Royal Oaks

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Health Services Administrator, Tony Agoncillo and Nurse director, Eusebio (Sev) Tienda, who assisted with the visit. LPA discussed the purpose of today's visit with administrator. During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records. The facility is licensed to serve two hundred fifty (250) residents ages 60 and above. A maximum of 25 Non-Ambulatory residents in the Bradbury Oaks building. Facility has approved Hospice Waiver for four (4) residents. Currently, there is one (1) resident on hospice. Approved Dementia Care plan is in place. This is a Continuing Care Retirement Community (CCRC) which includes three separate levels of care; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building which had 28 residents. Other residents are living at the Independent Living care section. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia, who have wandering behaviors. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. (-continued in LIC 809 C-) Hot water temperature is in a range of 107.5 to 118.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility. All exit doors are equipped with "wander guard system." Signal system is operational. Last emergency drill is conducted on 9/20/23 and fire drill on 7/18/23. Sufficient supply of perishable and non-perishable foods is observed. Kitchen has required equipment and is in compliance. Smoke detectors and carbon monoxide detectors are monitored by a fire prevention company. All mandated documents and signages are posted in common areas. No deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was discussed with Nurse Director, Eusebio P (Sev) Tienda.the state’s words, verbatim · CDSS document, Oct 24, 2023

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner. Staff did not provide medical assistance to resident in a timely manner. Food services are inadequate. Staff do not ensure resident's special diet is followed. Staff did not safeguard resident's personal belongings. Staff threatened resident. Staff placed unsafe equipment in resident's room. Facility is in disrepair. Facility did not follow Covid-19 testing protocols.

** This report supersedes report dated 8/24/23. LPA Villalobos gathered additional information and conducted further interviews regarding the allegations above. There are no changes to the findings** Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced subsequent complaint visit to the facility. Upon arrival, LPA met with Jill Crowell (Director of Resident Services) and explained the purpose of the visit. A short time later Eusebio (Sev) Tiendia (Director of Wellness) also met with LPA and assisted with the complaint investigation. During the initial visit on 09/21/22, LPA Kruz obtained a copy of the Staff/Resident rosters, Admission Agreement (R#1) and Charge Statement. LPA also toured the facility with Jill Crowell, interviewed Staff #1 and #2 (S1-S2) in the conference room and interviewed Resident #1 (R#1) in their living unit. During the second visit on 8/24/23, LPA Kruz obtained a copy of the Staff/Resident rosters and interviewed Residents #2 to #10 (R2-R10) in the office. (Continued on LIC 9099-C) Unsubstantiated On todays visit, LPA Villalobos toured the physical plant, interviewed staff #1-#7 (S1-S7), Collected work order report for R1's room, incident report for R1 dated 4/28/22, and R1's facesheet with physicians report. The investigation revealed the following: In regards to the allegation "Staff did not respond to resident's call for assistance in a timely manner." it was alleged R1 pulled the emergency cord in their room and no assistance arrived until 17 hours later. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. Interview with staff stated that R1 did have an unwitnessed fall in their room on 4/28/22. R1 is an independent living resident of the facility. Interviews state there are no signal or pull cords on 4/28/22 for R1's room. Interviews with staff state that there is a sensor that signals staff when a resident in the independent living rooms does not get out of bed by 10am. When they are alerted, staff will call the room to check on the resident and if there is no answer, they conduct a check. On 4/28/23 this specific signal came for R1's room and staff went to check on R1 and that is when they were observed on the floor by their bedside. There was no pull cord used by R1 and as R1 is an independent living resident, there are no continuous monitoring of residents location throughout the day other then the previous mentioned 10am signal. Interviews with other residents show that staff respond timely to emergency pull cords and there are no issues regarding staff timely responses. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not provide medical assistance to resident in a timely manner" it was alleged that R1 fell in their room and was not provided medical assistance in a timely manner. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. File review shows that R1 had a fall on 4/28/22 and was assisted by staff. R1 was transported to the hospital and returned to the facilities skilled nursing department. Interviews show that R1 was assisted immediately after being found on the floor by their bedside on 4/28/22. Resident interviews indicate medical assistance is provided by staff when needed. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC 9099-C) In regards to the allegation "Food services are inadequate." it was alleged that the food is dry and given in small portions. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. LPA toured the kitchen and observed all food are of good quality. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days is maintained. Interviews with Staff indicate food service is adequate. Interviews with (9) of (10) Residents indicate food service is adequate and different food choices are available. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff do not ensure resident's special diet is followed." it was alleged that staff do not follow the list of foods R1 can eat. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Per allegation details, it was alleged the facility is not providing Resident #1 with a special diet. Investigation revealed Resident #1 does not require a special diet and there is no physician's order for a special diet. Interviews with staff indicate residents requiring a special diet is provided with meals based on physician's order. LPA Villalobos reviewed R1's file and did not observe a physicians order for special diet. LPA observed a hand written letter by R1 of R1's preferred meals and methods of cooking their meals. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff did not safeguard resident's personal belongings" it was alleged that staff damaged R1's personal item and did not correct the situation and that medications were missing from their room. (7) of (7) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interviews show there was a day when staff damaged one of R1's personal items accidentally while conducting repairs to the living unit. Facility immediately reimbursed Resident #1 for the damaged item. LPA observed and collected documentation showing that R1 was compensated. Interviews show R1 accepted the compensation. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC 9099-C) In regards to the allegation "Staff threatened resident" it was alleged that S1 threatened R1 to sign documentation of money they were reimbursed. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. Staff interviewed denied that S1 ever threatened R1. Interviews with residents does not show staff to speaking to them in a threatening manner or to any other residents. LPA was not provided with proof that S1 threatened R1. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Staff placed unsafe equipment in resident's room." it was alleged that facility staff placed a dangerous gas powered heater in R1's room. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed denied the allegation. Interviews with staff state that there are no gas powered heaters in any rooms or any that are provided to residents. There are small electric powered heaters that can be provided upon request if a resident chooses. No gas heaters were observed throughout the visits. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation "Facility is in disrepair." it was alleged that there are multiple leaks and issues with the bathroom in R1's room that staff were not addressing. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegations. Interviews with staff and residents shows that items that need repair are completed in a timely manner. Work orders are completed and assigned dates to staff to complete. LPA observed work orders for leaks and ceiling repairs completed in R1's bathroom between 4/21/22-4/28/22. Residents interviewed stated the facility is always clean and in good repair and if an item is broken, an order is placed and maintenance will repair it right away. LPA's observed the facility to be clean and in good repair during visits. R1 stated that staff do repair the issues when they are informed of them. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (Continued on LIC 9099-C) In regards to the allegation "Facility did not follow Covid-19 testing protocols" it was alleged that the facility is supposed to test everyone for covid and never did. (7) of (7) Staff interviewed denied the allegation. (9) of (10) residents interviewed could not corroborate the allegation. During the initial visit, Staff checked LPA Kruz's temperature and was provided a Covid-19 questionnaire. Interviews with Staff indicate Covid-19 testing protocols were followed. Interviews with residents also indicated Covid-19 testing protocols were followed. During LPA Villalobos' visit, there are no requirements regarding covid screening. Interviews with staff shows that the only people who are testing for covid 19 at the moment would be someone who has tested positive on their own or anyone who is suspected of having covid due to exposure. Other than that, there is no policy to test residents and staff regularly. Based on interviews, observations, and file review conducted there was not enough supportive evidence to concur with the reported allegation; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 28-AS-20220915141701

Allegation investigated: Resident sustained multiple pressure injuries while in care of the facility. Staff did not respond to resident's call for assistance. Staff are not meeting resident's hygiene needs.

