Sakura Gardens at Los Angeles

Allegation investigated: Staff did not notify resident’s authorized representative of incident involving resident.

***This report supersedes the report dated 01/22/2026. The superseded report was created to add additional information obtained during investigation and to change the investigation findings as substantiated. *** Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegations listed above. LPAs met with Executive Director Tomoko Hino and explained the reason for the visit. On 01/22/2026, the initial investigation was conducted. The investigation consisted of interviews with staff from staff #1 (S1) to staff #8 (S8), residents from residents #1 (R1) to resident #9 (R9), and a visitor (V1). In addition, physical plant and R1’s facility file review were conducted. During today's visit the investigation revealed the following: LPA interviewed the Executive Director, interviewed additional staff, and obtained additional records. Substantiated The investigation reveals the following: In regards of allegation of staff did not notify resident’s authorized representative for an incident involving resident. Per residents' interviews, one (1) out of sixteen (16) residents interviewed was attempted but unable to contact residents. Fifteen (15) out sixteen (16) residents interviewed indicated that there had been no issues in contacting authorized representatives and that staff contacted responsible party to inform of residents’ incidents. Per staff interviews, eight (8) out of eleven (11) staff were not able to corroborate the allegation. Staff interviews revealed that staff described the procedure to follow in order to notify authorized representative. Three (3) out of eleven (11) staff interview revealed that staff were aware of incident on 12/02/2025 where R2 became aggressive towards staff and residents in the dining room. Staff described that R2 went to room shared with R1 and started throwing pictures frames and objects towards R1’s direction. Staff described that staff surrounded R1 to prevent objects from hitting R1. Staff stated R1 did not sustain any injuries. taff stated that responsible parties for both residents were contacted, but there is no record to support that the party responsible for R1 was contacted. In addition, there is nor incident report submitted to licensing agency describing the health and safety risk to R1 by roommate R2 throwing objects in R1’s direction. Therefore, there is sufficient evidence to support the allegation that staff did not notify resident’s authorized representative for incident involving resident’s safety or health risk. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Tomoko Hino. A copy of the report and appeal rights were provided. In regards of allegation of staff did not properly clean/wipe resident resulting in an UTI. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted. Eight (8) out nine (9) residents interviewed indicated that residents have not had any cleaning concerns that may cause an UTI issue. Residents indicated that staff are following residents cleaning and shower schedule twice a week or as per needed. Per staff interviews, all staff were not able to corroborate the allegation. Per document review, R1’s Medication Administrator Record (MAR) does not show any medication treatment for UTI. Staff are provided annual training for UTI care. During physical plant, LPA’s observed staff checking diapers and diaper changes were done. LPAs observed residents are provided drinking water in residents rooms and during their meals. Staff ensure that residents are hydrated. Therefore, there is no preponderance evidence to show that staff did not properly clean assistance and result in UTI. In regards of allegation of staff does not ensure water temperature was appropriate for residents. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted. Eight (8) out nine (9) residents interviewed indicated that there was no issue with water temperature. Per staff interviews, all staff were not able to corroborate the allegation. During physical plant, twelve (12) resident rooms were randomly selected, and the water temperature was measured in the range of 105-120 degrees Fahrenheit. Therefore, the water temperature was found to be within Title 22 regulation and water temperature was appropriate for residents. In regards of allegation of staff does not maintain resident’s hygiene. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted. Eight (8) out nine (9) residents interviewed indicated that there was no issue with residents’ hygiene. Per staff interviews, all staff were not able to corroborate the allegation. All staff indicated that the facility provides a schedule for shower, laundry, and toileting. All staff indicated that the schedule is being followed. On record reviewed, the facility keeps track of hygiene care assistance provided to residents. LPAs observed rooms to be clean, tidy, and free foul odor. Therefore, there is no preponderance evidence to show that staff is not providing hygiene assistance as needed by residents. (Report continues on LIC-9099c) Regarding allegation: Staff do not clean residents room. It is alleged that staff does not clean residents rooms. Investigation consisted of interviews with physical plant tour, staff, residents, and review of R1 facility file, including admission agreement and physicians report. The investigation reveals the following: interviews with seven (7) out of seven (7) residents stated that residents’ rooms are cleaned once a week, and if needed, residents may call housekeeping for additional cleaning services. Residents stated that residents have no issues with the room not being cleaned as often. Interview with seven (7) out of seven (7) staff indicated that residents’ rooms are cleaned once a week or as needed. Staff indicated that memory care unit residents’ rooms are cleaned every other day. Staff stated that housekeeping maintains a schedule that is followed by all housekeeping staff to make sure that rooms are maintained clean and free of odor. LPA observations during physical plant tour found that random rooms selected were observed to be clean including bathrooms. Based upon the investigation, resident and staff interviews, and LPA observations, there is not sufficient evidence to support that staff does not maintain residents’ rooms clean. Based on review of observations, documents and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was held with Executive Director Tomoko Hino. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 6, 2026 · control 28-AS-20260115123528

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 13, 2026

(a) Each licensee shall furnish to the licensing agency… (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents… This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above where licensee did not notify responsible party of incident that occurred on 12/02/2025 threatening R1’s welfare, safety or health which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: Licensee shall submitt incident report to license agency for incident on 12/02/2025 by POC date and submitt statement acknoledging understanding of section 87211 reporting requirements and that facility will comply with section.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced required 1-yr inspection. LPA met with Romeo Angeles, Resident Care Director, and explained the purpose of the visit. and observed the following: Operational Requirements: Infection prevention and control plans have been added to the Plan of Operation. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 01/01/2027. Fire and disaster drills are conducted quarterly, however the last drill was last conducted on 11/26/2025. Special equipment and supplies to meet the residents with special needs were observed. Personnel Records-Training: Five (5) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccination. Administrator Tomoko Hino certificate is pending. Ongoing training is not in personnel files for 3 of 5 staff. Residents Rights-Information: The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. The facility provides internet services to all residents and has access to the facility phone. Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council/Club. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities. Continued on 809C Continued from 809 Resident Records-Incident Reports: A total of seven (7) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information, Physician's Orders, Medical Consent, and Medication Records. Personal Property, and Valuables form was missing from files. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and there is an evacuation chair at the stairwell. fire drill was on 11/26/2025. Sprinkler/Fire Alram system was tested on 06/25/2026 and passed Residents with Special Health Needs: Resident Care Director stated that the facility retains residents with dementia if they are determined to be appropriate for the facility. Deficiency cited. Technical violations issued. Exit interview was held and a copy of the report and appeal rights was provided to Romeo Angeles , Resident Care Director. LPA will return to complete the annual inspection on another day.the state’s words, verbatim · CDSS document, Jul 13, 2026

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

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent complaint visit to this facility. The initial visit was conducted by Licensing Program Analyst (LPA) Luis DeLeon on 01/06/2026. Upon arriving at the facility, LPA met with Resident Care Director Romeo Angeles. Shortly after, Memory Care Director Sweayen Tabayan joined the visit. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to them. The investigation consisted of residents/witness/visitor/staff interviews, physical plant tour and facility records review. LPA obtained residents/staff roster, and staff/ residents’ facility files. The investigation revealed that, in regards of facility is in disrepair, it was alleged that the facility did not have proper emergency exits for residents. All fifteen (15) residents who were interviewed had never used the emergency exits and were not aware of any issue about it. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. (-continued on LIC 9099C-) Substantiated Per the physical plant tour, LPA Tao and Memory Care Director Sweayen Tabayan tested the emergency exits at the memory care unit. There are two emergency exits which were delay egress exits were not operable. Administrator had placed work order to have technician coming out and fixing it tomorrow on 5/27/26. Based on record review, observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator Tomoko Hino. The findings were discussed. A copy of this report and appeal right were provided. Per the fifteen (15) residents who were interviewed, one (1) of them was unable to comprehend the interview questions, three (3) of them declined to be interviewed, one (1) of them was corroborated with the allegation and the rest of ten (10) residents could not corroborate with the allegation. It revealed that residents were not left in soiled diaper overnight. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. Per the interview with witness and visitor, they could not corroborate the allegation which revealed they were not aware of any resident who had sat in soiled diaper overnight. Per observation during the physical plant tour, no foul odors or soiled diapers were observed. Residents seemed clean and neat. No foul odor from residents was noted. Per record review, it revealed staff have a status check / log on residents who need incontinence care at least twice per shift and change residents’ diapers or pull ups throughout the day as needed. In regards of facility staff did not administer resident's medication as prescribed, it was alleged that staff could not provide pain medication to resident during the night shift. Per the fifteen (15) residents who were interviewed, one (1) of them was unable to comprehend the interview questions, three (3) of them declined to be interviewed, and the rest of the eleven (11) residents could not corroborate with the allegation. It revealed that residents were able to get pain medication during the nighttime. Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation. Per the interview with witness and visitor, they could not corroborate the allegation which revealed they were not aware of resident who could not obtain medication at night shift. Per record review, residents’ medication log did not show missing medication. Therefore, there is no preponderance of evidence to prove the staff did not administer resident’s medication as prescribed. Based on the information obtained during the investigation, interviews with staff/residents/witness/visitor, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Tomoko Hino. The findings were discussed and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 26, 2026 · control 28-AS-20251229160056

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 29, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Per physical plant tour of memory care unit (Emil Brown Auditorium), two emergency exits with delay egress located at the entrance and back exit were not operable. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Adminsitrator agreed to repair the emergency exits and work order was placed to hire techincian to repair the emergency exit. Adminsitrator will submit the proof of repair to licensing by the POC due on 5/29/26

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue additional deficiencies. LPA met with the Executive Director – Tomoko Hino, to discuss the purpose of this visit. During the complaint investigation 28-AS-20250521082826, it was discovered that R-1 had multiple falls and/or being found on the floor between September 2024 through April 2025. A total of (11) known incidents occurred, however, the facility provided reports for the falls on 10/9/24 and 4/20/25. Therefore, the facility failed to submit written reports to licensing for all of R-1’s fall related incidents. In addition, during the same complaint investigation, R-1’s bedroom had a video surveillance monitor. During the visit today, staff noted that some residents’ rooms have video surveillance. The Executive Director is unsure if a written waiver was provided to licensing regarding the monitors in the residents’ rooms. Deficiencies are being issued today on the LIC809D. An exit interview was held. A copy of this report along with appeal rights were given to the Executive Director.the state’s words, verbatim · CDSS document, Apr 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 17, 2026

87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency (D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on record reviews, there were no incident reports provided to licensing for R1's related falls which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee shall submit a statement acknowledging this regulation and ensure that future incidents will be reported to licensing. The statement is due to LPA by 4/17/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87209(a)(2) · Plan of correction due date: Apr 17, 2026

87209 Program Flexibility (a) The use of alternate concepts, programs, services, procedures, techniques...(2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee. Based on interview, the facility did not have a waiver regarding the use of video surveillance in the residents' rooms which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: Licensee shall submit a waiver for video surveillance used in the residents' rooms by POC due date 4/17/26.

