Pasadena Police officer. On 7/31/25 LPA interviewed 1 staff over the phone. On 8/5/25 LPA delivered findings. The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident being attacked by another resident. It is alleged that on 5/7/25, R1 was attacked by roommate resulting in an injury. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with residents revealed 4 out of 5 residents stated not have observed R2 having aggressive behaviors, hearing an argument, loud noises, or being hurt by R2 at the facility. 1 out of 5 residents stated R2 hit resident with an open hand in the face seven times the evening of 5/7/25. Interviews with staff determined staff did not observe or hear loud noises that indicate the incident was happening. Staff stated that on 5/8/25 LVN noted the bruise around the eye when providing eye drops in the morning. Per staff, R2 has not shown aggressive behaviors in the last six months, other than the one incident they observed in the dining room on 6/11/25. Documents reviewed revealed; incident report dated 5/8/25 notes R1 was observed with a bruise in the eye and R1 stated that it was due to R2 hitting R1. R1 was provided with first aid assistance, R1’s responsible party was notified, and R2 was transferred to a different room. Incident report dated: 6/11/25 notes R2 was walking behind R1 in the dining room and pulled R1’s hair causing R1 to fall. The administrator contacted South Pasadena Police Department and police report was created. R2’s physician’s report does not note aggressive behaviors. Although R1 had a bruise on 5/8/25 it is unsure if R2 caused the bruise, and the incident on 6/11/25 did happen. The facility took action once the first incident and moved R2 to a different room. During the second incident Administrator contacted South Pasadena Police Department and sought care for R1 and R2. Therefore, the allegations is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff did not notify authorized representative of incident. It is alleged facility staff did not notified R1’s responsible party regarding incident that occurred on 5/7/25. Interviews with residents revealed facility staff notified their responsible party when necessary. Interviews with staff revealed Administrator or LVN notify responsible party when incidents take place. Per administrator, on 5/8/25 administrator contacted R1’s responsible party phone number at least three times and was unable to leave a voice message. Interview with R1’s responsible party revealed upon visit administrator had stated to them that they had attempted to notify them of the bruise but had not been able to reach them. Incident report dated 5/8/25 notes administrator notified responsible party. Although the administrator may not have reach R1’s responsible party. It was noted on incident report dated 5/8/25 that they contacted the responsible party. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lydia Pabion and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 28-AS-20250523163423

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Lydia Pabion and explained the reason for the visit. Facility is licensed to served 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. Facility is a two story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, a laundry room, front porch, and smoking area in the back. LPA conducted a tour of the facility with Jose de Leon and observed the following: Building is in good repair inside and outside. Lobby area was observed poster for Local Ombudsman and personal rights were observed in this area. Activity area is clean, fireplace is inaccessible to residents. Dining room was observed in good repair and clean. Kitchen was observed clean, storage of food supplies was observed with sufficient perishables for at least 2 days, and non-perishables for 7 days. A list of special diets was observed posted in the kitchen. LPA observed 6 random resident rooms and observed sufficient lighting, furniture, and bedding supplies. Each room has a bathroom and were observed in working condition. Water temperature was tested between 111.9 - 126.8 degrees F. which is not within the required 105-120 degrees F. Grab bars were not observed in room #121. Skid mats/strips were not observed in rooms #216 and 224. Ramps, and stairways were observed clear of obstructions. Both stairways were observed with an evacuation chair. Courtyard provides shaded sitting area, front porch provides sitting area, and back area provides a smoking area. Carbon monoxide/Smoke detectors were observed throughout and the facility has a fire sprinkler system. Fire extinguishers in hallways in each floor and last checked on 1/2/24. Last fire drill was conducted on 9/22/24. Additional linens, and cleaning supplies were observed in a closet. Sharps and chemicals were observed inaccessible to the residents. No large bodies of water were observed. LPA reviewed medication for 5 residents and files for 6 residents, of which one was under hospice and hospice plan was observed. Six staff files were reviewed. (CONTINUED ON LIC 809C) Each staff have 20 hours of training on file. Administrator certificate was observed for Lydia Pabion #6006152740 exp. date: 8/10/25. Emergency disaster plan and infection control plan were reviewed and have been reviewed yearly. First Aid kit was observed. LPA interviewed 4 residents and 4 staff. Deficiencies have been noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 21, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

