Prospect Manor

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

Type of visit: Annual/Random

This is a corrected version of previous Annual Visit dated 01/28/23. LIC 809-D page was amended to correct deficiency from "Type A" to "Type B" for 87303(e)(2) only. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required Annual Visit on 01/28/2023 at 9:25 am. LPA was met by Licensed Vocational Nurse (LVN) Gloria Madrid and Activities Director Roxana Deleon. Administrator Lydia Pabion was notified by phone of LPA’s visit. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020) and copy of Liability Insurance. 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, 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 were observed to fully charged. LPA OBSERVATIONS: Tour was given by LVN Madrid at 9:40 am. TV Room: was clean and had sufficient seating and tables. Kitchen: Staff was observed to be wearing masks, hair nets and gloves while preparing lunch for residents. LPA observed kitchen to be clean and appliances appeared to be in working order. Walk in refrigerator was observed to contain sufficient food supply for 2 days of perishables and 7 days of non-perishables and a temperature reading of 40 degrees F. Walk in freezer was clean and a temperature reading of 0 degrees F. Kitchen sink water temperature was measured at 184.1 degrees F. No warning sign posted above this sink or any other kitchen sink in kitchen area was observed. Signs promoting hand washing and social distancing were observed. Dining Room: Dining room area was clean, and tables were spaced out to promote social distancing. Signs promoting social distancing and cough/sneeze etiquette were observed throughout dining area. LPA observed a corner area of dining room to have several stacked dining room chairs, rectangle bbq grill, empty grocery cart, 4ft standing fan, boxed Christmas tree, and a beige serving cart to be cluttered in the corner of the room. Per LVN Madrid, the facility is using this area to store excess chairs until they can find another place to store them. Resident rooms 1st floor Non-Ambulatory: Rooms # 101 and 104 contained the required lighting, furniture, and linens. Water temperature in Room # 101-bathroom was measured at 106.2 degrees F and room # 104 water temperature in bathroom was measured at 107.8 degrees F which meets Title 22 Regulations. Room #108 is a shared room. Room #108 contained required lighting, furnishings, and linens. Bathroom contained skid matts and grab bars. Water temperature was measured at 99.8 degrees F which is does not meet Title 22 Regulations and poses an immediate health, safety, or personal rights risk to persons in care. Cabinet doors in bathroom are missing knobs and right cabinet door is cracked from top to the side of door. Resident rooms 2nd floor Ambulatory: Resident room # 201 contained required lighting, furnishings, and linens. Room was clean and LPA observed hand sanitizer nearby. Water temperature in bathroom was measured at 96.8 degrees F which does not meet Title 22 Regulations. Resident room # 209 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 95.4 degrees F which does not meet Title 22 Regulations. Resident room # 220 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 99.1 degrees F which does not meet Title 22 Regulations. Resident room # 223 contained required lighting, furnishings, and linens. Room was observed to be clean. Water temperature in bathroom was measured at 110.4 degrees F which meets Title 22 Regulations. Front lobby and Courtyard: Clean and free from hazards and clutter. LPA observed plenty of seating, tables and shade for residents and visitors. Staff and Resident Interviews: 3 staff and 3 residents were interviewed between 10:45 am and 11:15 am. Administrator certificate was observed for Lydia Pabion #6006152740 expiration date: 8/10/23. Last fire drill was conducted on 01/2023. A technical violation and deficiencies were cited during visit. Exit interview was conducted with Activities Director Deleon and a copy of this report, LIC 809D, LIC 9102, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 19, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jan 29, 2023

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Based on observation, resident room #108 water temperature read at 99.8 degrees F, resident room #201 water temperature read at 96.8 degrees F, resident room #209 water temperature read at 95.4 degrees F, resident room #220 water temperature read at 99.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2023

Plan of correction: Licensee/Administrator will adjust water heater accordingly and create a water log starting 01/29/2023 and record water temperature readings every 8 hours for the next 3 calendar days, ending on 02/01/2023. Licensee/ Administrator will send proof of water temperature log to LPA via email. First record of water log on 01/29/23 and subsequent recorded readings must measure within 105 -120 degress F.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(3) · Plan of correction due date: Jan 29, 2023

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Based on observation, water temperature in kitchen was measured at 184.1 degrees F, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2023

Plan of correction: Licensee/Administrator will place a warning signs above kitchen sinks where water temperature will be delivering water at 125 degree F or above.

Allegation investigated: Resident was sexually abused while in care.