Allegation investigated: Staff are not following proper reporting requirements

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint visit on 03/02/2026 to deliver findings related to the above allegation. LPA met with Administrator Tomoko Hino and explained the purpose of the visit. The investigation included a review of the client roster, staff roster, R1’s face sheets, and R1’s physician’s report. Additionally, the LPA reviewed Internal Incident Report and Narrative Charting Records regarding R1. The LPA also conducted interviews with four staff members (S1–S4). (continued 9099C) Substantiated Allegation: Staff are not following proper reporting requirements It is alleged that the facility failed to comply with regulatory reporting requirements regarding incidents involving R1. During staff interviews (S1–S4), staff reported the following reporting procedures: Staff are required to report incidents directly to their supervisor and provide factual information regarding incidents that occur during their shifts. Staff complete Narrative Charting and an internal incident report form following an incident. These reports are submitted to the supervisor, who is responsible for submitting an Unusual Incident Report to Community Care Licensing (CCL). During the record review of documents provided by the facility, there were no Unusual Incident Reports on file regarding any incidents involving R1. The facility did provide Narrative Charting summaries dated January 27, 2026 (a.m. shift), in which two staff members documented that R1 may have fallen in her room and that R1 was observed the following day with a bruise to her right eye. An additional internal incident report dated January 28, 2026 (a.m. shift) documented that staff observed R1 with a black eye. Additionally, a Narrative Charting entry dated February 11, 2026, indicated that an altercation occurred between R1 and their roommate, during which R1 was reported to have hit their roommate. No Unusual Incident Reports were present in R1’s file, and the facility did not have records indicating that Unusual Incident Reports were completed for these incidents. Community Care Licensing also does not have records of ever receiving Unusual Incident Reports for either of these incidents. Based on LPA's interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Mar 2, 2026 · control 28-AS-20260225102337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 9, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events. (D) Any incident which threatens the welfare, safety or health of any resident... This requiment is not met as evidenced by: Based on record review and interviews, the facility failed to submit Unusual Incident Reports to CCL for incidents involving R1 as required.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Administrator will submit Unusual Incident Reports involving R1 by POC due date. Administrator will also verify that all future reportable incidents are submitted to CCL within seven (7) days.

Allegation investigated: Staff did not notify resident’s authorized representative of incident involving resident. Staff did not properly clean/wipe resident resulting in an UTI. Staff does not ensure water temperature was appropriate for residents. Staff does not maintain resident’s hygiene.

Licensing Program Analysts (LPAs) Bonnie Tao and Luis De Leon conducted an initial unannounced complaint investigation visit for the allegations listed above. LPAs met with the Administrator Dennis Robeniol and explained the reason for the visit. Investigation consisted of interviews with staff from staff #1 (S1) to staff #8 (S8), residents from residents #1 (R1) to resident #9 (R9), and a visitor (V1). In addition, physical plant and R1’s facility file review were conducted. The investigation reveals the following: In regards of allegation of staff did not notify resident’s authorized representative for an incident involving resident. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted but unable to contact residents. (Report continues on LIC-9099c) Unsubstantiated Eight (8) out nine (9) residents interviewed indicated that there had been no issues in contacting authorized representatives. Per staff interviews, seven (7) out of seven (7) staff were not able to corroborate the allegation. Staff interviews revealed that staff described the procedure to follow in order to notify authorized representative. On document review, facility has provided training to notify authorized representative as required. Therefore, the staff has followed the procedure in the facility training to notify authorized representatives. In regards of allegation of staff did not properly clean/wipe resident resulting in an UTI. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted. Eight (8) out nine (9) residents interviewed indicated that residents have not had any cleaning concerns that may cause an UTI issue. Residents indicated that staff are following residents cleaning and shower schedule twice a week or as per needed. Per staff interviews, all staff were not able to corroborate the allegation. Per document review, R1’s Medication Administrator Record (MAR) does not show any medication treatment for UTI. Staff are provided annual training for UTI care. During physical plant, LPA’s observed staff checking diapers and diaper changes were done. LPAs observed residents are provided drinking water in residents rooms and during their meals. Staff ensure that residents are hydrated. Therefore, there is no preponderance evidence to show that staff did not properly clean assistance and result in UTI. In regards of allegation of staff does not ensure water temperature was appropriate for residents. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted. Eight (8) out nine (9) residents interviewed indicated that there was no issue with water temperature. Per staff interviews, all staff were not able to corroborate the allegation. During physical plant, twelve (12) resident rooms were randomly selected, and the water temperature was measured in the range of 105-120 degrees Fahrenheit. Therefore, the water temperature was found to be within Title 22 regulation and water temperature was appropriate for residents. In regards of allegation of staff does not maintain resident’s hygiene. Per residents' interviews, one (1) out of nine (9) residents interviewed was attempted. Eight (8) out nine (9) residents interviewed indicated that there was no issue with residents’ hygiene. Per staff interviews, all staff were not able to corroborate the allegation. All staff indicated that the facility provides a schedule for shower, laundry, and toileting. (Report continues on LIC-9099c) All staff indicated that the schedule is being followed. On record reviewed, the facility keeps track of hygiene care assistance provided to residents. LPAs observed rooms to be clean, tidy, and free foul odor. Therefore, there is no preponderance evidence to show that staff is not providing hygiene assistance as needed by residents. Based on review of observations, documents and interviews conducted, the preponderance of evidence standard has not been met, therefore the above allegations are found to be UNSUBSTANTIATED. Exit interview was held with Administrator Dennis Robeniol. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 28-AS-20260115123528

Allegation investigated: Staff did not seek timely medical care for resident resulting in injury.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent complaint visit to investigate the above allegations. LPA met with Alfonso Lozoya (Business Office Manager) and discussed the purpose of today's visit. Dennis Robeniol/Executive Director arrived at approximately 9:15 A.M.. LPA conducted an initial visit on 05/22/25. During this visit, LPA conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA reviewed Resident #1’s (R-1) file and obtained relevant documentation. Additionally, LPA obtained a copy of the staff schedule (including contact information) and resident roster. LPA also interviewed the Executive Director and Staff #1 (S-1) through Staff #3 (S-3). Refer to LIC 9099C for the contination of this report. Substantiated During the course of this investigation, Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) conducted staff and resident interviews (R-1 through R-3) and obtained medical records. All interviewed residents are residing in the Transitional Memory Care (TCM) (where allegation allegedly occurred) and the census for the memory care unit is (36). LPA was unable to interview additional residents from this unit (LPA attempted to interview R-4 through R-6). Both, IB Investigator and LPA attempted to interview staff #6 (S-6) and were unsuccessful. Allegation: Staff did not seek timely medical care for resident resulting in injury. Per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, the in-room camera video for 04/20/2025, R-1 was seen falling and could be heard complaining of pain in R-1’s right leg. Caregivers were observed picking R-1 up from the floor and placing R-1 in R-1’s wheelchair, then R-1’s bed. R-1 was visibly and verbally complaining of pain throughout the process and expressed R-1’s right leg and hip area hurt. Per S-4, S-4 did not call 911 immediately because S-4 did not know if R-1 “fell” or “slid” and S-4 wanted to obtain further information prior to calling 911. Per S-1, 911 should have been called immediately. R-1 was later transported to the hospital where R-1 was diagnosed with a fractured right hip. Staff interviews and medical records corroborate this allegation. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiency cited under LIC 9099D. Due to the seriousness of R-1’s injury, an immediate Civil Penalty of $1,000.00 is being issued during today’s visit. An exit interview was conducted. A copy of this report and appeals rights were provided to Dennis Robeniol. During the course of this investigation, Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) conducted staff and resident interviews (R-1 through R-3) and obtained medical records. All interviewed residents are residing in the Transitional Memory Care (TCM) (where allegation allegedly occurred) and the census for the memory care unit is (36). LPA was unable to interview additional residents from this unit (LPA attempted to interview R-4 through R-6). Both, IB Investigator and LPA attempted to interview staff #6 (S-6) and were unsuccessful. Allegation: Due to lack of supervision, resident was left on the floor for extended periods of time after falls. Per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, it was alleged that on 10/04/2024, R-1 fell and was not discovered for (4) hours. Videos from R-1 in-room camera do not depict any dates or times as well as screenshots of the videos which do depict dates and times. Per the screenshots provided for 10/04/2024, R-1 is seen sitting on the couch in R-1’s room at 0153 hours and staff in R-1’s room at 0605 hours. Per the video, R-1 is seen lowering self to the floor from R-1s bed and attending to a blanket which R-1 placed on the floor. There is no video or screenshot of the time R-1 fell. The facility was unable to provide documentation regarding the time R-1 fell but documentation showed staff found R-1 in R-1’s bathroom at 0540 hours. Regarding R-1’s subsequent falls, documentation provided showed R-1 was discovered within a matter of seconds, minutes, and up to approximately one hour. Per staff interviewed, residents are checked on every (2) hours per shift. R-1 was unable to provide a meaningful statement. Staff interviews and video footage/screenshots do not corroborate this allegation. Allegation: Staff do not ensure resident's walker is within reach. Per staff interviews, R-1 had a walker and wheelchair but could walk independently. Staff interviews revealed that R-1’s would move R-1’s walker away from R-1’s bed. Interviewed staff indicated that R-1 did not always use R-1’s walker, remembered to use the walker or refused to use the walker. Interviewed staff indicated that they would remind R-1 to use R-1’s walker. Interviewed staff indicated that they did not have a log of when R-1 refused to use the walker. Staff interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff did not respond to resident’s alarm mat timely. Per staff interviews, R-1 had a mat alarm next to R-1’s bed on the floor. Interviewed staff indicated that when R-1 stepped on the mat, an alarm would ring on a mat monitor (alert box) which was located in the dining room where there is always staff present. Per staff interviews, the alarm was loud and required staff to manually turn it off when it activated. Interviewed staff indicated that when R-1’s mat alarm would activate, staff would check on R-1 following the alarm notification. Interviewed staff indicated that they did not have a log of when R-1’s mat alarm would activate nor any kind of tracking on the mat monitor (alert box). Staff interviews do not corroborate this allegation. Allegation: Staff did not follow residents fall plan. Per staff interviews, R-1 did not have fall plan in place. Interviewed staff indicated that they conducted rounds “every 2 hours” and encouraged R-1 to use R-1’s walker which R-1 often refused to use or would forget to use it. Interviewed staff indicated that they did not have a log of the rounds that were conducted for R-1. R-1 file did not contain a fall plan in place. Interviews and lack of documentation pertaining to a fall plan do not corroborate this allegation. Allegation: Staff do not ensure residents oral hygiene needs are met. Per staff interviews, staff assisted R-1 with R-1’s oral hygiene. Interviewed staff indicated that at times, R-1 refused oral hygiene and would become physically aggressive with staff when attempting to assist R-1 with oral hygiene. Interviewed staff indicated that when R-1 cooperated with R-1’s oral hygiene (denture placement), staff would ensure that R-1’s dentures had polygrip. Interviewed staff indicated that they did not have a log of when R-1 refused to allow staff assist with oral hygiene. Staff interviews do not corroborate this allegation. Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted. A copy of this report and appeals rights were provided to Dennis Robeniol.the state’s words, verbatim · CDSS document, Jan 6, 2026 · control 28-AS-20250521082826