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

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Lydia Pabion and explained the reason of the visit. The investigation consisted of the following: On 10/15/24 LPA conducted and initial complaint investigation visit. During the initial visit LPA requested staff/resident roster, resident #1(R1)’s physician’s report dated: 8/21/23, admission agreement, pre-appraisal, needs and care plan, medication sheet, incident report. LPA interviewed Resident #1-#3(R1-R3) and 5 staff. On 10/18/24 LPA interviewed R1’s Assisted Living Waiver (ALW) case manager over the phone and obtained documents. On 10/21/24 LPA interviewed R1’s Power of Attorney (POA) over the phone. On 10/29/24 LPA Flores delivered findings for the above allegation. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate supervision resulting in a resident eloping from the facility. It is alleged a resident with dementia went missing for several hours. On 9/27/24 around 12:30pm R1 left the facility unattended with another resident. R1 did not return to the facility. Per administrator the facility’s policy is 24 hours to report the resident missing. Med-tech checked for R1 the morning of 9/28/24, R1 was not found. Med-tech contacted Pasadena police department to file a missing person report. A few hours later administrator was informed by Pasadena police department that they responded to a call for a person that seem to be confused around Del Mar and San Marino. Once the description was matched administrator and another staff went to pick up R1 around 11:00am from the area and returned R1 to the facility. No medical assessment was conducted. Interviews conducted with staff revealed R1 seems forgetful. However, staff believe R1 does not have dementia. Per staff, they know that R1 should not leave the facility unattended and when they see R1 in the lobby they redirect R1 to either R1’s room or dining room. LPA was unable to obtained information regarding the incident as R1 did not recall the incident. R2 who left the facility with R1 stated that when they were out R1 wanted to go for a walk, and they parted ways. Documents review revealed, two physician’s reports were obtained by LPA for R1; physician’s report dated: 8/21/23 notes R1’s has dementia and cannot leave the facility unattended. Physician’s report also dated: 8/21/23 obtained at the facility notes R1 has mild cognitive impairment and cannot leave the facility unattended. Medication sheet for September notes R1 is taking a medication prescribed for cognitive impairment. Therefore, the allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. *Immediate $500 Civil penalties were assessed due to lack of care and supervision.* Exit interview was conducted with Lydia Pabion and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 29, 2024 · control 28-AS-20241011081106

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Oct 30, 2024

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, ... such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidence by: Based on documents review and interviews conducted licensee did not ensure R1 was properly assess or reasses based on changes in condition which poses an immediate health, safety, or personal right to the persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Administrator will obtain a physician's reassessment for R1, will assist R1 based on reassement, and will provide a copy to the department by POC due date 10/30/24. **Immediate $500 Civil Penalties were assess**