Licensing Program Analyst (LPA) Flores conducted a subsequent complaint visit. LPA met with Lydia Pabion and explained the reason for the visit. The purpose of today's visit is to deliver findings for LPA Irra who was assigned this complaint. On 07/15/21, Licensing Program Analyst (LPA) Spencer conducted a Health and Safety check visit in response to the above personal rights allegation. LPA met with administrator Lydia Pabion. During this visit, LPA Spencer 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. The facility was clean and in good repair and there were no observable signs of neglect, abuse or other immediate health and safety threats. LPA Spencer obtained a copy of staff roster, resident roster, and for three (3) specified residents: resident face sheet, MAR log, physician's report, and appraisal needs & services plan. (CONTINUED ON LIC 9099C) Substantiated The investigation for this allegation was conducted by Investigator Dennis Seng. During this investigation, IB Investigator Dennis Seng, conducted interviews with staff (including the suspect/Staff #1 (S1)), witnesses and Resident #1 (Victim/R1). It was determined that R1 was a victim of sexual abuse by S1 at the facility. R1 stated that the relationship between R1 and S1 was consensual “due to R1 being overly medicated on medication” during R1’s treatment for a medical condition. R1 indicated S1 hugged R1, fondled/sucked on R1’s breasts, and kissed R1 on R1’s lips during multiple occasions. S1 was also discovered by Staff #2 (S2) hiding inside R1’s closet without an explanation. S1 denied sucking/fondling R1’s breasts or that S1 engaged in any sexual activity/abuse; however, S1 admitted to hugging and kissing R1 on R1’s lips on several occasions. S1 admitted that S1 was caught in R1’s closet by S2 and stated that S1 hid in R1’s closet because S1 knew the situation “looked bad”. Facility staff became suspicious of S1’s relationship with R1 and asked S1 about it. S1 admitted he/she was in a relationship with R1 and forwarded facility staff text messages between S1 and R1. Due to the totality of the situation, S-1 statements, text messages exchanged between S-1 and R-1, S-1 hiding in R-1’s closet, and the lack of explanation to justify why S-1 was hiding in R-1’s closet, it was more than likely S-1 did fondle/sexually abused R-1. Based on interviews conducted and records 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 is being cited. An immediate Civil Penalty of $500 is being issued today. Refer to LIC421IM. The issuance of an additional Civil Penalty is being assessed based on Health and Safety Code 1569.49(f) and could be issued at a later date. Exit interview held. A copy of the report, LIC421IM, and Appeal Rights were provided to Lydia Pabion Administrator.the state’s words, verbatim · CDSS document, Jun 6, 2023 · control 28-AS-20210714145302

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 7, 2023

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This standard was not met as evidenced by: S1 admitted to hugging and kissing R1 on R1’s lips on several occasions. S1 admitted being caught in R1’s closet by S2 and stated he/she hid in the closet because S1 knew the situation “looked bad”.the state’s words, verbatim · CDSS document, Jun 6, 2023

Plan of correction: Administrator to provide all staff with personal rights training. Training plan will be submitted by 6/7/23. Proof of training will be submitted by 6/14/23. Immediate civil penalties assessed.

Allegation investigated: Facility staff not repairing broken heating system at facility. Facility staff not meeting residents' needs for activities at facility.

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Lydia Pabion Administrator and explained the reason for the visit. The investigation consisted of the following: LPA Flores requested a copy of resident/staff roster, conducted a tour of facility's resident rooms #103,108,112,117,224,220,211,204, a total of 12 thermostats were observed throughout the facility's hallways next to the following rooms #104,107,111,119,232,227,220,216,212,208,201 all set up and read at 72 degrees F. except for thermostat next to room #107 read at 69 degrees F and set up at 72 degrees F., and thermostat next to room# 232 which was set up at 74 and read at 72 degrees F. Interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5) and staff #1(S1),#2(S2),#3(S3),#4(S4) and #5(S5). LPA Flores reviewed activity calendar for the month of January 2023, S3 duties and responsibilities sheets. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Facility staff not repairing broken heating system at facility. It is alleged that the heating system at the facility is broken. Interviews with residents revealed 3 out of 5 residents interview stated temperature at the facility is good and has not been cold in their rooms and/or hallways. 1 out of 5 residents interviewed stated temperature in the room is cold in the evening and 1 out of 5 residents was unable to be interview due to cognitive skills. Licensee stated heating system has not been broken. Interview with staff revealed 5 out of 5 staff stated temperature is preset at 72 degrees F., during the winter. During the facility tour conducted LPA observed the temperature was set at 72 degrees around the facility. The lowest reading was 69 degrees F., the rooms around that thermostat felt the same as the rest of the facility temperature wise. All other rooms observed felt at a comfortable temperature. Room #204 was slightly colder than the rest of the facility. During the visit Maintenance person contacted A/C/Heater technician and the temperature in that area of the building was address to ensure it match the reading on the thermostat. 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. Regarding allegation: Facility staff not meeting residents' needs for activities at facility. It is alleged facility staff is not meeting residents' needs for activities at facility. Interviews with residents revealed 3 out of 5 residents stated activities are offered and residents are part of the activities such as: exercises, bingo, art, etc. 1 out of 5 residents stated not to participate in the activities and performs activities on their own. 1 out of 5 residents was unable to answer due to cognitive skills. Interviews with staff revealed 5 out of 5 staff interview stated activities are provided to the residents throughout the day by the activity director. LPA reviewed activity calendar for January 2023 and observed activities such as: lottery, art classes, bingo, going to the store, movies, birthday celebrations are schedule in the afternoon on different days of the week. Exercises are schedule in the morning daily. 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 was conducted with Lydia Pabion Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 30, 2023 · control 28-AS-20230124121154