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 7, 2026

(a) PERSONNEL REQUIREMENTS. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This standard is not met as evidence by: Staff did not seek timely medical care for R-1 after R-1 fell which resulted in a fractured right hip. Civil penalty issued.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Administrator to provide an in-service training to staff and discuss the importance of seeking timely medical care for residents. Administrator to develop and implement a policy pertaining to fall protocol (when 911 will be called) and submit proof of training and and a copy of the policy to LPA Irra by POC due date. Administrator to provide a copy of the sign-in sheet with staff signatures, date and time and curriculum used for this training to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elizabeth Irra conducted a Case Management visit. LPA met Dennis Robeniol/Executive Director and discussed the purpose of this visit. During the course of a complaint investigation, (allegation: staff did not follow residents fall plan.), per Christine Ferris (Department of Social Services Community Care Licensing Investigation Branch) investigation, it was discovered that R-1 sustained multiple falls. During R-1’s residency from 06/22/2024 to 04/25/2025, there are at least (11) known incidents of R-1 falling and/or being found on the floor. Per S-1, the incidents did not require a reassessment as R-1 continued to have the ability to walk though R-1 fell or was found on the floor often. No fall precautions were implemented by the facility other than to check on R-1 every (2) hours and no additional accommodations were made available to R-1. Deficiency cited. Refer to LIC 809D. Exit interview and a copy of this report and appeals rights were provided to Dennis Robeniol.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 9, 2026

Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This standard is not met as evidenced by: R-1 had at least (11) known fall incidents and staff did not have R-1 reassessed.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: Administrator to review this regulation and provide a written statement as to how Administrator will comply with this requirement and submit this to LPA Irra by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPAs) Elena Mallet and Luis De Leon conducted a continuation annual required visit. LPA met with Director Dennis Robeniol and the purpose of the visit was discussed. The facility is licensed to serve elderly residents age 60 and above. It is approved for 136 non-ambulatory residents and 47 bedridden residents, approved for 10 hospice waivers. REVIEW OF FILES Resident record review consisted of Admission Agreements, Physicians Report, Needs and Service Plan, Personal Rights, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, and Background Clearance. Deficiencies were noted for resident’s for missing updated Needs and Service Plan for R4, TB results missing for R1 and R2, and ambulatory status for R5. Staff records were missing health screening for S1-S5, annual training missing for S2-S4, and first aid certificate missing for S2-S4. Deficiencies were noted on 809D pages. Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for residents. Wall and floors are in good repair. Hallways were clean and free of obstructions. Report continues on page 809C... Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. LPA observed list of residents with modified diets to be available to kitchen staff. LPA observed all food to be stored properly Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. POC was cleared for previously cited hot water deficiency. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents. Combo Smoke and carbon monoxide detectors were observed and tested on all rooms. Two (2) fire extinguishers were observed on each floor and were fully charged with the last inspection date on 9/23/2024. There has not been a fire/earthquake/emergency drill conducted since 12/19/2023. A deficiency was noted on page 809D. Front outdoor grounds provide seating and shade and are free from debris and obstructions. The facility offers residents various activities throughout the week. Residents were observed actively engaged on various activities. The medications are centrally stored and locked in the MedTech room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all five (5) residents. LPA conducted interviews with five staff and five residents. LPA reviewed Disaster Emergency Plan and noted deficiency because it calls for the use of inoperable emergency backup generator. The licensee needs to update plan to include instruction for alternate power in the event of power outage. Deficiency noted on page 809D. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D page. Reports LIC 809, LIC 809D and Appeal Rights were discussed and provided to Director Dennis Robeniol.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Elena Mallet and Luis De Leon conducted an unannounced Required- 1 year visit. LPA met with Director Dennis Robeniol and the purpose of the visit was discussed. The facility is licensed to serve elderly residents age 60 and above. It is approved for 136 non-ambulatory residents and 47 bedridden residents, approved for 10 hospice waivers. LPAs were only able to work on physical plant tour. The facility consists of three separate buildings: The retirement building is a 5-story building that consists of 127 units each with private restroom, lobby area, administrative offices, public restrooms, library, TV Room, Activity room, laundry room, Health & Wellness room. The first floor is made up of memory care residents with early symptoms of memory impairment. LPAs inspected rooms: 113, 216, 404, 424, and 521. LPA observed that on the south stairwell an evacuation chair was available while the north stairwell did not have an evacuation chair available on any floor. In room 521 the hot water temperature was measured at 121.5 degrees Fahrenheit which did not meet Title 22 regulation. Additionally, LPA tested the call signal from resident’s pendant and caregiver arrived 7 minutes later. Deficiencies were noted for hot water above Title 22 regulation and evacuation chair missing from stairwell. Report continues on page 809C... The south building consists of a commercial kitchen and dining room for Assisted Living Residents. A secured wing housing the Memory Care which consists of 13 rooms, 5 restrooms, gated courtyard, activity room/dining room, lobby, laundry room, medication room and administrative office. On memory care floor, the hot water temperature was measured at 122.0 degrees Fahrenheit in the shower room next to reception desk and 123 degrees in residents’ dining/activity room which did not meet Title 22 regulation. LPAs tested the call signal on rooms 1003 and 1015 and there was no response from the caregiver. LPAs inspected rooms: 1003, 1010, and 1015. Deficiencies were noted for both the call signal and hot water above title 22 regulation. Activity Hall that consists of an auditorium, activity room and area for storage. Residents are allowed access to Activity Hall for planned activities and staff supervision is provided at all times. Due to time constraints, LPA will return at a later date to complete all (12) CARE Tool domains. Exit interview conducted with Director Dennis Robeniol and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: POC

Licensing Program Analyst, (LPA), Mayra Cota, conducted a Plan of Correction (POC) visit today. LPA met with Dennis Robeniol, Executive Director and explained the reason for the visit. During today's visit, LPA toured the facility, conducted temperature measurements for (12) resident bathrooms, and conducted interviews with Residents 1 - 12 (R1-R12) and Staff 1 - Staff 2 (S1-S2). Also during today’s visit, a citation was cleared for deficiency CCR Section 87303(e)(2) which was issued on 5/29/2025. The deficiency was cleared by means of obtaining repairs for water heater proposal and temperature log from Licensee. Interviews conducted during today's visit with S1 and S2 indicated, repairs to water heater in the assisted living building of the facility were completed on 6/4/25. No deficiencies cited during today's visit. Exit interview conducted with Dennis Robeniol, Executive Director and a copy of this report and Letter of Deficiency Citations Cleared were provided during time of visit.the state’s words, verbatim · CDSS document, Jun 6, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management visit today. LPA met with Dennis Robeniol, Executive Director and explained the reason for today's visit. During today's visit, the following was discussed with Executive Director: A previous licensing report was issued on 12/9/2024 giving notice of violations of CCR Section 87303(e)(2) due to water temperature. On 5/29/25, a repeat violation of CCR Section 87303(e)(2) was issued due to water temperature. Because a citation was issued for repeating the same violation within 12 months, an immediate civil penalty of $250 is hereby assessed. Exit interview conducted with Dennis Robeniol, Executive Director and a copy of this report, Appeal Rights, and LIC421FC (CIVIL PENALTY ASSESSMENT – FAILURE TO CORRECT AND REPEAT VIOLATIONS) was provided during time of visit.the state’s words, verbatim · CDSS document, Jun 6, 2025

Allegation investigated: Staff did not ensure hot water was available at the facility for residents in care.

Licensing Program Analyst (LPA), Mayra Cota, conducted an initial unannounced complaint visit to investigate the above allegation. LPA met with Dennis Robeniol, Executive Director and explained the reason for the visit. The investigation consisted of the following: LPA, Cota, obtained copies of client and staff rosters, toured common areas of the facility, inspected 14 resident rooms/bathrooms and interviewed Resident 1 - Resident 9 (R1-R9) and Staff 1 - Staff 5. ***Continues on LIC 9099C Substantiated Regarding: Staff did not ensure hot water was available at the facility for residents in care. It is alleged, the victim hasn't had hot water for the past 4 days and therefore, wants to return back home. The investigation revealed the following: Water temperature measured by LPA revealed to be between 89.6 - 91.7 degrees F in 10 out of 14 resident bathrooms inspected, which is below the compliance range of 105 - 120 degrees F. S1-S3 corroborate the allegation. Interviews with S1-S3 indicated, water temperature is inconsistent and they are aware water is not delivered at an adequate temperature especially in the morning. S1-S3 stated, residents have complained regarding the water not being hot enough. Interviews with S4-S5 indicated, residents have complained to them regarding water not being delivered hot by their restroom's tap for several days. R1-R9 also corroborate the allegation. Interviews with R1-R9. indicated, their bathroom sinks do not deliver hot water which interferes with their showers and other personal hygiene routines. R1-R9 stated, they have brought it to the attention of staff, however, the issue persists. LPA, substantiated the allegation above based on the evidence obtained during this investigation. A finding of substantiated means the allegation is valid because the evidence meets the preponderance of the evidence standard. LPA cited the deficiency below per California Code of Regulations (CCR) Title 22. ***See LIC 9099-D An exit interview was conducted with Dennis Robeniol, Executive Director. A hard copy of the report and Appeal Rights were provided at the time of visit.the state’s words, verbatim · CDSS document, May 29, 2025 · control 28-AS-20250522082132

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: May 30, 2025

87303 Maintenance and Operation (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 degree C) and not more than 120 degree F (49 degree C). The licensee did not comply with the section cited above as water temperature in 10 resident's bathrooms measured at 89.9 and 91.7, which poses an immediate health, safety or personal righs risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee will send LPA, work order from vendor with ET of repair by due date. Licensee will monitor water temperature for three days in the morming and the evening and ensure water is within Title 22 regulation. Licensee will send water temperature log by June 2, 2025.

Allegation investigated: Staff did not ensure the facility generators were not in disrepair

Licensing Program Analyst (LPA) Glenn Trueman conducted a complaint investigation regarding the allegation above. LPA arrived unannounced and met with Executive Director Dennis Robeniol. The purpose for the visit was explained. LPA obtained a copy of the staff and resident roster. LPA interviewed Executive Director Dennis Robeniol and Staff S1. LPA and Staff S1 toured the exterior of the facility where the generators for the facility are located. In regards to the allegation Staff did not ensure the facility generators were not in disrepair, based on interviews conducted, tour conducted and information gathered it was revealed by the Executive Director that the generators have been non-operable for at least a year. Stated that the copper wires connected to the generators were stolen by individuals from outside the facility. Said the blackout was about 2 hours in the facility. Interview with Staff S1 who stated that all the wiring was stolen and that the generators have been non-operable for 1 year. Substantiated Said he believed the homeless took all the copper and the wiring. Stated that the blackout was the 1st time that it happened and lasted 2 hours and that residents were in dining room where there was good lighting. Tour of the exterior of the facility where the generators are located LPA observed wires cut that lead to the motor and to the breakers which made it non-operable. Based on LPA’s observations, tour and interviews conducted, the preponderance of evidence standard has been met, therefore, the allegation has been determined to be SUBSTANTIATED. Deficiency cited on LIC 9909-D. Exit interview was conducted with Executive Director.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 28-AS-20250228153319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 17, 2025

Maintenance and Operations The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interviews conducted, tour conducted and information gathered the facility was not kept in good repair with generator non-operable which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee/ Administrator will submit by POC due date the vendor who will repair the generator and also the date for when it will be completed and submit proof to LPA when it has been repaired.

