Santa Anita Assisted Living

Allegation investigated: Staff falsified residents' signature. Staff does not ensure facility is in good repair.

Licensing Program Analyst (LPA) Galarza conducted an initial visit to investigate the above allegation. LPA met with Executive Director Jacqueline Cortez. The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on video surveillance, office and break room areas. Records were reviewed. Relevant copies of resident (R1's) file documents were reviewed and obtained, along with facility rosters, job descriptions, and policies. Refer to LIC 9099C for the continuation of this report. Substantiated Allegation: Staff falsified residents' signature. It is alleged that resident (R1's) signature was falsified on "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment.." The complaint alleges that staff falsified their signature so that the resident was able to be seen by the in-house physician, as well as that a med-tech staff falsified R1's signature stating the resident was given their medications on 12/24/24. According to the complaint, R1 was not at the facility on (12/24/25), the date medications were allegedly given to the resident. Staff interviewed denied the allegation. Record review of forms: "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment" did not indicate there was signature falsification because they were electronically signed by R1 on 11/7/24 via Dropbox Sign. However, on 12/24/25, the facility filled out a Medication Release form. Resident (R1's) signature on that date was compared to other document signatures. The signature appears different and inconsistent with the majority of signatures on record. Copies of the Medication Release forms were obtained. There is sufficient evidence to support the allegation. Allegation: Staff does not ensure facility is in good repair. The complaint alleges the facility surveillance cameras are inoperable. According to information obtained, residents had an understanding the facility has surveillance cameras for their safety. However, in recent months many of the cameras have not been working. A total of 14 residents were interviewed, all the residents interviewed had knowledge of video surveillance in the building. However, the majority of the residents stated they do not know whether all the cameras are operable. Staff interviews confirmed that there are exterior cameras throughout the property, and that the majority of the interior cameras were removed. LPA observed one (1) surveillance camera in the hallway by the lobby area. Executive Director stated the camera video does not show on the main office monitor, and at this time only 3 cameras are displayed in the office surveillance monitor. Based on observation, the facility has multiple cameras, of which only 3 are showing as operable as of today. Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were issued. Allegation: Staff are not adhering to job duty. The complaint alleges that night shift staff have been observed sitting in the main office asleep resting their heads down on the desk after they conduct their rounds. According to information obtained, the staff set alarms to wake up and continue with their rounds, and once they finish doing their rounds they go back to sleep. It is alleged that staff tend to sleep between 12 AM - 4 AM. Based on eight staff interviews, the findings indicate that there is a total of 3 night shift caregiver staff, 2 night shift med-techs, and a receptionist that works from 3:30 PM - 12:00 AM. Caregiver staff are in the main office or break room and med-tech staff are located in the medication room. According to staff interviews, caregivers are required to attend to residents in care and do 2 hourly checks at night. Med-techs pass out medications, respond to incidents and/or emergencies, and organize medications. Two (2) out of the eight (8) staff stated sometimes night shift caregivers do put their head down on the desk, but they are not asleep. A total 14 residents were interviewed. Two (2) out of 14 residents stated they have observed staff sleeping during the night shift hours. It is unknown if night shift staff are on break when they have been seen with their head down on the office counter. Based on interviews conducted, there is insufficient evidence to support 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 conducted with Executive Director Jacqueline Cortez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 28-AS-20251010093333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Oct 28, 2025

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met evidenced by: Based on record review of Medication Release form dated 12/24/24 and multiple other forms on different dates it was observed that form dated 12/24/24's signature is different and inconsistent with the majority of signatures on record. Therefore, there is a signature mismatch. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Executive Director agreed to: 1. Provide proof of med-tech in-service training on Medication Release form, and protocols regarding obtaining resident signatures of residents that are unable to sign on their own. 2. Submit a written plan with facility procedures and training materials.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 11, 2025

Maintenance and Operation. 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 was not met evidenced by: Based on observation, there is one (1) indoor surveillance camera located in the hallway by the lobby, and multiple cameras in the exterior of the building. The main office camera monitors only show 3 operable cameras. The indoor camera is not operable. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: Executive Director agreed to submit a written plan that addresses surveillance use, policy, and repairs. If cameras are to be used indoors, the facility plan of operation, sketch, and admission agreement must be updated and submitted to Community Care Licensing.