Allegation investigated: Staff neglected resident's wound in care

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to continue investigation and deliver findings for the above mentioned allegation. LPA met with Administrator Lydia Pabion and discussed purpose of visit. LPA interviewed Five (5) residents and one (1) additional staff S#1 during this visit. LPA took tour of facility and did not observed any health and safety Hazards. On 09/25/2023; LPA conducted a health and safety check and took a tour of the physical plant including the common areas, kitchen, dining room, medications room, and five (5) resident rooms. LPA measured the water temperature, and it was within 105-120 degrees F. LPA observed that there was at least a 7-day supply of non-perishable foods, and a 2-day supply of perishable foods and medications were centrally stored and locked. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. (Continue on 9099C) Substantiated The investigation consisted of LPA interviewing five (5) residents (R#2-R#6) , R1 was not available for LPA to interview. LPA interviewed three (3) staff (S#1-S#3) and reviewed the following documents, staff roster, resident roster, and for three (3) specified residents: resident face sheet, MAR log for July, August September 2023, physician’s report, most recent incident report and appraisal needs & services, Noyan Home Health records, facility progress notes, R1 hospital records. R1 LIC602A for R1 dated 01/19/2022, 11/02/22, and 04/12/2023 The investigation revealed: Regarding Allegation: Staff neglected resident's wound in care LPA interviewed three (3) staff and three of three (3) staff denied the allegation. LPA interviewed five (5) residents and five (5) of (5) residents could not corroborate the allegation. According to records reviewed and obtained, R1 was admitted to facility on 01/17/2022 and at that time, records show that R1 had skin intact without any open wounds. According to medical records, R1 wound care was ordered by Medical Doctor on 06/15/2023. Review of Home Health records show that R1 had developed a stage 4 wound by 06/30/2023. Department review of Noyan Home Health records indicate that resident refused wound care on the following days: 07/01,02,03,04,06,07,08,09,13,15,16,18,20,22,23,27,29,30th. According to records reviewed, R1 also refused wound care for days in August and September 2023. S2 stated she discussed R1 refusal of wound care with Administrator S1 and mentioned to Administrator S1 that resident required higher level of care. Both S1 and S2 admitted to the department that R1 refused wound care while at the facility. S1 admitted to the department that the facility is no longer able to meet R1 needs due to his high-risk behavior that causes safety concerns and R1 requires a higher level of care elsewhere. Under the admission agreement, the facility should have notified R1 physician and/or other appropriate persons regarding his change in condition and refusal of wound care treatment. R1 basic services under the facility admission agreement were not met. R1 actions could have possibly met the criteria for eviction under the admission agreement, but the administrator, S1, chose not to do anything about it and continued to house R1 at the facility, making him a risk to himself and others. By retaining R1 at facility, facility neglected R1 wound care. Based on interviews 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, Tittle 22, Division 6 and Chapter 8 are being cited. The facility has been informed that Immediate civil penalty is being issued during today’s visit in the amount of $500.00, based on health and safety code 1569.49. “The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). “ Exit interview was conducted with Lydia Pabion, Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 10, 2024 · control 28-AS-20230922133247

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Oct 11, 2024

Additional Personal Rights of Residents in Privately Operated Facilities (a)...: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on department interviews conducted and documents reviewed licensee failed to ensure R1 did not develop a wound and neglected wound care by retaining R1 with stage 4 wound which poses an immediate risk to the health, safety, or personal rights to the persons in care. *Immediate Civil Penalty for $500 is being issue*the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Administrator will certify in writing that staff including administrator will follow up on any medical need(s) of residents who refuse care and upon observation, communication, or discovery of such and will provide training to staff on the above and submit training logs to the department by POC due date of 10/11/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to continue investigation and deliver findings for the for complaint 28-AS-20230922133247. LPA met with Staff Jose Deleon, and Administrator Lydia Pabion arrived a few minutes later and assisted with the visit. During the investigation for the complaint mentioned above, the department discovered that facility had three (3) other deficiencies. 1) The facility failed to report to the department all the incidents the resident refused wound care to the department and other parties including resident's doctor. 2) The facility falsified records. S2 wrote in resident's record that wound care was provided on more than one occasion and both S1 and S2 both admitted to the department was not actually done. 3) Medical assessment was not in file for R1 prior to admission to facility. Deficiencies cited on 809D, copy of report, 809D and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(d) · Plan of correction due date: Oct 17, 2024

87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidence by: Facility did not report incidents when resident refused wound care during the months of July, August, and September, 2023the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee will provide all the incident reports for the month of July, August and September 2023 for all the days the resident refused wound care. licensee will train all staff including administrator on reporting requirements and send signed log of staff attending, topic and name of trainer to LPA by POC date which is 10/17/2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Oct 17, 2024

87458 Medical Assessment (a)(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: R1 LIC602 when admitted was not in resident's file and the LIC602A dated on 11/22/2022 was signed by medical doctor who stated he did not have R1 as patient.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: The administrator will obtain and keep on file documentation of residents Medical Assessment or LIC602A signed by a physician prior to a person’s acceptance as a resident. The administrator will send LPA the future plan about obtaining medical assessment prior to accept resident by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Oct 11, 2024

False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This deficiency was evidenced by the following: During the course of a complaint investigation, Facility provided hand written documentation indicating that S2 had provided wound care to R1 on several occasions. Both S1 and S2 told the department that wound care was not provided.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Licensee will document a statement indicating the understanding of the regulation and will confirm that all staff have been notified about consequences regarding false claims made to licensing staff.