Allegation investigated: Staff member mismanages residents’ medication Staff failed to meet residents' needs

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Lydia Pabion Administrator and explained the reason for the visit. The investigation consisted of the following: LPA Flores requested a copy of the staff/resident roster. LPA Flores reviewed medication for Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) and interviewed R1,R2,R3,R4R5,R6, staff #1(S1),#2(S2),#3(S3),#4(S4). LPA toured the facility and observed rooms #107,108,118,212, and 219. LPA Flores requested copies of medication sheets for June, July, August, medication delivery invoices, physician's reports, admission agreement, identification and appraisal/needs and care plan. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff member mismanages residents' medication. It is alleged staff administers the residents’ medication too early and it conflicts with the residents’ last medication doses. Interviews with residents revealed 3 out of 6 residents interviewed stated to be receiving medication at the times provided and that it does not interfere with their other doses. 1 out of 6 residents stated to not take medication. 1 out of 6 residents was unable to be interview due to cognitive skills and 1 out of 6 residents refused to be interview. Interviews with staff revealed 4 out of 4 staff stated medication is provided to the residents for each dose according to the prescription. Administrator stated that morning dose is provided to residents between 7:30am - 8:00am, Noon dose is provided between 11:30am - 12:00pm, Evening dose is provided between 4:30pm - 5:00pm and Bedtime dose is provided between 7:30pm - 8:00pm. LPA Flores reviewed medication sheets for R1,R2,R3,R4,R5,R6 did not observed any medication listed that will interfere with other medication provide to the residents based on the doses or times. Facility last provided medication training to S3 and S4 on 8/21/22 and S2 vocational nurse license expires on 11/30/22. 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. Regarding allegation: Staff failed to meet residents' needs. It is alleged the facility doesn’t provide masks to residents/staff members and doesn’t enforce masks at the facility. Interviews with residents revealed 4 out of 6 residents stated staff wear a face mask at the facility and provide a face mask when needed and facility is meeting their needs. 1 out of 6 residents was unable to be interview due to cognitive skills and 1 out of 6 residents refused to be interviewed. Interviews with staff revealed 3 out of 4 staff stated facility provides face mask for staff and residents and 1 out of 4 staff stated not to be sure if facility continues to provide face mask for staff or residents. LPA Flores observed administrator maintains mask at the facility, staff were observed wearing a face mask during the tour of the facility. No further details were provided in the complaint description regarding the needs of the residents not being met. Based on interviews conducted and observations made, there was insufficient evidence to prove the allegation(s).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 was conducted with Lydia Pabion - Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 29, 2022 · control 28-AS-20220822155527

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit during a complaint investigation visit conducted on 8/29/22. LPA Flores met with Lydia Pabion Administrator and explained the reason for the visit. On 8/29/22 LPA Flores reviewed medication sheets for Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) during the review LPA Flores observed medication sheets were not updated for morning dose provided to each resident. Per facility's nurse (LVN) medication is provide to residents either during breakfast at the dining room, or residents walk to the medication room to request, or provided in the residents room and does not note after providing the dose to each resident at the time each is provided. LPA Flores observed medication bubble packs are out of cycle and was unable to identify if medication was provided that morning. LPA Flores observed medication bubble pack for Resident #7 was crossed out with black marker and rename with red marker with R2's name. Per administrator pharmacy made a mistake in the order and place the order for R7 instead of R2. LPA Flores observed R2 and R7 had two sets of bubble packs for the same medication for each dose. Last medication training provided on 8/21/22, Deficiencies were given based on observations per Title 22 Division 6 Chapter 8 and noted on LIC809D. Exit interview was conducted with Lydia Pabion - Administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 29, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Sep 5, 2022