Allegation investigated: Staff did not meet resident’s needs.

Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA met with Dennis Robeniol, Execitive Director and discussed the purpose of the visit. The investigation consisted of the following: LPA toured the facility, reviewed file and records of Resident #1 (R1) and obtained copies of the following documents: Face Sheet, Needs and Service Plan, Resident Assessment, Admissions Agreement, Physician’s Report, Medication Administration Record (MAR) for November 2024, Admission Orders (medication), photo of purchase receipt for glucometer and test strips, Physician Orders for Life-Sustaining Treatment (POLST), Unusual Incident Report (11/14/24) and Admission Record and Order Summary Report from convalescent hospital. Staff also provided staff and resident rosters. LPA conducted interviews with residents 1-9 (R1-R9), staff 1-4 (S1-S4), and convalescent hospital staff (CS). ***Continues on LIC 9909-C Substantiated Allegation: Staff did not meet resident’s needs. Regarding allegation, “Staff did not meet resident’s needs,” it is alleged, staff did not provide resident with insulin and diabetic supplies to check sugar. During the investigation, interview with R1 indicates, facility staff did not have their insulin after being transferred from convalescent hospital. R1 reported to staff they were feeling sick and was transported to hospital via ambulance. Review of Special Incident Report dated 11/14/2024, indicates, R1 was assessed by paramedics with Hypoglycemia being high, at 561. Interviews with S1 indicate, facility received the insulin, however, it was not administered. Interview with S2 also confirms, R1 did not receive insulin dose at the facility. Additionally, interviews with DS indicate, R1 was transferred to facility from convalescent home with all their medication, including their insulin. Review of medication inventory lists from facility and convalescent hospital further indicate insulin was included in the medication R1 took to the facility during their transfer from convalescent hospital. Based on LPA’s observations, file and record reviews, and interviews conducted, the preponderance of evidence standard has been met, therefore, the allegation has been determined to be SUBSTANTIATED. Deficiency cited on LIC 9909-D. Exit interview was conducted with Dennis Robeniol. A copy of the report and Appeal Rights were provided. It is alleged, staff declined to listen to resident and only listened when they asked staff to call the ambulance when they did not feel well. During the investigation, eight out of nine residents interviewed stated, staff are helpful, and they meet their needs in a timely manner. Residents stated staff are nice and they have not experienced any problems during their time at the facility. Staff interviewed stated, staff ensure care and supervision of residents is met by conducting scheduled status checks. There is Life Alert necklace system in place for all residents to ensure they have a way to communicate with staff at any time. During tour of the facility, LPA observed multiple staff providing care and supervision to residents in their rooms and during daily activities throughout the facility. Based on LPA observation, file and record review, and interviews conducted, the allegation listed above could not be corroborated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview conducted with Dennis Robeniol, Executive Director. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 28-AS-20241118081448

From the deficiency page — Deficiency type: Type A · Section cited: CCR 876289(b)(1) · Plan of correction due date: Feb 14, 2025

Diabetes 87628(b)(1): (b) In addition to Section 87611, General Requirements by Allowable Health Conditions, the licensee shall ... : (1) Assisting residents with self-administered medication as specified in Section 87465, Incidental Medical ... Services. This requirement is not met as evidenced by: Based on observation, file and record review, and interviews conducted, Licensee did not provide resident with insulin and diabetic supplies which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Licensee will email LPA proof of scheduled training with staff which will address policies and procedures regarding new admissions to the facility. Upon completing training, licensee will also send LPA training agenda and attendance rosters.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs), Mayra Cota and Blanca Gonzalez, conducted an unannounced case management visit due to deficiencies noted during a complaint visit conducted on 11/26/24. LPA met with Dennis Robeniol, Executive Director and explained reason for the visit. During complaint investigation, LPA Cota reviewed Medication Administration Record (MAR) logs for Resident 1 (R1) and Resident 2 (R2). LPA Cota noted, R2's MAR logs for September, October and November 2024 were incomplete. MAR logs reviewed were missing multiple initials. The MAR logs were missing initials for medication required to be administered daily, once or several times a day. Deficiency cited on LIC-809D per Title 22 Regulations. Exit interview conducted with Dennis Robeniol, Executive Director and a copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 13, 2025

Resident Records 87506(a) Licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility ... readily available to facility staff and to licensing ... This requirement is not met as evidenced by: Based on file and record review of R2's MAR logs were incomplete. MAR logs were missing multiple initials for medication required to be administered daily, once or several times a day, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Director will provide in-service training with staff pertaining to medication administration and proper documentation. Director will review job duties with med-techs and their supervisory staff and provide proof of training and attendance roster to LPA via email by POC due date.

Allegation investigated: Staff are not following proper infection control protocols with residents in care. Licensee is not ensuring that the facility is kept free from bed bugs. Facility is in disrepair. Licensee does not ensure facility serves food of good quality and quantity to residents in care. Facility is not adhering to resident(s)' Admission Agreement.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Jina Malekarkissians and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 12/09/2024, LPA interviewed Staff #1- Staff #4, Residents #1 -Residents #5, and toured the facility, LPA obtained copies of the following documents: personnel report LIC 500, resident roster, invoice for pest control, invoices for food purchased, food menu, and physicians reports along with narrative report for three (3) residents. During todays visit LPA Gutierrez interviewed Residents #6- Residents #9, and Staff #5- Staff #6 and obtained copies of elevator maintenance repair receipts, and room change letters. SEE LIC 9099C Unsubstantiated In regard to the allegation” Staff are not following proper infection control protocols with residents in care”, it is alleged that residents are having stomach problems resulting in massive diarrhea problems. During interviews with residents all nine (9) stated they had contracted the stomach vires although some residents stated they did hear it was going around. During interviews with staff, it was reported that the 3rd floor did have a stomach bug going around and that signs were posted and that PPE supplies were being used. All staff stated they were following Infection Control protocol. In regard to the allegation “Licensee is not ensuring that the facility is kept free from bed bugs”, it is alleged that the 3rd floor has bed bugs. During interviews with residents seven (7) out of the nine (9) stated they have not heard of any problems of bed bugs at the facility. R4 stated that they only heard about it but had no problems. During interviews with staff, it was discovered that a resident on the 3rd floor did bring in bed bugs but they facility had Ecolab come in and spay. Administrator stated that it was a is isolated incident and that it did not spread to any other rooms. In regard to the allegation “Facility is in disrepair”, it is alleged that elevators are non-functioning at certain times, no hot water, or heaters in multiple rooms. During interviews with residents seven (7) out of nine (9) residents stated there are problems with the elevators at times. All nine (9) residents stated there is hot water and working heaters in their bedrooms. During interviews with staff all stated that elevators are old, but they always have at least one elevator working. Administrator stated anytime an elevator does not work they call for repair. LPA was provided monthly maintenance receipts along with repair orders. In regard to the allegation “Licensee does not ensure facility serves food of good quality and quantity to residents in care”, it is alleged that food is always the same and that the portions are small. During interviews with residents seven (7) out of nine (9) stated there was enough food and their offered a different variety. R8 stated they try to cook Japanese food, but it could be better and that they could always ask for seconds if they are still hungry. During interview with staff five (5) out of the six (6) stated there is enough food and a variety of it. S6 stated they go by the recommended serving amount, but residents can always ask for more if they are still hungry. SEE LIC 9099C In regard to the allegation “Facility is not adhering to resident(s)' Admission Agreement”, it is alleged that residents were moved from 1st floor to another room and rent prices increased. During interviews with residents eight (8) out of nine (9) residents stated they had not moved rooms. R7 stated they did move from 1st floor to 4th floor, but price did not change. During interviews with staff, it was discovered that 1st floor was under remodeling and 1st floor would be adding additional memory care rooms. LPA was provided with letters that were sent to eight (8) residents and family explaining the move with no additional charges. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Administrator Jina Maleksarkissians.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 28-AS-20241204135046

Allegation investigated: Resident was sexually abused while in care

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit to investigate the above allegation. LPA met with Tomoko Hino, Marketing Director and Alejandro Lozoya, Business Office Manager and explained the purpose of today’s visit. LPA spoke with Jina Maleksarkissian, Executive Director on the phone and discussed the purpose of the visit. On 12/24/2024, LPA Cota conducted the initial 10-day complaint visit and obtained relevant documentation. During today's visit, LPA Pena obtained staff & resident rosters, Facility's Abuse Neglect and Exploitation Policy, Resident #1 (R1) files such as: Identification and Emergency Information (Face sheet), Pre Admission Application, Resident Assessment, Admission Agreement, Physician's report, Kaiser Hospital Discharge record (12/24/2024), Medication Administration Record (MAR) for Nov. 2024-Jan. 2025 and Incident Report (12/22/2024). LPA interviewed Staff #1 (S1)-Staff #5 (S5) and Resident #1 (R1)-Resident #12 (R12). LPA requested copies of R1's LA USC Hospital Discharge Record and latest staff training log for Zero Tolerance Policy and Mandated Reporting.******CONTINUED ON LIC 9099C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Resident was sexually abused while in care." It is alleged that a resident with dementia is potentially being sexually abused while in care due to being tested positive for HIV. Interviewed staff denied the allegation and indicated they have not witnessed nor received any complaints in regards to residents being sexually abused while in care. S1-S3 stated that R1 was taken to the hospital emergency room for an evaluation related to R1's unwitnessed fall. During the evaluation, LA USC hospital conducted various tests which included HIV and was tested positive. However, additional tests/retests were performed when R1 was moved to Kaiser hospital, and R1 tested negative for HIV and STDs. R1 was subsequently discharged from Kaiser hospital after a few days. S1 and F1 indicated that LA USC hospital made a mistake in giving them R1's HIV positive result. Interviewed staff indicated there are only female staff in Assisted Living who provide care and supervision for all the female residents. Interviews conducted with F1 and W1 indicated no additional concerns after R1 tested HIV negative. R1 stated that she feels safe in the community and denied being sexually abused. Interviewed residents indicated female staff provide them with assistance, especially bathing/showering. 12 out of 12 residents interviewed indicated they have not witnessed any type of sexual abuse nor have been inappropriately touched by staff. Interviewed residents stated that they have not heard any complaints related to this allegation and feel safe in the facility. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the 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 and a copy of this report was provided to the Business Office Manager, Alfonso Lozoya.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 28-AS-20241223145347