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Lydia Pabion and explain the reason of the visit. The investigation consisted of the following: LPA requested copies of staff/resident roster, reviewed resident #1’s file, and requested copies of identification and emergency sheet, physician’s report, admission agreement, notice to pay rent, receipts for payment from January 2023 – February 2024, to the facility. LPA interviewed 5 residents and 5 staff. The investigation revealed the following: Regarding allegation Illegal eviction it is alleged R1 was given an eviction notice on 2/23/24, for lack of rent payment, per complainant R1 has paid the rent in full every month. Interviews conducted with administrator and licensee revealed R1 has not been given an eviction notice yet. (CONTINUED ON LIC 9099C) Unsubstantiated He was provided a notice to pay to encourage resident to pay the balance due and have been waiting for R1 to make arrangements before providing R1 with a 30-day notice. Per administrator R1 pays $450 per month which is not the full amount due to the facility for the monthly rent and R1 has been reminded verbally of the amount due. Interviews with residents revealed residents were cleared of the amount due at the time of admission and the increase rate yearly on the addendum provided by the administrator. Staff interviewed stated that residents have not complaint about facility given them an illegal eviction. Documents review revealed a notice to pay rent in three days or quit in thirty days was given to R1 on 2/22/24 for the total amount due of $12,573.98 due from Jan. 1st, 2023 to Feb. 1st, 2024. Per addendum provided on 1/1/23 the monthly rate for 2023 was at $1344.82 and the addendum dated 1/1/24 monthly rate of $1418.07 per the state rate. LPA reviewed receipts of payment collected for the amount of $450 a month from 1/3/23 – 1/3/24 and $550 for 2/2/24, form of payment was noted as cash for a total of $6,400.00. Although the facility did requested payment for due balance, the facility has not provided an eviction notice at this time. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lydia Pabion and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 4, 2024 · control 28-AS-20240226102810