87465 Incidental Medical and Dental Record: (e) For every prescription and nonprescription... there shall be a signed, ..., and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidence by: Based on observation licensee did not ensure medication for R2 had the proper pharmacy label which poses a potential risk to the health, personal rights, or safety of the residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2022

Plan of correction: Administrator will request medication with corrected label from pharmacy for medication for R2 and submit picture of the medication by 9/5/22.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(6) · Plan of correction due date: Sep 5, 2022

87465 Incidental Medical and Dental Care: (a) A plan... shall be developed by each facility... (6) ... a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidence by: Based on observation licensee did not ensure Med techs are recording medication dosages provide to the residents at each dose for R1,R2,R3,R4,R5,R6 review which poses a potential risk to the health, personal rights, or safety of the residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2022

Plan of correction: Administrator will ensure medication provided to the residents is on cycle and record properly by staff on medication sheet by certifying on LIC 9098 by POC due date 9/5/22.

Allegation investigated: Facility elevator is in disrepair.

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Lydia Pabion Administrator and explained the reason for the visit. The investigation consisted of the following: On 1/11/22 LPA Flores requested facilities resident and staff roster conducted a tour of the facility with Lydia Pabion, observed and used elevator to access 2nd floor, tour room #209, 216,219, 224. Interview residents #1(R1), #2(R2), #3(R3), #4(R4) and obtained copies of facility's fire disaster evacuation plan, and activities January 2022 schedule. On 6/13/22 LPA Flores requested staff/resident roster, interviewed resident #5(R5),#6(R6) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5) and obtained copies of physician's report, emergency and identification information sheet and medication sheets for December 2021, January, February, and May 2022 for 6 residents interviewed. (CONTINUED LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Facility elevator is in disrepair. It is alleged the elevator is broken and has been for about a month. Interviews with residents revealed 3 out of 6 residents interview stated elevator is not working and residents have to use stairs causing some physical discomfort. 2 out of 6 residents interview stated not to use elevator as they reside in the first floor and 1 out of 6 residents refused to be interviewed. 5 out of 5 staff interviewed stated elevator was out of service in January and residents were assisted in stairway. On 1/11/22 Licensee stated a part on the board of the elevator had to be special order as the part is no longer produced by the company which delayed the repaired of the elevator. During the visit on 1/11/22 LPA Flores used the elevator to go to the second floor. LPA review service repairs invoice #41646 dated 12/27/21 notes "Returned Elevator to Service Ticket # 39334 12/02/21" and invoice #41647 dated 12/27/21 notes "Returned to service and ran as intended Ticket # 39359 12/09/21". 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. Exit interview was conducted with Lydia Pabion Administrator and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Residents are not being provided activities. It is alleged that due to the elevator not working, residents on the second floor are not able to come downstairs and engage in exercise and social activities. Interviews with residents revealed 3 out of 6 residents interview stated not to join activities provided by personal choice. 1 out of 6 residents interview stated residents in second floor are not able to join activities as "it is hard to come down" stairs. 1 out of 6 residents interview stated to join activities and receive assistance coming down stairs if needed. 1 out of 6 residents interview refused to be interviewed. Interviews with staff revealed, 5 out of 5 staff stated that residents were assisted to come down stairs to participate in activities. Documents reviewed revealed activity schedule for January 2022 list activities provided daily for residents in care and 4 out of 6 residents residing in the second floor are noted as ambulatory in physician's report. 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. Regarding allegation: Medications are not being administered to residents properly. It is alleged the elevator is use to bring medication carts with resident's medications, but now that elevator is not working results in staff not being able to fill the medication cup in front of the residents. Interviews with residents revealed 3 out of 6 residents stated to have received their medication during the time the elevator was out of service. 2 out of 6 residents do not take medication and 1 out of 6 residents refused to be interview. 5 out of 5 staff stated medications were being provided to residents in their room and previously preparing dose in the medication room, placing medication from bubble pack or container into a label cup with residents name and room number and carried in a tray instead of medication cart along with water to residents in second floor. Medication sheets reviewed revealed 4 out of 6 residents received medications during the time elevator was out of service. 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. Regarding allegation: Residents do not have a safe escape route in case of a fire. It is alleged if a fire were to happen at this facility many of the residents on the second floor who are wheelchair bound, or use walkers would be trapped because they would not be able to take the stairs to escape due to elevator not working. Interviews with residents revealed 3 out 6 residents interview stated to be able to use the stairs, (CONTINUED LIC 9099C) residents have physical discomfort but are not restrained from using stairs. 2 out of 6 residents interview do not use stairs as they reside in the first floor and 1 out of 6 residents refused to be interviewed. Staff interviews revealed 5 out of 5 staff stated that residents in the second floor are ambulatory but may use walker for support and when they use stairs staff provide assistance to ensure their safety. Documents reviewed revealed Fire Drill Report dated 12/3/21 was conducted at 1:00pm and on 2/25/22 at 1:40pm. Fire & Life Safety Inspection Form from City of South Pasadena Fire Department dated 9/2/21 notes that exit doors, aisles and stairways are free of obstruction and all exit doors are unlocked. Emergency and Disaster Plan for Residential Care Facilities for the Elderly was reviewed and updated on 11/2/21 and on 6/1/22. Physician's Reports reviewed revealed R1,R2,R3,R4 residing in second floor are ambulatory. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted with Lydia Pabion Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2022 · control 28-AS-20220104152734