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit in order to tour the physical plant of the facility. LPA met with Tomoko Hino, Sales Director for the facility, and explained the purpose of the visit. During today's visit, LPA interviewed Staff #1 and 2 (S1 and S2), and toured the main building of the campus, the activity hall, the memory care unit, the dining hall and kitchen, along with the perimeter of the building. During the tour LPA observed that the former Intermediate Care Facility (ICF) building, which still remains on the facility campus, has been painted over in white in recent months to cover graffiti that was on the building. Additionally, the back entrances of the ICF building which border the Santa Ana 101 freeway have been welded shut as well to prevent trespassers from entering the building. During a tour of the facility the main building of the facility along with the activity room, memory care unit, dining hall, and the campus grounds were all observed to be clean and in good repair. LPA also observed that additional reinforced fencing has been installed along the Santa Ana 101 freeway as well in recent months, and has barbed wire encircling the top of the new fence. Pictures were taken of several areas of the campus grounds including the new perimeter fencing for the facility. No deficiencies observed during today's visit. Exit interview help and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christian Gutierrez generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-20241204135046 pertaining to observations made during the physical plant inspection. The purpose of the report was explained to Business Office manager Alfonso Lozoya. At 10:55 AM, during the tour of physical plant inspection LPA Gutierrez checked water temperature in rooms and observed room #137 water temperature at 133.4F, room# 212 water temperature at 134F and room# 206 water temperature at 132.3F not in between the required range of 105-120 degrees F. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted, and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Dec 10, 2024

87303 Maintenance and Operation (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 degree C) and not more than 120 degree F (49 degree C). Based on Observations three (3) out of four (4) bathrooms hot water did not measure between the required range of 105-120 degree.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: Business manager will adjust water temperture and send LPA pictures as proof. Facility will create water log and check water for one week and send log to LPA.

Allegation investigated: Licensee does not ensure that residents are provided with a comfortable environment while in care. Facility is in disrepair.

During today's visit, Licensing Program Analyst (LPA) Nune Margaryan conducted an initial complaint visit to investigate the allegations listed above. LPA met with Tomoko Hino, Marketing Director. Administrator Jina Malesarkissians arrived shortly thereafter. The inspection consisted of the following: LPA conducted a tour of facility including kitchen, dining room, common areas. LPA obtained staff and resident rosters, a copy of documents pertaining to this complaint, interviewed Administrator, Staff 1 - Staff 3 (S1 - S3) and Resident 1 - Resident 12 (R1 - R12). Continue 9099C Substantiated Allegation: Licensee does not ensure that residents are provided with a comfortable environment while in care. It was alleged that the residents cannot eat comfortably because facility had failed to provide adequate air conditioning and the residents are suffering tremendous heat in the dining room. LPA interviewed 12 residents and 10 out of 12 residents reported the air conditioner in the dining room was not working and the temperature was very high in the dining room. Interviewed residents stated that there are 2 portable A/C units were installed in the dining room couple of days ago but was not enough to maintain a comfortable temperature. Interviewed Administrator and staff admitted that dining room was very hot when it was extreme hot a week ago. Interviewed Administrator stated that the dining room temperature was suitable and comfortable up until recent heat wave on 09/05/24. To which they coordinated the portable AC units to be installed. Also stated more AC units will be installed in the dining room. Interviewed S2 stated that 4 AC units were provided, which had no effect in the kitchen and dining room. Allegation: Facility is in disrepair. It was alleged that the air conditioner in the dining room has not been working for the past 6 months. During visit, LPA toured the physical plant along with S1 and observed that the AC unit is missing from the cage in the back of facility. Interviewed Administrator and staff stated that about 6 mounts ago AC unit was stolen. Interviewed Administrator stated that facility was faced with theft due to trespassers who vandalized the building. Administrator stated that they communicated with the home office and construction team to look for alternative measures such as adding wrought iron gates to the back end of the property as well to better secure. The AC unit to be manufactured and once in placed they need to cage it off with the wrought iron to prevent future damage and theft. However A/C unit was stolen about 6 mouths ago and until today was not replaced / restored Based on interviews conducted and observations, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC9099D. An exit interview was conducted with Administrator and the copy of this report and appeal right were provided.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 28-AS-20240905151659

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87303(b) · Plan of correction due date: Sep 19, 2024

Maintenance and Operation. (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by: Based on observation and interviews, the Licensee / Administrator did not comply with the section cited above. Dining room temperature was extreme hot a week ago, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: Licensee / Administrator will ensure that comfortable temperature/ environment will maintained for residents and agreed to purchase additional portable AC units to place in the dining room. Proof will be submitted to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Sep 30, 2024

Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on observation and interview, the Licensee / Administrator did not comply with the section cited above. A/C unit was stolen about 6 mouths ago and until today was not replaced / restoredthe state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: Licensee / Administrator confirm that AC unit will be purchased and proof of purchase will be submitted to CCL / LPA by POC due date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff Janice Shimozawa and the purpose of the visit was discussed. Administrator Jina Maleksarkissian arrived shortly after. LPA completed the following domains: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. LPA observed and reviewed the infection control plan 2. Physical Plant/Environmental Safety: LPA toured the facility inside and out to ensure there are no health and safety hazards. The facility consists of three separate buildings: Retirement building is a 5 story building that consists of 127 units each with private restroom, lobby area, administrative offices, public restrooms, library, TV Room, Activity room, laundry room, Health & Wellness room, commercial kitchen and dining room. Memory Care Wing consists of 13 rooms, 5 restrooms, gated courtyard, activity room/ dining room, lobby, laundry room, medication room and administrative office. Activity Hall that consists of an auditorium, activity room and area for storage. LPA inspected rooms #111, #113, #1007, #1001, #1003, #1002, #523, #415, and #207 they all have required grab bar and non-skid mat in the bathrooms. Each residents' bathrooms are clean, sanitary and in a operable condition. LPA tested hot water temperatures and they were between 105 and 120 degrees F. which are within Title 22 regulation. LPA also inspected the smoke detectors and carbon monoxide detectors and they are all working well. Facility also has a fire panel inspected regularly. Each residents room have the required furniture, bedding and sufficient lighting and closet space. The facility have a telephone services in the premises. 3.Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility does have a Dementia Care Plan. A hospice waiver is approved for (10) residents. A fire clearance for (183) capacity of which (136) may be non-ambulatory and (43) bedridden . Liability Insurance reviewed and matches Licensing requirements. Continued on LIC 809-C 4. Staffing: completed initial visit 5. Personnel Record/Training's : The Administrator is Administrator Jina Maleksarkissian and her administrator certificate is currently pending review for renewal. All the facility staff have criminal background clearance and associated with the facility and the required training. Nine (9) staff files were reviewed. 6. Residents Records-Incident Reports: A total of ten (10) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. 7. Residents Right-Information: RCFE complaint poster and Personal rights were observed and its posted near the entrance and reception area. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is available and the facility has a full time activity director in place. 9. Food Services: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on residents' file. LPA observed list of residents with modified diets to be available to kitchen staff. LPA observed all food to be stored properly. 10. Incidental Medical and Dental Services: Ten (10) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. 11. Disaster Preparedness: The facility has a Emergency and Disaster Plan created by the facility. The facility also has two alternative temporary shelter locations listed. Technical Violation will be provided due to further information needed on the emergency disaster plan. 12. Resident with Special Health Needs: Five (5) residents are receiving home health services. There are no residents receiving hospice care. No postural support residents currently reside in the facility. No half bed or full bed rails were observed in resident rooms. Individual Service Plans and Appraisals are on File. No residents have prohibited health condition. No deficiencies were observed during the annual inspection. Exit Interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 28, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Jina Maleksarkissian and the purpose of the visit was discussed. LPA was only able to work on the following domains: Staffing: The facility has sufficient staffing in the facility to provide care and supervision to residents. All staff are over 18 years old. LPA observed there to be NOC shift staff available every day. Facility signal system is operational. Personnel Record/Training's : Nine (9) staff files were reviewed. Proof of staff training, health clearance, food handling certificates, and staff First Aid /CPR certificates were observed. LPA to continue domain at a later date. Due to time constraints, LPA will return at a later date to complete all (12) CARE Tool domains. Exit interview conducted with Administrator Jina and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 25, 2024