*This is a corrected version of initial 10-day complaint investigation dated 8/15/23. No changes to finding.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/15/23 regarding the above allegations. LPA Ramirez was met by Administrator Andrew Smith and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1 interview (R1 ), Copies of Resident #1 (R1): Profile Face Sheet, Interdisciplinary Notes dated 7/31/23 and 8/1/23, facility staff response notes for the month of July 2023, Doctor’s Order Sheet dated 5/18/23 through 7/25/23, Pomona Valley Hospital History and Physical Report dated 8/1/23, Addendum to Care and Residence Agreement dated 10/4/22, Preplacement Appraisal Information dated 7/26/20, Physician’s Report dated 5/20/20, Device Activity Reports dated 7/31/23 and 8/1/23, Special Incident Reports (SIR) for R1, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Resident sustained multiple pressure injuries while in care of the facility- It is alleged R1 sustained multiple injuries while in care of the facility. R1 was admitted into the independent living unit of the facility on 8/18/20. Records review revealed that R1 sustained three (3) unwitnessed falls in R1 accommodation from June 2023 through July 2023. On 6/3/23, staff reported R1’s had an unwitnessed fall, and no injuries were noted. On 6/28/23, staff reported R1’s unwitnessed fall, and no injuries were noted. On 7/23/23, staff reported R1’s unwitnessed fall and injuries were noted. Doctor’s Order Sheet signed and dated by R1’s physician, indicates R1 is okay to return to accommodation. LPA Ramirez reviewed Pomona Valley Hospital notes dated 8/1/23 and no observations of pressure injuries were noted on history of present illness. LPA Ramirez could not locate any documentation or staff interviews indicating R1 suffered from any pressure injuries prior to unwitnessed falls. Four (4) out of four (4) staff interviewed deny this allegation. R1 denied this allegation however, R1 could not articulate what a "pressure injury" is or how such injury can occur. 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. Staff did not respond to resident's call for assistance- It is alleged that facility staff did not respond to R1’s accommodation after R1 pushed panic button. On or around 8/1/23 at 10:14 am, R1 was discovered by staff wedged in between side rail and bed. According to staff interviewed, R1 was wearing alert pendant when R1 was discovered on 8/1/23. Per S1 interview, R1 was wedged in an angle that prohibited R1 from accessing pendant around neck. On 7/31/23 at approximately 9:51 pm, R1 pushed alert pendant. At 10pm, staff responded and noted R1 sitting on floor and indicated that R1 fell. R1 stated that no injuries and was assisted back to bed. On 8/15/23, LPA Ramirez toured R1’s accommodation and tested emergency pull cord in bathroom. Facility staff responded within 1 minute by calling R1’d bedside phone. LPA Ramirez reviewed facility Device Activities Report dated 8/1/23 and could not locate a request for assistance by R1. Facility staff did respond to a request for assistance on 8/1/23 to R1’s accommodation due to staff finding R1 wedged in between bed and half rail. Four (4) out of four (4) staff interviewed deny this allegation. Interview with R1 revealed, R1 recalled pushing pendant but stated staff did not arrive. R1 later stated during interview that R1 could not reach pendant due to left arm being wedged in between bed and rail. 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. See 9099-C for continuation. Staff are not meeting resident's hygiene needs- It is alleged R1 appeared disheveled and lacked proper hygiene. Physician’s report dated 5/20/20 indicates R1 is ambulatory and does not require bathing/grooming assistance. On 10/14/22, R1 signed Addendum to Care and Residence Agreement that provides additional care to R1 with personal care, escort, housekeeping, errands, pet care, and additional services at R1’s request. LPA Ramirez reviewed staff response notes for the month of July 2023. LPA Ramirez counted at least eleven (11) documented instances of R1 requesting staff assist with bathing and staff responding to R1’s request. Four (4) out of four (4) staff interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited during visit. Exit interview was conducted and a copy of this report was provided via email due to printer problems.the state’s words, verbatim · CDSS document, Sep 15, 2023 · control 28-AS-20230811161004