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 13, 2022

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure elevator was in working conditions at all times wich poses a potential health, safety, or personal rights risk for residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2022

Plan of correction: Licensee provided elevator repaired order dated 1/19/22 during this visit. Deficiency has been cleared as of 6/13/22.

Type of visit: Required - 1 Year

Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an annual inspection visit at the facility with focus on the infection control domain, food and medication review. LPAs Flores and Baptiste met with Lydia Pabion administrator 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 Baptiste conducted a walk through of the facility with Jose DeLeon - Maintenance around 12:10pm and observed the following: Kitchen area has sufficient food worth 2 days of perishables and 7 days of non-perishables. All bedrooms have sufficient lighting, furniture, and all required bedding. Bathrooms were observed with skid matts and grab bars. Water temperature was tested in bathrooms for rooms #104,108,114, 209,216, and 223 between 105.5- 117.1 degrees F, which is within the required 105-120 degrees F. LPA observed supplements (tums/vitamins) in room #114. Facility is currently following COVID-19 recommendations, signs were posted through out the facility, bathroom was observed with soap, signs and paper towels. Screening is conducted for clients, staff and visitors. LPA observed enough PPE supplies for at least 30 days. N95 fit testing has been conducted for all staff. All staff are wearing face mask. LPA Flores conducted a review of files and medication around 12:15pm for Resident #1,#2,#3,#4,#5 and staff files #1,#2,#3,#4, #5. Administrator certificate was observed for Lydia Pabion #6006152740 expiration date: 8/10/23. A technical violation was given during this visit. No deficiencies were noted. Exit interview was conducted with Lydia Pabion administrator and a copy of this report and technical violation was given.the state’s words, verbatim · CDSS document, Feb 22, 2022

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff caused injury to resident. Facility staff handles resident in a rough manner. Facility staff threatened resident with eviction. Facility staff failed to meet resident's needs Food withheld from resident Medications are not refilled in a timely manner

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Administrator, Lydia Pabion who assisted with today's visit. Regarding the allegation that Facility staff caused injury to resident #1 and Facility staff handle resident #1 in a rough manner, the investigation consisted of interviews with Administrator, Staff #1 - #3, and interviews with Residents #2 - #5. Administrator and Staff interviewed denied the allegation. They stated that they have not observed any staff handle residents in a rough manner, and that staff have not caused injury to any resident. Staff indicated that they have been trained on how to treat the residents. Staff interviewed stated that they were not aware that resident #1 had any bruises on her body, and denied that resident #1 was handled in a rough manner. Residents interviewed were unable to corroborate the allegation. 4 out of 4 residents stated that they have not observed staff handle resident(s) in a rough manner and have not heard of staff causing any injury to residents. Residents stated that staff treat them well. Resident #1 no longer lives at the facility, and was not interviewed. Unsubstantiated Regarding the allegation that Facility staff threatened resident #1 with eviction, the investigation consisted of interviews with Administrator, Staff #1 - #3, and interviews with Residents #2 - #5. Administrator and Staff interviewed denied the allegation. They stated that they did not threaten resident #1 with eviction. Residents interviewed were unable to corroborate the allegation. 4 out of 4 residents interviewed stated that they have not observed staff threaten any residents with eviction. Resident #1 no longer lives at the facility, and was not interviewed. Regarding the allegation that Facility staff failed to meet resident #1's needs, specifically that resident #1's incontinent needs were not being met, the investigation consisted of interviews with Administrator, Staff #1 - #3, and interviews with Residents #2 - #5. Administrator and Staff interviewed denied the allegation. They stated that residents with incontinent needs are met. They stated that they order incontinence supplies in sizes to meet all of their residents needs. They denied that resident #1's incontinent needs were not met. Residents interviewed were unable to corroborate the allegation. 4 out of 4 residents interviewed stated that their needs are being met at the facility. They stated that to their knowledge the facility provides incontinence supplies to residents who need them. Resident #1 no longer lives at the facility, and was not interviewed. Regarding the allegation that Food was withheld from a resident, the investigation consisted of interviews with Administrator, Staff #1 - #3, and interviews with Residents #2 - #5. Administrator and Staff interviewed denied the allegation. They stated that they do not withhold food from any residents. Residents interviewed were unable to corroborate the allegation. 4 out of 4 residents interviewed stated that the facility provides sufficient food to all residents and food is not withheld. Resident #1 no longer lives at the facility, and was not interviewed. Regarding the allegation that Medications are not refilled in a timely manner, the investigation consisted of interviews with Administrator, Staff #1 - #3, and interviews with Residents #2 - #5. Administrator and Staff interviewed denied the allegation. They stated that staff order medications in a timely manner. Residents interviewed were unable to corroborate the allegation. 4 out of 4 residents interviewed stated that they have not had any problems with receiving their medications in a timely manner. Resident #1 no longer lives at the facility, and was not interviewed. Based on LPA's observations and interviews, investigation revealed: 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. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Administrator, Lydia Pabion.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 28-AS-20191122155817