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with and explained the reason for the visit. Facility is licensed to served 99 adults over the age of 60 years old, of which 35 may be non-ambulatory. Facility has a hospice waiver for 4 and the following rooms are cleared for bedridden residents; 102 thru 110, 115 thru 119, and 123. Facility is a two story building with a commercial kitchen, a dining room, an activity room, a courtyard, a medication room, and front porch. No large bodies of water were observed. Sprinkler fire system throughout the facility. Fire extinguishers in hallways in each floor. LPA conducted a tour of the facility and observed the following: Activity area is clean, fireplace is inaccessible to residents. Dining room was observed in good repair and clean. Kitchen was observed clean, storage of food supplies was observed with sufficient perishables for at least 2 days, and non-perishables for 7 days. Kitchen wall behind the stove, was observed caved into the kitchen and with a gap between the floor and the wall the length of more than half the size of the wall and the width of about 3 inches. LPA observed 5 random resident rooms and observed sufficient lighting, furniture, and bedding supplies. Each room has a bathroom and were observed in working condition, with grab bars, and skid mats. Water temperature was tested between 110.6 - 138.3 degrees F. which is not within the required 105-120 degrees F. Shower faucet in room #207 was observed cracked and missing half of the faucet. Ramps, and stairways were observed clear of obstructions. Stairways are missing an evacuation chair. Courtyard provides shaded sitting area, front porch provides sitting area, and back area provides a smoking area. Carbon monoxide/Smoke detectors were tested and are in working condition. Facility stores additional linens, and cleaning supplies were observed in a closet. Sharps are stored in the kitchen and residents do not have access to the kitchen. (CONTINUED ON LIC 809C) LPA reviewed medications for 5 residents, resident #2(R2) was out of prescribed medication filled on 1/25/24 and LVN stated to have been giving R2 additional pills due to R2 requesting it. Per prescription R2 is to have 2 pills per day, LVN has been providing more per day. LPA reviewed 5 resident and 5 staff files. Emergency Disaster plan and Infection control plans were reviewed last reviewed/updated in 2022. A copy of Liability Insurance was provided. Administrator certificate was observed for Lydia Pabion #6006152740 exp: 8/10/25. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Lydia Pabion and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 15, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not provide correct medication. Untrained staff is providing medication to residents. Staff does not treat residents with dignity and respect. Staff not assisting resident with needs.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit to investigate the above allegations. LPA met with Lydia Pabion, Administrator and explained the reason for the visit. The initial complaint visit was conducted on 12/28/2023. During the initial and subsequent complaint visits, the investigation consisted of the following: LPA conducted a physical plant tour of the facility, interviewed Resident #1- Resident #11 (R1- R11) and Staff #1- Staff #7 (S1- S7) altogether. LPA unable to interview Staff #8 (S8) who was not on duty. LPA also attempted to interview Resident #12 (refused to speak to LPA/on Hospice care) and Resident #13 (R13) - Resident #14 (R14) but unsuccessful as they are both non verbal. LPA obtained copies of the Resident and Staff Rosters, reviewed Residents #1-#2 (R1-R2's) file documents such as; Face Sheet, Needs and Services Plan, Physician's Report LIC 602, and Progress notes. Additionally, (5) Staff files, (3) additional Resident files (R3-R5), (5) random residents Medication Administration Records (MARs dated Oct 2023- Dec 2023), Staff In-service training logs (2022-2023) and Plan of Operation were reviewed. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Staff did not provide correct medication.” It is alleged that staff do not provide supervision when administrating medication to residents and do not provide the correct medication. No other details provided. The interviewed staff denied the allegation. S1 indicated that Caregivers are not allowed to pass medications because they do not have medication training. Staff members interviewed also indicated that they provide clients with their medications as prescribed following doctors’ orders. Other interviewed staff indicated that they received medication training as part of the educational requirements and get enough training from the Administrator to make sure that they administer the medications to the residents correctly. Interviewed residents stated that the staff never provided them with the incorrect medication. (11) of (11) residents indicated that the staff give them their medication on time and only those prescribed by their doctors. LPA reviewed (5) random residents Medication Administration Records (MARs dated Oct 2023- Dec 2023), their medications including PRNs and observed medications to be documented properly and given as prescribed. Records reviewed did not show any past or current issues regarding medication being given out to the residents incorrectly. Documentation reviewed and interviews conducted with staff and residents do not corroborate this allegation. In regards to the allegation: “Untrained staff is providing medication to residents.” It is alleged that staff let caregivers administer medications to residents. The interviewed staff denied the allegation. S1 stated that based on their policy, only staff who have medication training are responsible for preparing and administering medications to residents. S1 indicated that none of the caregivers are allowed to pass medications because they do not have medication training. Interviewed staff indicated that only the Nurse and Med Techs are responsible to administer the medications to the residents because they have the required training. LPA reviewed (3) staff training files and their records indicated that they have all been trained in medication management, policy and procedures regarding medication, documentation, side effects and adverse reactions. Interviewed residents stated that either the Nurse or Med Techs provide them with their medications, not the caregivers. LPA did not find additional evidence that residents have been hospitalized or injured because of medication errors. Based on the information obtained, there was not enough supportive evidence to concur with the reported allegation. In regards to the allegation: “Staff does not treat residents with dignity and respect.” It is alleged that staff fight with residents due to them asking for additional help and being too loud at the facility. Staff members interviewed denied the allegation. All staff interviewed indicated that they treat all residents equally and with respect. Staff indicated that they do not fight with residents due to them asking for additional help and being too loud at the facility because they understand that the residents are here because they need help. Staff also indicated that they receive training regarding residents’ personal rights. (2) out of (7) staff interviewed stated that they have heard and witnessed S2 yelled and became impatient with some residents in the past. (9) out of (11) residents interviewed denied the allegation and indicated facility staff treat them with respect and dignity. Some residents interviewed indicated that they are happy with their interactions and the services they receive from facility staff. (2) out of (11) residents stated that they have heard S2 yelled at residents sometimes. LPA reviewed the staff in-service training logs (2022-2023) indicating that the staff received training on residents’ personal rights. During the visit, LPA did not observe any staff to be disrespectful to residents. LPA also observed sufficient staff providing the services necessary to meet the residents’ needs. Therefore, there was insufficient evidence to corroborate the allegation. In regards to the allegation: “Staff not assisting resident with needs.” It is alleged that a resident has considered committing suicide due to feeling like a burden to the facility because staff are not helping the residents with his needs. It is also alleged that another resident recently went to the hospital due to an infection that could have been caused by staff not changing the diaper as often as needed. Additionally, the resident does not want to ask for help because staff mistreat the resident. Interviewed staff denied the allegation. None of the staff interviewed heard or received a report regarding a resident being hospitalized due to an infection nor a resident committing suicide. Staff stated that they provide care and assistance to meet the residents’ needs. Staff also stated that they conduct rounds every 2-3 hours to do incontinent care or even sooner if necessary and check on residents. (10) out of (11) residents denied the allegation and stated that staff always assist them with their daily needs. None of the residents knew or heard about another resident considered committing suicide or had been sent to the hospital due to an infection. LPA reviewed R2’s files and did not find any records showing hospitalization due to infection. Therefore, there was insufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to Lydia Pabion, Administrator.the state’s words, verbatim · CDSS document, Feb 9, 2024 · control 28-AS-20231222091841