Allegation investigated: Staff did not respond to resident's call for assistance in a timely manner. Staff did not provide medical assistance to resident in a timely manner. Food services are inadequate. Staff do not ensure resident's special diet is followed. Staff did not safeguard resident's personal belongings. Staff threatened resident. Staff placed unsafe equipment in resident's room. Facility is in disrepair. Facility did not follow Covid-19 testing protocols.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to the facility. Upon arrival, LPA met with Jill Crowell (Director of Resident Services) and explained the purpose of the visit. A short time later Eusebio (Sev) Tiendia (Director of Wellness) also met with LPA and assisted with the complaint investigation. During the initial visit on 09/21/22, LPA obtained a copy of the Staff/Resident rosters, Admission Agreement (R#1) and Charge Statement. LPA also toured the facility with Jill Crowell, interviewed Staff #1 and #2 in the conference room and interviewed Resident #1 (R#1) in their living unit. During today's visit, LPA obtained a copy of the Staff/Resident rosters and interviewed Residents #2 to #10 in the office. Continue to LIC9099C.... Unsubstantiated Regarding allegation: Staff did not respond to resident's call for assistance in a timely manner. Interview with Staff indicate Staff response on a timely manner when a call is made for assistance. Interviews with 9 of 9 Residents also indicate Staff responds to calls for assistance on a timely manner. During a tour of various Resident living units, LPA observed the call system to be operable. Regarding allegation: Staff did not provide medical assistance to resident in a timely manner. Interview with Staff indicate medical assistance such as appointment setting or transportation is provided upon Resident's request. Interviews with 9 of 9 Residents also indicate medical assistance is provided it needed. Regarding allegation: Food services are inadequate. LPA toured the kitchen and observed all food are of good quality. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days is maintained. Interview with Staff indicate food service is adequate. Interviews with 9 of 9 Resident indicate food service is adequate and different food choices are available. Regarding allegation: Staff do not ensure resident's special diet is followed. Per allegation details, it was alleged the facility is not providing Resident #1 with a special diet. Investigation revealed Resident #1 does not require a special diet and there is no physician's order for a special diet. Interviews with 9 of 9 Residents indicate Residents requiring a special diet is provided with meals based on physician's order. Regarding allegation: Staff did not safeguard resident's personal belongings. Interview with Staff indicate there has never been a complaint that Staff did not safeguard Resident's personal belongings. Interviews with 9 of 9 Residents indicate their personal belonging are safeguarded and never had an incident of missing items. Per allegation details, Staff damaged one of Resident #1's personal items while conducting repairs to the living unit. Facility immediately reimbursed Resident #1 for the damaged item. Regarding allegation: Staff threatened resident. Interviews with Staff indicate they have never threatened a Resident nor have they ever witnessed other Staff threaten a Resident. Interviews with 9 of 9 Residents also indicate they have never been threatened by Staff nor have they witnessed Staff threatened a Resident. Regarding allegation: Staff placed unsafe equipment in resident's room. Interviews with Staff indicate unsafe equipment has never been placed in Resident's room. Interviews with 9 of 9 Resident also indicate Staff has never placed unsafe equipment in Resident's rooms. Continue to LIC9099C.... Regarding allegation: Facility is in disrepair. LPA toured the facility and observed the facility to be in good repair including Resident's living units. Interviews with Staff indicate items that need repair is completed in a timely manner. Interviews with 9 of 9 Resident indicate the facility is always clean and in good repair and if an item is broken, an order is placed and maintenance will repair it right away. Regarding allegation: Facility did not follow Covid-19 testing protocols. During the initial visit, Staff checked LPA's temperature and was provided a Covid-19 questionnaire. Interviews with Staff indicate Covid-19 testing protocols were followed. Interviews with 9 of 9 Residents also indicate Covid-19 testing protocols were followed. Based on LPA's observations, interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Eusebio (Sev) Tiendia (Director of Wellness) and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 24, 2023 · control 28-AS-20220915141701

Allegation investigated: Resident sustained multiple pressure injuries while in care of the facility. Staff did not respond to resident's call for assistance. Staff are not meeting resident's hygiene needs.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/15/23 regarding the above allegations. LPA Ramirez was met by Administrator Andrew Smith and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1 interview (R1 ), Copies of Resident #1 (R1): Profile Face Sheet, Interdisciplinary Notes dated 7/31/23 and 8/1/23, facility staff response notes for the month of July 2023, Doctor’s Order Sheet dated 5/18/23 through 7/25/23, Pomona Valley Hospital History and Physical Report dated 8/1/23, Addendum to Care and Residence Agreement dated 10/4/22, Preplacement Appraisal Information dated 7/26/20, Physician’s Report dated 5/20/20, Device Activity Reports dated 7/31/23 and 8/1/23, Special Incident Reports (SIR) for R1, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Resident sustained multiple pressure injuries while in care of the facility- It is alleged R1 sustained multiple injuries while in care of the facility. R1 was admitted into the independent living unit