Allegation investigated: Facility staff engaged in inappropriate interactions with resident. Facility staff is financially abusing resident. Facility staff failed to safe guard resident's personal belongings.

Licensing Program Analysts (LPAs) Mary Flores and Luis Mora conducted an unannounced complaint investigation visit for the above allegations. LPAs met with Lydia Pabion administrator and explained the reason for the visit. The investigation consisted of the following: On 07/07/21, LPA Flores conducted a tour of the facility at 1:15pm which consisted of the common areas, kitchen, and random rooms #227, 210, 110, 107, 105 water temperature was tested in each room and tested between 77.6 to 114.5 degrees F which is not between the required 105 - 120 degrees F. LPA interview administrator and resident #1 (R1), and requested the following documents; Admission agreement, physician's report, medication sheet for June, any incident reports, face sheet for R1, resident #2(R2), #3(R3), #4(R4), #5(R5) and job description for staff #1 (S1), #2(S2), #3(S3), #4(S4), and staff and resident roster. LPA Flores interviewed pharmacist over the phone. On 7/29/21 LPA Flores conducted interviews with S1,S2,S3,S4,staff #5(S5), #6(S6). On 08/16/21, LPAs conducted interviews with resident #1 (R1),#2 (R2), #3 (R3), #4 (R4), #5(R5). (CONTINUED LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Facility staff engaged in inappropriate interactions with resident. It is alleged staff has a “Crush on resident” and has bought gifts several times and offered to buy resident a cell phone. Interviews with residents revealed the following 4 out of 5 residents stated staff have not made inappropriate comments or had inappropriate interactions with residents and 1 out of 5 residents stated that staff wants to be involved in resident's affairs. Interviews with staff revealed 5 out of 6 staff stated staff are respectful and have not observed inappropriate behavior's with residents. 1 out of 6 staff stated that facility terminated a staff member due to inappropriate behavior with a resident. Administrator stated that there have not been additional concerns regarding other staff being inappropriate with residents. Based on LPA's, interviews, and file review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Regarding allegation: Facility staff is financially abusing resident. It is alleged facility billed resident stating that the bill is for medicine, however medications are covered through resident's medical insurance. Interviews with residents revealed 5 out of 5 residents stated facility has not billed residents with additional charges or requested money. Interview with staff revealed 6 out of 6 residents stated not to have heard residents state that they are being financially abuse by facility. Administrator stated some residents receive pharmacy bills as the co-payment for the medication order for residents. On 7/7/21 LPA Flores interviewed pharmacist from Specialist Medical Pharmacy, who stated that residents receive an invoice whenever medication order is not cover by medi-cal/medi-care and a fee must be charge and medication is requested by resident. Invoices are provided to the facility to be given to the residents. Based on LPA's interviews, and file review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Regarding allegation: Facility staff failed to safe guard resident's personal belongings. It is alleged that in October 2020 someone stole resident's cell phone. Interviews with residents revealed 4 out of 5 residents stated to not have had any items stolen from their rooms and 1 out of 5 residents stated to have had items missing from room. Interviews with staff revealed 6 out 6 staff stated to not have heard any residents say that items have been stolen from their rooms or from a resident. Administrator stated that a resident reported to have lost cellphone in the bus around December 2020. Based on LPA's interviews, and file review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Exit interview was conducted with Lydia Pabion administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 16, 2021 · control 28-AS-20210628101748