Allegation investigated: Staff are not providing adequate supervision to residents. Staff yell at residents. Staff do not treat residents with respect. Staff did not safeguard residents' personal belongings. Staff are not properly dispensing medication as prescribed.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was explained to new Executive Director Jina Maleksarkissians. The investigation consisted of the following: On11/28/23, 2/8/24, and 5/9/24 LPA visited the facility to investigate complaint allegations. On 2/8/24, findings were delivered on 4 allegations. Each visit consisted of physical plant observations, records review, and interviews. Resident file documents were requested and obtained, which included [Medication Administration Records [MARs Sep. 2023- Nov. 2023], Appraisals, Physician's Reports, incident reports] and other relevant documents. Copies of the Neurocognitive Disorder Care Plan of of Operation, Designation of Facility Responsibility, Administrator Certificate, LIC 500 Personnel Report, and resident rosters were obtained. During the course of the investigation, pictures and video evidence was obtained. ***Narrative summary continues next page. Substantiated Allegation: Staff did not safeguard residents' personal belongings. The complaint alleges that staff are instructed to wash resident's clothing and bedding linens together and as a result many of the resident's clothing/personal items are misplaced and/or lost because staff are washing all Memory Care resident's linens together in order to save time. During the course of the investigation, LPA interviewed staff, and family members and information gathered revealed that facility staff ask resident's family members to label the resident's clothing items with permanent marker or a customized name tag label. Family stated that they have noticed their loved one sometimes wearing other resident's clothing, but stated that for the most part the belongings kept at the facility do not have major value. Staff stated the clothing is washed during the NOC shift on days residents are showered. Staff acknowledged that sometimes the resident's clothing is misplaced or lost because the NOC shift staff do not place the belongings in the right resident room, and that the resident's clothing is all washed together. In November 2023, the Memory Care Unit's dryer was not working and staff had to walk to the outside laundry building. Staff stated that due to current laundry assignment protocols the resident's belongings do get mixed up. Staff also reported that some ambulatory residents take other resident's clothing and/ belongings due to cognitive impairment. Allegation: Staff are not properly dispensing medication as prescribed. It is alleged that the Memory Care Director instructed med-tech staff not to follow physician's orders and dispense extra dosages by increasing the frequency of behavioral medications for at least three (3) residents. Information revealed that resident (R3) had a physician order for Quatiapine "Seroquel" twice a day [8 AM & 8 PM], but the medication was being given 3 times a day as a routine medication per Memory Care Director's instruction, in order to immediately control the resident's behaviors instead of utilizing redirection techniques. The Memory Care Director denied the allegation, and stated that R3 had a previous physician order that was supposed to be dispensed 3 times a day, but the MD changed the order, and stated that it is a routine medication. However, staff all med-tech staff confirmed that R3 was not being given the right dosages, for example a medication of 75 mg (30 min) before breakfast, was being given as 25 mg 3 times a day. Resident (R3's) was supposed to be administered 3 pills of Seroquel at 8 AM and 3 pills at 8 PM, but the Director instructed med-techs to dispense it at 2 AM, 8 AM, 2 PM, and 2 pills at bedtime. According to interviews, the Memory Care Director changed the dosage frequency for multiple residents. Resident (R2's) family member stated that they received a phone call from staff notifying them that Seroquel 25 mg medication ran out, which meant that staff were administering the medication incorrectly and too much. R2 was supposed to be administered Seroquel 25 mg in the AM and 100 mg at bedtime, but they were dispensing Seroquel 25 mg in the AM, 25 mg at noon, and 100 mg at bedtime. Per record review of non-electronic Medication Administration Records (MARs), the findings revealed that staff did not document on MAR records that they were dispensing extra dosages to multiple residents and concealed that multiple residents were being improperly medicated, putting the residents at risk for serious mental and/or physical complications. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. Exit interview was conducted and a copy of the report and appeal rights was issued. Allegation: Staff are not providing adequate supervision to residents. The complaint alleges that on November 3, 2023, resident (R1) who resides in the Memory Care Unit left the dining room /activity area after breakfast time and returned to their room to take a nap. It is alleged that the two (2) caregiver staff on duty on 11/3/2023, were sitting in the dining room with other Memory Care residents and failed to check on residents that were in their rooms. At approximately 10:40 AM housekeeper staff (S11) found R1 on the floor of the common shower room. Resident (R1) reported feeling pain in their hip, head, and back. The resident was transported to the hospital where the resident underwent hip surgery because of the injuries sustained after falling. Per resident (R1’s) Needs and Services Plan the resident wanders, is at risk of falling, and requires supervision and assistance when ambulating. Staff are to provide verbal reminders to R1 that they need to use a walker. A total of 11 staff were interviewed. Staff admitted resident (R1’s) injuries occurred because there was a lack of supervision due to staffing shortages i.e., only 2 caregivers in the Memory Care unit because the med-tech/caregiver sometimes must go to the Transitional Memory Care Unit to assist. As a result, many of the residents that are sleeping in their rooms are not always checked every 2 hours per protocols. According to interviews conducted the Memory Care Unit morning shift typically has three (3) staff on the floor, 2 caregiver staff and 1 med-tech staff. Family members interviewed stated they have knowledge that there have been many unwitnessed fall incidents in the Memory Care Unit, and unwitnessed resident to resident aggressive behaviors resulting in injuries. It was also reported that resident (R2) had a private caregiver, and as a result facility staff did not check on the resident as required. In addition, resident (R3) fell during the night shift and was admitted to a hospital with a brain bleed. Memory Care Director stated that caregiver staff are supposed to check on residents every 2 hours. However, the findings indicate that resident (R1) returned to their room after breakfast time at approximately 8:00 AM, and the resident was found injured on the restroom floor until approximately 10:40 AM, which indicates caregiver staff failed to provide adequate care and supervision. Three (3) family members were interviewed, all stated there is not enough supervision of residents. Based on review of records and interviews, there is sufficient evidence to corroborate the allegation. ***Narrative continues next page. Allegation: Staff yell at residents. The concerns pertain to the Memory Care Unit staff. It was reported that two (2) Memory Care Unit caregiver staff yell at residents and speak loudly to them, which at times causes residents to get upset and/or have behaviors. According to information obtained, caregiver staff (S5) speaks in an impolite and teasing manner towards cognitively impaired residents. It was also reported that staff (S4) speaks to residents in a very loud voice. It was reported that a resident asked for help and staff mocked the resident in front of everyone in the dining room area. It is alleged that Memory caregiver staff (S5) has been heard speaking in an abnormally loud and aggressive tone of voice to residents. Staff (S4) denied the allegation, and stated that they speak to the residents loudly due to hearing issues. Staff (S5) denied the allegation, yelling across the hallway at residents, and stated that they speak to them in a loud tone because many residents are hard of hearing. According to both staff identified as yelling at residents, they both have high deeper voices that may come across as aggressive. However, a total of 11 staff were interviewed, eight (8) staff confirmed the allegation by stating that staff (S5) talks to residents in an impatient, abrupt tone of voice, rude, inappropriate manner, easily gets irritated by resident's requests, has a bad attitude with the residents, and says "you're crazy" to the Memory Care residents. The findings indicate that the Memory Care Director has addressed staff (S5's) conduct, but their was no disciplinary action, therefore, the behavior continued until recently when Community Care Licensing began investigating the complaint. Allegation: Staff do not treat residents with respect. It was reported that Memory Care staff sometimes speak to the residents in a disrespectful manner and laugh at residents because staff know that due to their cognitive impairment they cannot discern that they are being made fun of. Information gathered revealed that one resident carries their pillow around and staff laugh, some caregivers ask residents for massages for fun, some staff fail to refer to the residents in a culturally appropriate manner i.e., using "San" after addressing them by their first name; instead address the residents by saying "mama or papa". The findings indicate staff (S5) often verbally provokes residents, has been observed sitting in resident walkers, and inappropriately handling/lifting/pulling up a resident while toileting in the bathroom. Staff (S5) pulled the back of the resident's shirt to lift the resident, which is not an appropriate way of handling an elderly non-ambulatory resident. Seven (7) out of 11 staff acknowledged they have observed or heard other staff address and treat the residents in a disrespectful manner. Video and two (2) pictures were obtained, one depicted staff (S10) sitting on a resident's walker being given a upper back massage by a resident, and another picture depicted a resident eating a meal with a cloth napkin on their face, while the resident was holding a cup of juice. The video sound captured staff laughing. Allegation: Staff did not inform resident's authorized representative of incident. According to information received resident (R1) sustained two falls in 2023. It is alleged that the fall that occurred on September 20, 2023, at approximately 12:45 AM was not reported to R1’s authorized representative. Per record review, the authorized representative was notified shortly after the fall. Family (F1) resident (R1’s) authorized representative stated they do not remember whether staff called them after the September 20, 2023, incident, but acknowledged receiving notification of the fall incident that occurred on 11/3/2023. Most of the staff interviewed stated it is protocol to call the resident’s authorized representative and their doctor after incidents. Staff interviewed denied the allegation, and per record review the findings indicate that the facility documented they called responsible parties, 911 emergency, doctor, and submitted incident reports to Community Care Licensing as required. There is insufficient evidence to corroborate the allegation. Allegation: Staff did not provide resident with food or water. It is alleged that there have been multiple incidents in which Memory Care staff failed to serve resident (R2) breakfast or lunch meals because the resident is primarily in their room and sleeps in during the morning hours. According to information obtained, if the resident is sleeping, they do not call the resident to the dining room to eat and have forgotten to feed or provide hydration to the resident and when the Memory Care Director was informed that R2 had not been fed lunch at approximately 2 PM, the Director responded by saying that R2 has a private caregiver. Eight (8) out of 11 staff denied the allegation and stated that R2 liked to eat their breakfast between 8 AM- 9 AM, therefore, they ate their lunch later as well. All staff stated that R2 had a good appetite and always ate their 3 meals but refused to eat with other residents in the dining room. Staff reported that when residents are in their rooms, they are supposed to check on them every 2 hours and leave water on the commode side table. Resident (R2's) family member stated that the resident slept a lot, water was always observed in the resident's room, and the resident ate vert fast and finished their food. Family did not have concerns regarding the allegation but did state that they were not present during most mealtimes. There is insufficient evidence to prove the allegation. Allegation: Staff are not following reporting requirements. It is alleged that staff are not reporting all incidents to family members and Community Care Licensing Division (CCLD) because the Memory Care Director instructed staff to only report when there is visual blood. According to information obtained, there were 2 incidents involving resident altercations that were not reported to responsible parties, and there was a fall incident that occurred during the NOC shift, in which 911 was not called, nor was it reported to appropriate parties. Staff interviewed stated that it is the med-tech’s responsibility to report incidents to family, physicians, and write a report that is then provided the Memory Care Director. Most of the caregiver staff and med-techs stated they do not know whether there is an issue with reporting appropriate parties and/or agencies. A total of 3 family members were interviewed, one stated they do not have knowledge of whether staff are not following reporting requirements, another stated that they receive immediate notification if there is an incident, and the 3rd family member reported that their loved one was a victim of financial fraud, but that staff have not notified them of the suspected abuse. There is insufficient evidence to corroborate the allegation, because CCLD did receive via fax the majority of the aforementioned incidents. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was discussed and provided to Executive Director Jina Maleksarkissians.the state’s words, verbatim · CDSS document, May 17, 2024 · control 28-AS-20231120121606

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 18, 2024

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidenced by: Based on records review and interviews conducted, staff failed to provide provide adequate care and supervision, resulting in injuries that occurred on 11/3/23 to R1 that required hospitalization and hip surgery. This is an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Administrator agrees to: 1. Submit a written plan by tomorrow how the deficiency will be corrected. 2. Conduct caregiver staff training on regulation 87466, Memory Care care and supervision protocols, and staff communication regarding resident incidents and/or changes in condition. 3. Submit proof that staff were trained by 5/22/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 22, 2024

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of: Based on interviews, the findings revealed that staff (S5) yells at residents, is impatient, and mocks Memory Care residents, and multiple residents are not treated with respect and dignity due to S5 & S10's behavior, this poses a potential health and safety risk.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Administrator agreed to conduct Personal Rights training/sign-in sheets and will submit written proof of how the facility will address the issues. Submit by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: May 18, 2024

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all .... requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on records review and interviews, Memory Care Director instructed med-tech staff to increase the frequency of medication administration of behavioral medication Quetiapine (Seroquel) to residents (R2 & R3) without a physician order; which poses an immediate health and safety hazard to the residents.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Administrator agreed to submit proof of staff in-service training in facility medication administration procedures, and "CCLD Medication Guide". Administrator shall ensure that medication administration procedures are being evaluated routinely and adhered to by all med-tech staff. Submit proof of staff training by 5/22/24. ***NOTE: The facility does not have a Electronic Medication Administration Record (eMAR) system in place. Administrator was advised to look into EMAR software.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 22, 2024

Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.... This requirement was not met evidenced by: Based on interviews conducted, residents clothing and bedding linens are being misplaced or lost because in order to save time Memory Care staff are washing residents clothing/bedding items together, and sometimes items are not returned after being laundered, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Administrator agreed to: 1. Develop a written Plan of Correction (POC) in which a system is created that safeguards resident’s personal items after laundering the clothing and bedding linens. 2. Conduct/submit proof of staff training

Allegation investigated: Staff did not provide a safe and comfortable environment for residents Facility is in disrepair