Allegation investigated: Staff does not provide adequate food service. Staff does not ensure to follow food handling practices. Staff do not provide residents with a sufficient amount of food.

Licensing Program Analyst (LPA), Mayra Cota, conducted a 10-day complaint investigation visit regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. During today’s visit: LPA conducted tour of the common areas of the facility, with a focus on inspecting the kitchen and dining rooms, obtained copies of staff and resident rosters, interviewed Staff 1 – Staff 9 (S1-S9) and Resident 1 – Resident 15 (R1-R15). LPA, also reviewed and obtained copies of facility's Plan of Operation and Resident and Employee Lunch forms. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff does not provide adequate food service. It is alleged that a resident had placed an order for a meal prior to going to the dining room and had to wait 45 minutes before getting their food. It is also alleged that staff are not assisting with delivery of meal services for (2) residents and that resident is the one to take their food to their room. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that meal service schedules are followed every day and that meals are served within (5) to (10) minutes of an order being taken by staff for residents waiting in the dining room. Staff indicated that many residents have their meals in the dining area and therefore, sufficient servers are available to conduct meal service in a timely manner. Staff further indicated that they have not received complaints from residents regarding waiting for prolonged periods of time for their food. Furthermore, staff indicated that bedside meal trays are delivered to all residents who have the service as part of their care plan and for residents who have minor/temporary illness or are recovering from surgery with a physician’s order. Caregiving staff indicated that they deliver all scheduled meals to residents and return to check on residents in case residents want a second helping of food or need their trays to be taken away after finishing their meals. Interviews with (12) out of (15) residents revealed that meal services are conducted in a timely manner in the dining area and residents usually get their food within (10) minutes from the time their order was taken by staff. A resident who stated that they deliver meals to R2 and R3 indicated that staff are not delivering meals and therefore, resident picks up meals for R2 and R3 to ensure they have something to eat. Interviews with R2 and R3 indicated that they go to the dining area to have their meals, unless they are sick in which their meals are then delivered to their room by staff. R2 and R3 indicated that their care plan does not include their meals being delivered to their rooms; however, the facility has made accommodations to have meals delivered to their rooms when they are sick and recovering from illness. R2 indicated, a resident does not deliver their food to their room. R3 indicated that a resident has delivered food to their room; however, R3 had already eaten in the dining room and had an extra meal in her room which they did not need. R2 and R3 indicated, when their meals had to be delivered to their room by staff when they were sick, all their trays arrived in a timely manner, and no meals were skipped due to staff not conducting the delivery. LPA review of Plan of Operation indicates, bedside meal trays are available to residents with minor/temporary illness or recovering from surgery with a physician order. Staff and resident interviews do not corroborate the allegation. ***Continues on LIC 9099-C page 2 Regarding: Staff does not ensure to follow food handling practices. It is alleged that staff are not wearing a hair net and hair is getting into resident’s food. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff who work in the kitchen preparing the food must always wear a hair net. Staff indicated that cooks cannot be in the kitchen without a hair net which has to cover their hair when they are handling food. Staff stated they always adhere to safe food handling practices at all times. Staff further indicated that staff nor residents have expressed concerns regarding hair being in the food served at the facility. Interviews with (14) out of (15) residents also deny the allegation. Residents indicated that they have not observed cooks or other staff handling food without a hair net. Residents stated that they have not observed any hair in their food and have not heard other residents express concerns about finding hair in their food. A resident indicated that they observed a staff from the kitchen without a hair net during food preparation and service; however, resident did not indicate finding hair in their food. During today’s visit, LPA observed staff handling food were wearing a hair net. Staff and resident interviews, and LPA observation do not corroborate the allegation. Regarding: Staff do not provide residents with a sufficient amount of food. Staff do not provide residents with sufficient amount of food. It is alleged that a staff’s meal had more food than the rest of the residents. Staff deny the allegation. Interviews with (9) out of (9) staff revealed that staff meals are not portioned differently from residents’ meals. Staff indicated that when staff request the (1) meal a day the facility provides, it is prepared equitably for residents and staff. Staff indicated that staff have to place their order by using the Employee Lunch Form in advance to be able to get their meal for the day, however, resident meals are priority and kitchen staff serve residents first and would not give staff more food than residents. Interviews with (14) out of (15) staff indicated that they have no concerns with portions not being appropriate. Residents indicated their food is plentiful and if needed they can request seconds from the kitchen staff. Interview with a resident indicated that they observed a staff member receiving more food than what residents were being served. Interviews with staff and residents do not corroborate the allegation. ***Continues on LIC 9099-C page 3 Based on interviews and observation the above mentioned allegations could not be corroborated. 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 Jacqueline Cortez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 28-AS-20251006131012

Allegation investigated: Staff did ensure resident was provided a safe environment while in care. Licensee is financially abusing resident in care.