Allegation investigated: Staff is sleeping at the facility.

*This report supersedes report dated 11/07/2023 due to findings changed for 1 allegation* Licensing Program Analysts (LPAs) Mora and Vaid conducted an unannounced complaint visit regarding the above allegations. LPAs met with Lydia Pabion (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPAs obtained copies of staff and resident rosters, reviewed pest control reports dating back to June 2023, and interviewed Administrator, Staff 1 - Staff 6 (S1 - S6) and Resident 1 - Resident 7 (R1 - R7). LPAs also toured 3 resident rooms and the facility's TV room. The investigation revealed the following: regarding the allegation "staff are sleeping at the facility", it is alleged that staff are sleeping at the facility during their shifts. Administrator stated 2 months ago she reviewed her camera footage and noticed a graveyard staff sleeping on job. She confronted the staff and the staff resigned on 09/14/23. Administrator stated this was a one time incident and no other staff have slept on the job. Staff interviewed could not corroborate the allegation. Residents interviewed could not corroborate the allegation. (Continued to LIC 9099-C) Substantiated Based on LPA's interviews, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided. The other residents interviewed could not corroborate the allegation. During the tour, LPAs did not observed bedbugs in the facility's TV room nor in rooms 201 and 227. Room 205 was locked due to resident was out in the community. LPAs also reviewed pest control reports dating back to June 2023 and all reports stated no activity was noticed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jan 9, 2024 · control 28-AS-20231030095916

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 16, 2024

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs..... Based on interviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. A staff was caught sleeping on the job.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Licensee is to comply with Title 22 Section 87411 at all times. Additionally, Licensee will conduct an in-service training with all staff and submit a training log with all staff signatures to Community Care Licensing Division (CCLD) by 01/16/2024.

Allegation investigated: Facility has bedbugs. Staff are sleeping at the facility.

Licensing Program Analysts (LPAs) Mora and Vaid conducted an unannounced complaint visit regarding the above allegations. LPAs met with Lydia Pabion (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPAs obtained copies of staff and resident rosters, reviewed pest control reports dating back to June 2023, and interviewed Administrator, Staff 1 - Staff 6 (S1 - S6) and Resident 1 - Resident 7 (R1 - R7). LPAs also toured 3 resident rooms and the facility's TV room. The investigation revealed the following: regarding the allegation "facility has bedbugs", it is alleged that there are bedbugs in rooms 201, 205, 227 and the facility's TV room. Administrator denied the allegation and stated no bedbugs complaints have been brought to her attention. Staff interviewed could not corroborate the allegations. Residents in rooms 201 and 227 denied having bedbugs and resident in room 205 was out in the community and not available for an interview. (Continued to LIC 9099-C) Unsubstantiated The other residents interviewed could not corroborate the allegation. During the tour, LPAs did not observed bedbugs in the facility's TV room nor in Room 201 and 227. Room 205 was locked due to resident was out in the community. LPAs also reviewed pest control reports dating back to June 2023 and all reports stated no activity was noticed. Regarding the allegation "staff are sleeping at the facility", it is alleged that staff are sleeping at the facility during their shifts. Administrator stated 2 months ago she reviewed her camera footage and noticed a graveyard staff sleeping on job. She confronted the staff and the staff resigned on 09/14/23. Administrator stated this was a one time incident and no other staff have slept on the job. Staff interviewed could not corroborate the allegation. Residents interviewed could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Nov 7, 2023 · control 28-AS-20231030095916