During today's visit, Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit to investigate the allegations listed above. LPA met with Janice Shimozawa, Front Desk Receptionist for the facility, and was granted entrance. Current Administrator Jina Malesarkissians arrived shortly thereafter. The inspection consisted of the following: LPA obtained staff and resident rosters, a copy of the sketch of the facility, interviewed residents #1 - 10 (R1 - R10), and staff #1 - 4 (S1 - S4). The inspection revealed the following: In regards to the allegation that "Staff did not provide a safe and comfortable environment for residents," it is alleged that homeless people have been entering the facility campus by cutting holes in fencing that surrounds the facility, and they have been squatting in a large abandoned building formerly known as the Intermediate Care Facility (ICF) building that stands next to the main assisted living building for the facility as well as in back lot of the facility. Substantiated During interviews with the residents, one (1) out of ten (10) residents interviewed stated that they have been uncomfortable by the homeless at the facility. This resident stated that about a week ago a homeless individual began came from the ICF building area of the facility and began following the resident, who then proceeded to retreat into the main lobby of the facility due to being uncomfortable. One (1) other resident stated that they have witnessed homeless people staying in the ICF building, however they also indicated that they have not come to the main building on the facility campus. During interviews with the staff, all indicated that homeless have been entering the abandoned ICF building by cutting through the fencing. One staff stated that the ICF building is abandoned and therefore no longer part of the facility campus, however it is true that homeless people have been coming into the campus through fencing next to the ICF building as well as along the back lot of the facility which is connected to the Santa Ana 101 Freeway. This staff further explained that the fencing along the highway belongs to Caltrans, and that they routinely fix the fencing however the homeless continue to cut new holes through the fences. Another staff interviewed stated that they call police whenever a homeless is spotted on the campus, and that they have been advised by other staff to not confront the homeless alone because they may potentially have weapons on them. During the physical plant walk through, LPA observed that there were multiple holes cut into the fencing along the ICF building, as well the fencing along the 101 freeway through which homeless have been coming into the facility campus. LPA also observed that there were rooms along the basement of the facility that had been broken into by the vagrants to use as rooms to sleep in, and found mattresses inside these rooms as well. LPA also observed that there were shards of broken glass along the floor of the main campus of the facility next to the ICF building, which were part of the windows of the ICF building that the vagrants have broken while squatting in the building. The building has graffiti on several walls and broken windows which LPA took a picture of. Additionally, according to the facility sketch obtained by the administrator, the ICF building is still listed as one of the buildings of the facility. In regards to the allegation that the "Facility is in disrepair," it is alleged that the homeless individuals who have been entering the facility have been stealing the copper wiring from the ICF building as well as from the main back up power generator from the facility as well, as wall as the phone and fax lines which has caused some of the resident phones to not work. During interviews with the residents, two (2) out of ten (10) residents confirmed that their phones were not operational. During interviews with the staff, four (4) out of four (4) corroborated the allegation that the wiring in the facility has been tampered with. One resident interviewed stated that the phone in her room has not been working for one (1) to two (2) weeks and that it has been very annoying for them. One staff explained that the homeless individuals who have been entering the facility have been stealing the copper wiring from the abandoned ICF building as well as other materials from the building to sell for money. Another staff stated that they have tampered with the AT&T phone box, which has caused disruptions to the phone service for several residents as well as the fax lines for the facility. During the physical plant walk through, LPA observed that the backup power generator the facility has been completely stripped of most of its components, and is therefore not operational at the moment. It has additionally been proven that the fax lines of the facility have not worked for a period of time. Based on LPAs interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegation, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 9, 2024 · control 28-AS-20240501153246

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 24, 2024

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation and interview, LPA determined that homeless individuals have been entering the campus of the facility through holes cut into the fencing along the 101 freeway and also along the ICF building, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Administrator is to ensure that all residents are afforded a safe, comfortable, and healthful environment to reside in. Administrator is to submit her written plan on how the facility will address the issue of homeless individuals entering the facility campus by welding the ICF building's doors, erecting iron fencing along the Boyle Street side of the facility which borders the ICF building, by demolition, or other means by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 24, 2024

(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 evidenced by: Based on observation and interview, LPA determined that the facilities phone lines, fax lines, backup power generator, and also dining room AC units have been damaged by individuals stealing their parts, which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Administrator is to ensure that the facility is in goor repair at all times. Administrator is to submit her plan on how the facility will fix the facility's broken backup power generator, restore the phone and fax lines, and also restore a functional AC unit for the dining hall of the facility by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Reyes generated this Case Management - Deficiencies report in conjunction with complaint control #28-AS-20231120121606 pertaining to observations made during the physical plant inspection of the Memory Care Unit. The purpose of the report was explained to Administrator Maleksarkissians,Jina. At 11:18 AM, during the tour of physical plant inspection of the Memory Care Unit LPA Reyes witnessed in resident's #1 (R1) on the window seal a bottle of opened Listerine Antiseptic Mouthwash. LPA took photos of the open bottle of Listerine Antiseptic Mouthwash on the window seal before it was removed by staff #1 (S1). LPA interviewed S1 and observed S1 remove the bottle of Listerine Antiseptic Mouthwash and centrally store and lock bottle. Upon LPA's record review of R1 it was observed that R1's Physician Report was dated 2/22/2021. Resident (R1) resides in the Memory Care Unit and is diagnosed with Alzheimer's/Dementia. Per title 22 California Code of Regulation 87705 Care of Persons with Dementia 87705(c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(g)(1) · Plan of correction due date: May 10, 2024

Care of Persons with Dementia (g) residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1)Evidence means documentation from the resident’s physician that the resident is at risk if allowed direct access to personal grooming and hygiene items. Based on LPA's observation during the tour of the physcial plant at 11:18am in room number 1010 an open bottle of Listerine Antiseptic Mouthwash on the window seal was observered. The poses an immediate health/safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Executive Director agreed to submit proof of staff in-service training and a written plan of correction stating how the deficiency was corrected that includes facility protocols.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: May 16, 2024

Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. Based on LPA's record review of R1's file the Physician's Report dated 02/02/2021 it was observed that the resident did not have an annual medical assesment, as required for Dementia residents; which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Executive Director agreed to submit a written plan of correction and proof of staff training on regulation 87705.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit following the completion of a complaint visit which was conducted on 5/9/2024 and is related to the complaint investigation control #28-AS-20240501153246. LPA met with Janice Shimozawa, Front Desk Receptionist for the facility, and explained the purpose of the visit. Administrator Jina Maleksarkissians arrived shortly thereafter During the course of the investigation, it had been revealed that police were called to the facility multiple times in the facility's efforts to get homeless individuals to leave the facility premises, however a special incident report (SIR) was never submitted to Community Care Licensing Division (CCLD). There were other serious incidents revealed as well including the resident phone lines being disconnected, copper wiring and other materials were stolen from the facility dining room AC unit as well as the backup power generator for the facility, however incident reports were not submitted for these incidents either to CCLD. These incidents are considered ones that threaten the welfare, safety, or health of the residents, and therefore an SIR should have been submitted to CCLD. The deficiencies are noted on LIC809D pages per Title 22 Regulations. Exit interview was held and a copy of this report, along with the LIC809D page and appeal rights were provided.the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 16, 2024

(a) Each licensee shall furnish to the licensing agency (...) (1) A written report shall be submitted to the licensing agency (...) within seven days of (...) (D) Any incident which threatens the welfare, safety, or health of a resident. Based on record review and interview, the LPA determined that the facility did not submit incident reports for events involving police being called to the facility, along with the phone, fax, AC unit, and backup generator being dismantled, which poses a potential safety risk to residents.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: The administrator is to ensure that special incident reports are sent to CCLD for all incidents that threaten the welfare, safety, or health of a resident. The administrator is to submit incident reports that detail all of the above incidents to CCLD by the POC due date.

Allegation investigated: Administrator is not at the facility for the required amount of time.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegation above. LPA arrived unannounced and met with Administrator, Jina Maleksarkissian. The purpose for the visit was explained. LPA obtained a copy of the staff and resident roster. LPA also reviewed the administrator's file and interviewed the administrator, 6 staff and 5 residents. For allegation, administrator is not at the facility for the required amount of time. It is alleged that the administrator is not available for residents and staff and is not in the building. LPA interviewed the administrator who started on 2/21/24. She stated she works Monday through Friday, 9:30am - 5pm, and is available on call. She is normally in the building except when she has any business meetings or business developments. She will attend the meeting and return to the community right after. Unsubstantiated Per the administrator, she had introduced herself to the residents when she first started and held meetings to get acquainted with staff. LPA interviewed 6 staff and they all stated the administrator is available when needed. 4 out of the 5 residents can identify the administrator and stated she is often at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 28-AS-20240315143603

Allegation investigated: Staff interfere with resident's sleep. Staff do not properly store residents' personal hygiene care items.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was explained to receptionist Janice Shimozawa. The facility does not currently have an Executive Director. Rodora Marijna Merana arrived later and assisted with today's visit. The investigation consisted of the following: On 11/28/2023, LPA conducted a tour of the facility with focus on the Memory Care Units and one staff was interviewed. The Neurocognitive Disorder Care Plan of of Operation, Designation of Facility Responsibility,Personnel Records and training, LIC 500 Personnel Report, and resident rosters were obtained. Photographs were taken of the storage rooms were resident's hygiene products were being stored. During today's visit, LPA obtained Dementia Care Plan of Operation [Service Plans, Resident Dining, Northstar Food Service, and kitchen meal time schedule. A tour of the facility and Memory Care Unit was conducted, 7 staff were interviewed, and room observations were made. ***Narrative continues next page.*** Substantiated Allegation: Staff interfere with resident's sleep. It was reported that NOC shift staff wake up Memory Care residents between the hours of 4:30 AM - 5:00 AM in order to get them ready for breakfast and before the AM shift starts. A total of eight (8) staff were interviewed, of which five (5) out of eight (8) staff stated that the NOC shift staff wake up the residents between 4:30 AM - 5:00 AM, and start changing the residents in order to get them ready for breakfast meal time. After they are changed they are taken to the activity room at 6:00 AM. Their breakfast time is 6:30 AM. According to Memory Care Director, some Memory Care unit residents are already awake at that time. However, the majority of the staff interviewed stated that they feel the residents are awakened too early, and the primary reason for the protocol is to have the residents ready before the AM shift begins at (6:00 AM). Staff reported that sometimes residents are sleepy and fall asleep in the activity room tables. Therefore, the resident's sleep is being affected. Family interviews revealed that they did not have knowledge of the resident wake-up time and also reported that the resident are put to bed early in the evening, usually by 7:00 PM. Former Administrator Daniel Konishi was not interviewed. Assisted Living residents have Personal Rights that state they are to be free from....actions of a punitive nature, such as... interfering with daily living functions such as eating, sleeping, or elimination. Allegation: Staff do not properly store residents' personal hygiene care items. It is alleged that resident's hygiene box and toothbrushes are stored in the laundry room/cleaning tools storage room. A total of eight (8) staff were interviewed. All confirmed the allegation. They stated the hygiene products have been stored there for a long time because the Memory Care unit does not have enough storage areas. They stated that the laundry room is cleaned every 2 months. On 11/28/2023, LPA observed the storage room and confirmed the allegation. Toothbrushes and incontinence supplies were stored uncovered and the room contained cleaning supplies, dirty laundry, and had dirty floors. Pictures were taken. Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D. An exit interview was conducted with Memory Care Director Rodora Merana.A copy of the report and appeal rights were issued. Allegation: Staff do not provide residents with a reasonable amount of time to consume meals. It is alleged that Memory Care staff rush the residents during mealtimes and are often heard asking the residents "Are you done" in an impatient manner. Additionally, it was reported that staff do not always provide feeding assistance to residents and say that the residents did not want to eat and put the food back in the tray for removal. Three (3) out of eight (8) staff stated they do rush residents because the dining room staff want the meal trays by a certain time. One (1) staff stated that staff rush the residents and purposely feed the residents large spoonful’s so they can finish their meals faster. LPA observed several mealtimes and did not observe staff rushing the residents. Based on staff interviews, there is insufficient evidence to corroborate the allegation. Allegation: Licensee does not ensure facility administrator has an active administrator certificate. It is alleged that the Memory Care Director does not have an Administrator's certificate but is saying that they are an Administrator. It was also reported that Administrator Daniel Konishi delegates all Memory Care responsibilities to the Director and is not in charge of the facility. Based on record review, the findings indicate that the Memory Care Director does not have an Administrator Certificate. However, Executive Director Daniel Konishi has an active Administrator Certificate that expires 04/28/24. Note: Executive Director Daniel Konishi last day of employment at the facility was January 31, 2024. According to Title 22 Reporting Requirements 87211(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator.... Based upon record review and interviews conducted the findings indicate that, 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 Memory Care Director Rodora Merana. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 8, 2024 · control 28-AS-20231120121606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Mar 7, 2024