***This report supersedes the report delivered on 10/28/25. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** On 10/28/25, Licensing Program Analyst (LPA) S Vaid conducted a subsequential complaint investigation visit for the above allegations. LPA met with Jacqueline Cortez-Administrator, and the purpose of the visit was discussed. On 4/22/25, LPA Vaid conducted an initial 10-day complaint investigation visit for the above allegations. LPA met with Ruth Villa, Wellness Director and Joel Niblett, Administrator. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#6 (S1-S6) and residents #1-#15 (R1-R15). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential admissions agreement, medication, physicians’ orders, residents' facility financial history for R1. Staff and client rosters were obtained. LPA collected six (6) random residents files. The investigation revealed the following: CONTINUED ON 9099C....................... Unsubstantiated ***This report supersedes the report delivered on 10/28/25. The reason for the amendment is to remove confidential information listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did ensure resident was provided a safe environment while in care. It is alleged that the facility staff are not providing a safe environment for the residents that reside at the facility. R1 was placed with an aggressive resident/roommate who was verbally abusive and R1 felt uncomfortable and unsafe. Six (6) out of six (6) staff deny this. The staff stated they provide all residents with comfortable living accommodations and safety throughout the facility. Staff determine compatibility when placing residents together. The staff stated they ensure that all residents are provided with a safe environment by settling disputes between residents and keeping residents comfortable and treating the residents with respect and dignity. Fourteen (14) out of fifteen (15) residents interviewed could not corroborate this allegation. Nine (9) out of fifteen (15) residents interviewed stated they feel safe and comfortable living here and the staff assist with residents’ well-being. According to interviews with residents, R3, R14 and R15 have not resided in room #131 with R1 as a roommate. Based upon observations and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Regarding the allegation: Licensee is financially abusing resident in care. It is alleged that the licensee is financially abusing resident #1(R1) in care by charging R1 with services not provided while resident was at Westwood Acute Care in another facility. Per co-complaint, the business office is not providing residents with copies of residents facility financial records. It is further alleged that staff are stealing monies from residents banking accounts by making residents sign blank pieces of paper. Six (6) out of six (6) staff interviewed deny this allegation. According to R1’s admissions agreement, ‘Residents are obligated to pay rent when on vacation or transferred temporarily to an outside health care facility’. Admissions agreement, pages 8-9, section VI-Fees, subsection D-Adjustments to fees and services, item 4- Absence from the Community. Signed by R1 on 05/03/2024 acknowledging the rules and responsibilities for residing in the facility. Staff interviewed stated that financial transactions related to the monthly rent and financial records are handled by the corporate accounting office to ensure proper billing and payments are received and correctly posted to residents’ accounts. The accounting office sends financial receipts to all residents for monthly rent and residents can receive a copy of their financial records upon written request. Staff stated they are not making any residents sign blank sheets of paper to gain access to the residents’ bank accounts. Thirteen (13) out of fifteen (15) residents could not corroborate licensee financially abusing residents. Seven (7) out of fifteen (15) residents stated they are not having monies stolen by staff. Most residents have their family handling money matters. Based upon records reviewed and interviews conducted the findings indicate that, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Copy od this report was provided to Jacqueline Cortez -Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 28-AS-20250418090103