Allegation investigated: Staff allow residents to smoke inside the facility

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegations. The investigation consisted of the following: On 6/16/21 LPA Flores interviewed administrator, conducted a tour of random rooms at the facility #223,222,209,211,206, 102,103,110,115,117,120,228,224,222, tested smoke detectors in rooms and hallways and observed designated smoking area per administrator approved by fire and police department. LPA interviewed residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5), and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5). On 6/17/21 LPA Flores contacted South Pasadena Fire Department (SPFD). On 7/29/21 LPA Flores contacted SPFD and clarify code for smoke detectors. The investigation revealed the following: Regarding allegation: Staff allow residents to smoke inside the facility. It is alleged staff allow several residents on the second floor to smoke in their rooms. During facility's tour on 6/16/21 LPA observed resident in room #222 smoking in balcony and on 7/7/21 during a complaint investigation LPA observed resident in room #210 smoking inside the room. (CONTINUED LIC9099C) Substantiated During interviews with residents, 4 out of 5 residents stated to not observed or have bed bugs or cockroaches at the facility. 1 out of 5 residents stated to have observed a cockroach in the bedroom's bathroom. During interviews with staff, 4 out of 5 staff stated to have not observed bed bugs or cockroaches in resident's rooms or facility. 1 out of 5 staff stated that resident brought a very small cockroach to her in a plastic bag but there are no other signs of pest at the facility. Facility has a pest control contract and services facility every two weeks. Facility was last served on 6/7/21. Based on LPA's observations, interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Regarding allegation: Facility smoke alarms are inoperable. It is alleged the second floor does not have functioning smoke detectors. During facility's tour LPA observed 12 out of 14 bedrooms had a smoke detector in the bedrooms, all smoke detectors were tested and are in working order. 2 out of 14 bedrooms did not have a smog detector in the room. LPA observed a sprinkle fire system throughout the facility and sprinklers in each room. Maintenance staff stated the smoke detector in vacant room #228 was removed for remodeling and updating. On 7/29/21 LPA Flores contacted SPFD and spoke with Firefighter Rodriguez who stated per code it is not required for facility to have smoke detectors in each room only if facility has a sprinkle system which facility does. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Regarding allegation: Resident's room door is obstructed. It is alleged room 211 is cluttered with random items that constantly block the resident's window and door. During facility's tour LPA observed room 211 does have many items in the floor and tables. Resident in room #211 has created about 4 feet path throughout the room to bathroom and door as well as floor room near bed and desk which allows resident usage of walker. Resident stated to be able to move around the room freely, does not want to get rid of items in his room, and has been assisted previously to dispose of some items. Administrator stated to have assisted resident in the past to get rid of some items and will continue to assist as resident brings new items. 3 out of 5 staff interview did not show concern in accessibility to the room to provide care or housekeeping. 2 out of 5 staff interview stated resident collects items but administrator assist with ensuring it does not block area. (CONTINUED LIC 9099C) Regarding allegation: Facility elevator is in disrepair. It is alleged elevator stopped working on 6/10/21 and residents are having trouble going up an down stairs. During facility's tour LPA observed elevator working properly. Administrator stated elevator was out for about an hour or less between the week of 6/6/21 to 6/11/21 once. Per administrator elevator door was not closing. Administrator called Performance Elevator Services who arrived within an hour removed an item that was preventing the door from closing, it was removed and no repairs were done by service company as there is no invoice regarding incident. Interviews with residents, 2 out of 5 residents stated elevator was out for a short time and 3 out of 5 residents do not use elevator or do not know if elevator was out. Interviews with staff, 3 out of 5 staff interview stated elevator was not working for less than an hour and 2 out of 5 staff stated to not know that elevator was not working. Resident roster shows residents in the second floor are ambulatory. Based on LPA's observations, interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Regarding allegation: Facility does not have a resident council. It is alleged facility also does not have a resident council. During interviews with residents, 4 out of 5 residents stated facility has a resident council, 1 out of the 4 stated not to go because he does not hear the announcement in the intercom when they are announced. 1 out of 5 residents stated not to know if there is a council meeting as resident has been out in doctor's appointments and does not know if it is held or not. Interviews with staff, 5 out of 5 staff stated facility has a council meeting once a month and staff announces the meeting over intercom before it begins to allow residents to join. LPA reviewed copies of resident council meetings signing sheet and notes held on 4/16/21, 5/19/21, and 6/9/21. Based on LPA's observations, interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found UNSUBSTANTIATED. Exit interview was conducted with Lydia Pabion administrator and a copy of report was provided. During interviews with 3 out 5 residents stated residents are not allowed to smoke in the facility and there is a smoking area in the back of the building. 1 out of 5 residents stated not to know if other residents were smoking outside, and 1 out of 5 residents stated residents are smoking in rooms. Interviews with staff, 3 out of 5 staff interview stated residents do not smoke in the rooms and 2 out of 4 staff stated residents smoke in balcony or residents must be reminded of no smoking in room policy. Facility's house rules state that residents should not smoke in rooms. Administrator stated house rules will be updated to reflect no smoking in facility or balconies which was previously discuss between administrator and licensee. Facility has zero residents under hospice and 2 residents in room 107 and 115 are under oxygen care per doctor's request. Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Lydia Pabion administrator and a copy of this report LIC 9099D, and appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 29, 2021 · control 28-AS-20210611130511