of the facility on 8/18/20. Records review revealed that R1 sustained three (3) unwitnessed falls in R1 accommodation from June 2023 through July 2023. On 6/3/23, staff reported R1’s had an unwitnessed fall, and no injuries were noted. On 6/28/23, staff reported R1’s unwitnessed fall, and no injuries were noted. On 7/23/23, staff reported R1’s unwitnessed fall and injuries were noted. Doctor’s Order Sheet signed and dated by R1’s physician, indicates R1 is okay to return to accommodation. LPA Ramirez reviewed Pomona Valley Hospital notes dated 8/1/23 and no observations of pressure injuries were noted on history of present illness. LPA Ramirez could not locate any documentation or staff interviews indicating R1 suffered from any pressure injuries prior to unwitnessed falls. Four (4) out of four (4) staff interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff did not respond to resident's call for assistance- It is alleged that facility staff did not respond to R1’s accommodation after R1 pushed panic button. On or around 8/1/23 at 10:14 am, R1 was discovered by staff wedged in between side rail and bed. According to staff interviewed, R1 was wearing alert pendant when R1 was discovered on 8/1/23. Per S1 interview, R1 was wedged in an angle that prohibited R1 from accessing pendant around neck. On 7/31/23 at approximately 9:51 pm, R1 pushed alert pendant. At 10pm, staff responded and noted R1 sitting on floor and indicated that R1 fell. R1 stated that no injuries and was assisted back to bed. On 8/15/23, LPA Ramirez toured R1’s accommodation and tested emergency pull cord in bathroom. Facility staff responded within 1 minute by calling R1’d bedside phone. LPA Ramirez reviewed facility Device Activities Report dated 8/1/23 and could not locate a request for assistance by R1. Facility staff did respond to a request for assistance on 8/1/23 to R1’s accommodation due to staff finding R1 wedged in between bed and half rail. Four (4) out of four (4) staff interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff are not meeting resident's hygiene needs- It is alleged R1 appeared disheveled and lacked proper hygiene. Physician’s report dated 5/20/20 indicates R1 is ambulatory and does not require bathing/grooming assistance. On 10/14/22, R1 signed Addendum to Care and Residence Agreement that provides additional care to R1 with personal care, escort, housekeeping, errands, pet care, and additional services at R1’s request. LPA Ramirez reviewed staff response notes for the month of July 2023. LPA Ramirez counted at least eleven (11) documented instances of R1 requesting staff assist with bathing and staff responding to R1’s request. Four (4) out of four (4) staff interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited during visit. Exit interview was conducted and a copy of this report was provided via email due to printer problems.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 28-AS-20230811161004

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Jose Juarez Licensed Vocational Nurse (LVN) and explained the reason for the visit. The purpose of the visit is to complete the required inspection. Shortly thereafter Tony Agoncillo Health Services Administrator arrived. LPA Trueman toured the facility along with Jose Juarez Licensed Vocational Nurse (LVN) today 12/09/2022 at 9:45 AM and the following was observed: Facility contains : The second floor of the Bradbury Oaks building which consists of a dining room, kitchen, resident rooms, computer room, library, television room, coffee room, medication room, laundry room, storage room, janitor's room, and a greenhouse area (used for planting). LPA toured resident rooms #200-208. Resident rooms were furnished appropriately. Each resident room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have a signal system located by the resident bed and in the restroom. Required Annual inspection included Infection Control Domain and check of the food supply, medications and criminal clearance check. LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated. Medication for clients were verified as being administered and a 30 day supply on hand. Visitation signage was posted along with signage for hand washing and proper sanitizing. Temperature checks are conducted 2x a day and logged. Staff have been trained in hand washing. Staff are sufficient with no shortages and there is a plan to replace workers if ill. There are rooms available if isolation is needed. Staff wear masks, gloves and face shields. Social distancing is implemented. Meal times are sanitized after each meal. Facility has sufficient supply of PPE. Facility has a specific plan to ensure proper cleaning and disinfection of environmental surfaces and laundry; commonly touched surfaces are cleaned and disinfected at least once every shift . Plan when to notify medical provider if symptoms develop or COVID-19 exposure or when to call 911 for severe respiratory distress. No deficiencies. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 9, 2022