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow up on incident report received by the department. LPA met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. According to Special Incident Report (SIR), a medication error was noted on 9/25/25 in which Resident #1 (R1) was administered Oxycodone three times within a six-hour period. The order for Oxycodone is for every six hours for R1. According to Staff #1 (S1), a staff who was monitoring documentation informed S1 that a medication error was noted on the narcotic count sheet from 9/25/25 for R1. S1 checked R1’s QuickMar entries and found that Oxycodone was administered at 4:00 p.m., 7:00 p.m. and 10:00 p.m. S1 indicated that review of R1s QuickMar confirmed that R1 received excessive dosage of Oxycodone medication on 9/25/25 between the noted time period. S1 stated, R1 had to be closely monitored by staff to ensure R1 did not experience adverse effects from the medication. R1’s vitals were closely monitored and R1’s physician was notified immediately about the incident. The incident was also reported to the ombudsman and licensing. S1 further indicated, R1’s physician ordered a temporary suspension of R1’s Oxycodone and doses were resumed once R1’s vitals stabilized. Interview with Staff #2 (S2) indicated, S2 became aware of the medication error through staff communication and was assigned to conduct check of vitals on R1. S2 further indicated that during wellness checks, R1 slept soundly, and later was observed walking around the facility. S2 also stated that R1was observed returning their food tray which showed indications that food was eaten by R1. ***Continues on LIC 809-C S1-S2 stated, once R1 was observed to continue with normal activity, med-tech staff resumed administration of R1’s Oxycodone on 9/26/25 at 10:00 p.m. According to S1, R1 was informed about the medication error and R1 agreed to have the medication paused while staff observed R1. Review of R1’s Controlled Medication Count Sheet, indicates Oxycodone was administered on 9/25/25 at 4:00 p.m., 7:00 p.m. and 10:00 p.m. S1 stated, they conducted meetings with the staff who administered the medication incorrectly to R1 and corrective actions were discussed and set in place. LPA conducted interview with R1 during today’s visit. R1 indicated, staff have been managing their medication correctly after the incident on 9/25/25 and has no concerns at this time. Further action may be required, and LPA Cota may return to gather additional documents and conduct additional interviews. Deficiency noted and citation issued during today’s visit. Exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 10, 2025

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews conducted and documents reviewed, licensee did not ensure that R1 received their medication at the correct times and thus, received excessive medication within a six-hour period. Medication was administered too soon between doses which poses an immediate risk to the health, safety, or personal rights to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: Administrator will provide medication training to med-tech staff which will include shadowing and will submit a copy of training log, topic, description of training, and duration of training by POC due date.

Allegation investigated: Staff did not ensure resident received medical care in a timely manner Staff does not ensure residents are spoken to in an appropriate manner

The purpose of this Amended Report 12/01/25 is to remove confidential information from the subsequent complaint visit conducted on 10/07/25. Licensing Program Analyst (LPA) Glenn Trueman, made an unannounced subsequent complaint visit in response to the above mentioned allegations. LPA met with Jacqueline Cortez, Administrator, and explained the purpose of the visit. The initial visit was conducted on 8/25/25 and included the following: LPA obtained a copy of the staff and resident roster, Special Incident Report's (SIR's), and Staff Communication Notes. LPA Interviewed the Administrator and Staff S1. File was reviewed for Resident R1 and Resident R2 and various documents were submitted. Resident and Staff Roster was submitted., At today's visit Resident's R1- R16 were interviewed . Administrator and Staff S1-S3 were interviewed. Unsubstantiated In regards to the allegation Staff did not ensure resident received medical care in a timely manner, based on interviews conducted and information gathered 14 of 16 residents stated that staff have been quick to help them. Also stated that staff does a good job with any type of medical attention including visits with the primary care doctor, medication administration and 911 calls and visits to Urgent Care. Resident R2 stated he was found unconscious in his room and the staff responded right away. Resident R13 stated that he broke his ankle at night falling on the sprinkler. Said staff responded right away. Resident R9 stated that he knows of Resident R1. Stated R1 harasses residents and staff. Said R1 jumps into argue for someone else and causes problems. Administrator stated that Resident R17 was at the front desk waiting for Hospice to arrive. Said R1 was diagnosing R17 and that staff doesn't have to explain what they are doing. Said there are HIPPA laws. Staff S1-S3 all stated that R1 was diagnosing R17 and telling R17 that he was having a heart attack. Said that R17 was on Hospice and the protocol is to wait for the Hospice Nurse to tend to R17. Hospice Notes dated 08/15/25 at 9 PM and Hospice checked vitals for R17. States R17 had been given medication for chest pain during the day. Hospice had facility call 911 and R17 was sent to San Gabriel Hospital and admitted on 08/16/25. Discharge instructions to follow-up with your Prmary Care Provider in 1 to 2 weeks. Although the allegation 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. In regards to the allegation Staff does not ensure residents are spoken to in an appropriate manner, based on interviews conducted and information gathered 14 out of 16 residents stated that staff have not yelled or screamed at residents. Also stated that residents are the ones who scream at staff. Said staff have to use a loud and stern voice. Stated the staff act respectfully and check on them often. Administrator stated that staff didn't tell R1 to stay in her room. Said staff did tell R1 to stay out of other resident's business. Staff S1-S3 all stated they are mandatory reporters and they know that you are not allowed to hold resident's in their room. Said they did ask R1 to stop diagnosing resident's. Special Incident Report dated 08/19/25 and states R17 had chest pain and was taken immediately to USC Arcadia hospital and returned the same day with no new orders. On 08/21/25 SIR indicates that medication prescribed in a Physican's order was administered. R17 still had chest pain and 911 was called immediately. Although the allegation 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 conducted and report issued to Administrator Jacqueline Cortez.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250820143204