Personal Rights of Residents in All Facilities. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met evidenced by: Based on interviews conducted, the findings indicate that Memory Care NOC shift staff are waking up the residents between 4:30 AM - 5:00 AM, in order to get them ready and transported to the dining room at 6:00 AM, which interferes with sleeping. This poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Licensee shall ensure that the Memory Care Unit staff are trained in Personal Rights and are familiar with Dementia Care Plan of Operations. Submit written proof of how the defiicency was corrected, and staff training staff sign-in sheets. NOTE: Training must be done by a Certified Administrator/qualified person.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(g)(1) · Plan of correction due date: Feb 15, 2024

Maintenance and Operation. Facilities which have machines and do their own laundry shall: ... Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noises shall not reach resident or employee areas Based on observation, the laundry room is being used as a storage room for resident's hygiene products i.e. toothbrushes, incontinence care; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Licensee shall ensure the laundry room is only used for associated laundry activities, and not as a storage room for resident's hygiene products or incontinence supplies. Submit picture proof of correction, and proof of staff training.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Galarza generated this Case Management - Deficiencies report in conjunction with complaint control #28-AS-20231120121606 pertaining to observations made during the physical plant inspection of the Memory Care Unit. The purpose of the report was explained to Memory Care Director Rodora Merana. All resident bedrooms in the Memory Care Unit have surveillance cameras installed in a wall corner of each room. The cameras have wiring that connects to electrical outlets. LPA spoke with Rodora Merana and she stated that the cameras were donated, but it was determined to be non-compliant with Title 22 regulations. However, maintenance staff have not removed the cameras from the resident rooms. No Exception Waiver has been submitted to the department. Per Title 22, residents shall be afforded privacy. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Feb 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: Feb 15, 2024

Personal Accommodations and Services. Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement was not met evidenced by: Based on observation, all resident rooms in the Memory Care Unit have surveillance cameras installed in a wall corner of each room with wiring that connects to electrical outlets. This poses a potential health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Feb 8, 2024

Plan of correction: Facility shall remove all surveillance cameras from the Memory Care Unit resident rooms, and/or if applicable may submit an exception waiver for surveillance cameras for specific residents. Please submit a written POC and picture proof evidence that the cameras were removed from all resident rooms.

Allegation investigated: Resident sustained multiple falls due to staff neglect Staff did not follow protocol regarding resident falling Staff administered resident medications not on medication list Facility staff did not report resident's fall to the proper agencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Tomoko Hino and explained the reason for the visit. Whitney Blake Regional Vice President of Operations and Sale for North Star was notified of the reason of the visit via phone. The investigation consisted of the following: LPA requested a copy of staff and resident roster. Interviewed administrator, 5 staff, 8 residents, reviewed resident’s #1(R1) file, staff provided a copy of R1’s file and incident reports for incidents on 1/15/24 and 1/24/24. Interview hospice services over the phone. The investigation revealed the following: Regarding allegation: Resident sustained multiple falls due to staff neglect. It is alleged R1 has a history of falls and fell on 1/15/24 and 1/24/24. Interviews with staff revealed R1 resided at the assisted living prior to moving to their transitional memory care unit. While living at the assisted living R1 had sustained one fall only. (CONTINUED ON LIC 9099C) Substantiated After the fall R1 obtained rehabilitation at an outside facility and returned to the transitional memory care in November of 2023. R1 had two falls one on 1/15 and one on 1/24/24. Document review revealed the following: Physician’s report dated 9/6/23 notes R1 is ambulatory. Resident assessment dated 12/4/23 notes special concern – care level description fall concern. Needs and Services Plan dated 11/21/23 notes “resident will ambulate with walker”, however it does not note that the resident is at risk of falls. Incident report dated 2/2/24 to report incident on 1/15/24 notes R1 “glided on the floor hitting the knees” and does not note information on action taken or planned to prevent future falls. Incident report dated 2/2/24 to report incident on 1/24/24 notes care staff found R1 siting on the floor and was picked up. No action taken or follow ups are noted. Hospice plan of care dated 2/7/24 notes R1 has had repeated falls. Hospice plan was created on 12/13/23. One of the goals created was to prevent falls and minimize injury. Facility staff failed to follow Hospice care plan to prevent falls and to update or provide a plan of care to be followed by staff to prevent falls for R1. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff did not follow protocol regarding resident falling and Facility staff did not report resident's fall to the proper agencies. It is alleged staff did not follow protocol of assessing the resident, calling hospice, and picked up resident and staff decided not to report the fall to reporting parties. Interviews with residents revealed 6 out of 8 residents stated staff are helpful and will call 911 for them in case of a fall. 2 out of residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed that staff are to evaluate the resident, notify supervisor, call 911 or hospice services, notify family, and notify community care licensing (CCLD)/ Local Ombudsman (LTCO). Per Memory Care Director, for residents under hospice they are to call hospice agency and speak with a nurse who will provide instructions for care of a resident that has fallen. Interview with hospice agency revealed that facility did not notify them of the falls R1 had on 1/15/24 and 1/24/24 and only came to know of the incidents through a third party during the visits. Incident occurred on 1/15/24 does not note any action taken by the facility. Incident occurred on 1/24/24 notes “sitter said not to call 911 and was assisted to get up”. Incident reports for incidents occurred on 1/15/24 and 1/24/24 were submitted to the department on 2/2/24. Facility failed to follow their own protocol to call hospice services for R1 and obtain instructions of care for R1 and facility failed to report to CCLD within 7 days. (CONTINUED ON LIC 9099C) Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff administered resident medications not on medication list. It is alleged facility med tech provided medication to R1 that has not been prescribed. Interviews conducted revealed 6 out of 8 residents interviewed either managed their own medication or had no issues with medication provided. 2 out of 8 residents were unable to be interviewed due to cognitive skills. Interviews with staff revealed only Med-Techs provide medication to residents and before providing medication staff review the medication sheet and ensure they are providing the correct medication before giving it to the resident. Documents review revealed Facility’s medication administrator record for January 2024 notes R1 was provided acetaminophen 500mg, noted on a posted note dated 1/24/24 attached to medication administration record which notes “give R1 acetaminophen 500, 1 table at 10:25am” with staff initials. R1 hospice current treatment/medication/DME list does not list Tylenol 500 mg as a prescribed medication for pain between 12/13/23 – 1/26/24. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Tomoko Hino and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 28-AS-20240129142303

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 8, 2024

87468.2 Additional Personal Rights of Residents...: (a)...residents...: (4) To care, supervision,... meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency... This requirement is not met as evidence by: Based on interviews conducted and documents review licensee did not ensure that R1 had a plan of care for fall risk after hospice documented which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee will provide training to memory care staff regarding updating needs and care plan, notifying staff providing care of updates, and following care plan for residents and will provide a copy of training with subject, duration of training, and signing log to the department by POC due date 2/8/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 8, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable...: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on documents review and interviews licensee failed to ensure that R1 received medication as prescribed and was given acetaminophen 500mg on 1/24/24 which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Administrator will provide staff training on Medicaiton safety, and ensuring correct medication to memory care staff and will provide a copy of training with subject, duration of training, and signing log to the department by POC due date 2/8/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Feb 14, 2024

87705 Care of Persons with Dementia (c) Licensees...shall be responsible...: (4) ...direct care staff to support each resident’s physical, social, emotional, safety and health care needs... This requirement is not met as evidence by: Based on documents review and interviews licensee did not ensure to follow protocol for R1 after falls obtained on 1/15/24 and 1/24/24 which poses a potential risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee will provide provide training on protocols and guidelines for care of residents after a fall and will submit a copy of training with subject, duration of training, and signing log to the department by POC due date 2/14/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 14, 2024

87211 Reporting Requirements a) Each licensee shall ..: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidence by: Based on documents review and interviews conducted licensee failed to inform CCLD and physician (hospice agency) regarding falls ocurred on 1/15/24 and 1/24/24 which poses a potential risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee will provide training to reporting staff on time, description, action taken, follow up information on incident reports and will submit a copy of training with subject, duration of training, and signing log to the department by POC due date 2/14/24.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tena Herrera conducted a Subsequent Case Management Visit for Change of capacity. LPA explained the purpose of today's visit to Daniel Konishi - Executive Director who assisted with this visit. The facility’s physical plant sketch was provided during initial visit. Licensee applied for the change the capacity from 177 to 183 non-ambulatory residents. Fire inspection was conducted and fire clearance was approved for 183 non-ambulatory elderly residents ages 60 and over, of which 47 may be bedridden. Per Daniel Konishi of the 183 non-ambulatory residents, 24 residents will be in Transitional Memory Care Units, 23 residents in Memory Care Units and the rest (136) in Assisted Living. During today's visit LPA toured the Transitional Memory Care area of facility that is included in the capacity increase. LPA inspected the facility per the updated physical plant sketch and granted fire clearance. Tour of the Transitional Memory Care Units included 13 resident rooms with private bathrooms, dining/activity room, court yard and delayed egress system. Each of the 13 rooms had proper furnishing and linens to meet the capacity increase. Water temperature was tested throughout resident rooms and were within required range of 105-120 degrees F. Room 120's air conditioning unit is being repaired, administrator to ensure that the air conditioner unit is operable prior to residents residing in room. There is sufficient amount of linens and dining wear available for the increase and are stored within the "Assisted Living" kitchen and laundry areas. It appears that the physical plant meets Title 22 Regulations. Capacity increase to be processed. No deficiencies were noted during the visit. Exit interview conducted and copy of this report was provided to Executive Director Daniel Konishi.the state’s words, verbatim · CDSS document, Oct 10, 2023