Allegation investigated: Resident is being financially abused while in care.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Director of Wellness / Sev Tienda and Executive Director / Andrew Smith who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Resident is being financially abused while in care". During today's visit, LPA interviewed the Executive Director, Director of Wellness, Staff #1 (S1) and Resident #1 (R1). Also, copies of the following documents were obtained and reviewed in reference to R1; • Resident Face Sheet • Physician's Report The investigation revealed the following; Allegation: Resident is being financially abused while in care. The details of this allegation states that there is suspicion of possible financial abuse by the Private Caregiver (PC) towards R1. No further information was Unfounded provided. Based on interviews conducted, the statements obtained did not corroborate with the allegation listed above. There were no concerns observed or reported by facility staff or R1 regarding the PC financially abusing R1. LPA discovered that the PC is not an employee of Royal Oaks and was hired by R1 through an outside agency in 2017. The PC is an employee of Comfort Keeper agency. The PC providing care to R1 has been the same PC since time of hire in 2017. The PC normally works five (5) days per week, between the hours of 8am - 2pm. Facility staff monitor the resident while R1 is with the PC, to ensure the needs of R1 are being met. When the PC is not at the facility, the facility staff are in full control of the care being provided to R1. Based on the information gathered, the allegation of "Resident is being financially abused while in care" is Unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Therefore, the complaint allegation is being dismissed. An exit interview was conducted and a copy of this report was provided to the Director of Wellness.the state’s words, verbatim · CDSS document, Feb 17, 2022 · control 28-AS-20220214115534

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nina Galarza and Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Upon arriving at the facility, LPAs met with Executive Director Andrew Smith and stated the purpose of the visit. The facility is licensed to serve for a capacity of two hundred fifty (250) residents ages 60 and above. A maximum of 25 Non-Ambulatory residents in the Bradbury Oaks building. The facility has an approved Hospice Waiver on file for four (4) residents. The facility also has an approved Dementia Care plan as part of their operation. This is a Continuing Care Retirement Community (CCRC) which includes three separate levels of care; Independent Living, Assisted Living and Skilled Nursing. The Assisted Living residents reside on the second floor of the Bradbury Oaks building. There are currently 27 residents in Assisted Living and 139 in Independent Living. The wander guard system is used in the Bradbury Oaks building (second floor) for residents diagnosed with dementia, who have wandering behaviors. LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During the tour, LPAs were accompanied by Executive Director and Sev Tienda, Director of Wellness. The second floor of the Bradbury Oaks building consists of a dining room, kitchen, resident rooms, computer room, library, television room, coffee room, medication room, laundry room, storage room, janitor's room, and a greenhouse area (used for planting). LPAs toured a random selection of resident rooms. Resident rooms were furnished appropriately. Each resident room has their own restroom. The bathrooms were observed to be clean and operational w/grab bars. The resident rooms have a signal system located by the resident bed and in the restroom. The signal system was tested in various locations and is operable. The hot water temperature was tested throughout the facility and did not meet Title 22 Regulation guidelines. CONTINUED 809-C detectors were observed to be fully charged and in compliance. The front grounds of the facility are well landscaped and have a leveled walkway to the entrance. The kitchen, food supply and emergency food and water supply were observed. There was a sufficient amount of perishable and non-perishable food supplies. No pesticides or poisons were stored in the food areas. Medications are centrally stored in the locked medication room located on the second floor. A random selection of medications were reviewed to ensure they are being administered as prescribed and prescription and non-prescription PRN medications have signed and dated written orders from the physician. All required information (Emergency Exiting Floor Plan, Personal Rights, Ombudsman information, Theft and loss policy and Emergency Telephone Numbers) are posted in the facility. The following deficiencies were observed during today's visit; - At 10:00 a.m. LPAs observed water temperature in room F111 at 121.3 degrees Fahrenheit - At 11:45 a.m. LPAs tested the wander guard system and observed it to be inoperable near the exit doors leading to the kitchen and outside area making it a hazard for dementia residents with wandering behaviors. The following deficiencies were observed to be in violation under California Code of Regulations Title 22. (refer to 809D). An exit interview was conducted and a copy of this report was provided to Sev Tienda along with the appeals rights.the state’s words, verbatim · CDSS document, Nov 9, 2021