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(C) · Plan of correction due date: Jul 30, 2021

87618 Oxygen Administration-Gas and Liquid:(b)... the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (C)Smoking shall be prohibited where oxygen is in use. This requirement is not met as evidency by: Based on observation and interviews conducted residents in room 210, and 222 were observed smoking in rooms/balcony which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2021

Plan of correction: Administrator will ensure that residents at the facility are not smoking in bedrooms by certifying in LIC 9098 by 7/30/21 and will update and notify each resident by providing a copy of udated house rules: regarding house rules, smoking in rooms, smoking in the facility, and consequences of smoking in rooms by 8/4/21.

Allegation investigated: Facility is in disrepair

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegation(s). LPA Flores met with Lydia Pabion administrator and explained the reason for the visit. The investigation consisted of the following: LPA Flores conducted a tour of the facility at around 1:15pm which consisted of the common areas, kitchen, and random pick rooms #227, 210, 110, 107, 105 water temperature was tested in each room and tested between 77.6 to 114.5 degrees F which is not between the required 105 - 120 degrees F. LPA interviewed administrator and resident #1 (R1), and requested the following documents; Admission agreement, physician's report, medication sheet for June, any incident reports, face sheet for R1, resident #2(R2), #3(R3), #4(R4), #5(R5) and job description for staff #1 (S1), #2(S2), #3(S3), #4(S4), and staff and resident roster. The investigation reveled the following: Regarding allegation; Facility is in disrepair. It is alleged patio door is broken, has told several times to the facility and nothing has been done. (CONTINUED LIC 9099C) Substantiated During the facility's tour LPA observed a plastic covered holed in the dinning room's ceiling due to a leak, kitchen's refrigerator temperature at 45.2 degrees F and freezer temperature at 20.0 degrees F, second floor left hallway middle window crack on left bottom corner and right hallway middle window screen ripped on bottom left corner, room #210 water temperature read at 96.1 degrees F, and balcony screen door was off rails leaning against window, room# 105's ceiling had 3 patches large about a foot long of peel paint and sink's water drain is rusted around, and room #107 water temperature was read at 99.4 degrees F. Based on LPA's observations, conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Lydia Pabion and a copy of the report, LIC 9099D, and appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 7, 2021 · control 28-AS-20210628101748

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(21) · Plan of correction due date: Jul 8, 2021

87555 General Food Service Requeriments: (a) The following food service requirements shall apply: (21) Freezers... shall be maintained at a temperature of 0 degrees F ..., and refrigerators... shall maintain a maximum temperature of 40 degrees F .... This requirement is not met as evidence by: Based on LPA observation, administrator did not ensure refrigerator and freezer temperature were under the require temperature as observed freezer at 20 degrees, and refrigerator at 45.2 degrees which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2021

Plan of correction: Administrator will certify on LIC 9098 and ensure to maintain proper refrigerator and freezer temperature. Administrator contacted refrigerator maintenance company, will have schedule refrigerator repair, and submit LIC9098 by 7/8/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 21, 2021

87303 Maintenance and Operation: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2).... Hot water temperature controls shall be maintained to automatically regulate.. temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by: Based on observation facility failed to maintain water temperature within the required 105-120 temperature as read in rooms #105 at 77.6 degrees F, #107 at 99.4 degrees F and, #210 at 96.1 degrees F which poses a potential health, safety, or personal rights risk to person in care.the state’s words, verbatim · CDSS document, Jul 7, 2021

Plan of correction: Administrator will ensure water temperature is maintain within the required range of 105-120 degrees F at all times. Administrator will certify with LIC 9098 and maintain a water temperature log that will be submitted to the department by 7/21/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 21, 2021

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation facility did not ensure facility is in good repair as room #210 has a balcony screen door off rails, #105 ceiling is peeling in three areas, 1 middle window in 2nd floor hallway crack and 1 window screen ripped and leak in dinning room which poses a potential health, safety, or personal risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2021

Plan of correction: Administrator will schedule repairs of room #105, room #210 and windows in second floor and will submit a picture of the repairs to the department by 7/21/21.

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.