Allegation investigated: Staff did not prevent resident from being harmed by another resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent complaint investigation visit to deliver findings on the above-mentioned allegation. Today’s visit stems from an initial visit conducted on 9/25/25. LPA met with Jacqueline Cortez, Administrator, and explained the reason for today’s visit. The investigation consisted of the following: During visit on 9/25/25, LPA obtained a copy of the staff and resident roster, reviewed Resident 1 and Resident 2's (R1-R2) file, obtained copies of relevant documents and conducted interviews with Staff 1-6 (S1-S6) and R2. During today’s visit, LPA toured common areas of the facility, obtained a copy of staff and resident rosters and conducted interviews with Resident 3 – Resident 8 (R3-R8) and telephonic interviews were conducted with R1 and (2) of R1’s family members. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff did not prevent resident from being harmed by another resident. It is alleged that resident has been punched by roommate multiple times in which one incident resulted in a bruise on resident’s torso. It is also alleged that resident reported the incident to staff and asked to be moved to another room, but nothing was done. Interviews with (6) out of (6) staff deny the allegation. Staff interviews indicated that R1 did not report an altercation with R2 which resulted in an injury to R1’s torso to staff. Staff stated that no other incidents between R1 and R2 have been reported by them to staff. Staff stated that R1 and R2 have disagreements from time to time about the volume on the television set being too loud or about the AC settings being too cold; however, disagreements do not escalade to physical aggression. S1- S4 indicated, R1 had been moved to another room after R1 made a request to administrative staff; however, R1 requested to be moved back to the room with R2. S1 and S2 indicated that when the change of room was granted for R1 to return to the room with R2, R1 was informing that requesting another room change may be difficult to undergo due to rooms not being available. Staff further indicated, when residents have altercations with their roommates, staff intervene by deescalating tension between them and providing the option to spend the night in an empty room to put space between residents. Furthermore, staff are mandated reporters, and any form of abuse is reported to ombudsman, licensing and or/law enforcement. Interview with R2 indicated that R2 did not hit R1 on the torso and has never hit R1. R2 stated, R1 and R2 sometime argue about the temperature in the room being too cold, but they have not hit R1 during their disagreements. R2 further indicated, their health is not good and cannot make jolting movements to hit another person. R2 stated, they suffer from joint pain and have had heart surgery in the past and cannot risk getting hit back by a person. Telephonic interview conducted with R1 indicated, R1 and R2 have argued about the temperature of the room which R2 likes to maintain in the coldest setting. R1 indicated, R2 punched R1 on the left side of their torso due to complaining to staff about the disagreements they have had about R2 setting the AC too cold and about R2 engaging in frequent sexual acts in R1’s presence. Two (2) of R1’s family members were also interviewed telephonically, and they indicated that R1 expressed concerns about R2 punching R1 in the torso as retaliation for R1 reporting R2 to staff. Family members also indicated that they saw the bruise on R1’s left side below the arm pit which looked like a fist mark. Record review indicated that R1 was moved to a secondary room after initial admission to the facility. Record indicates, R1 remained in the secondary room for a short period; but requested to return to the room R1 was initially installed in with R2. Based on interviews and record review, the allegation could not be corroborated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250923115304

Allegation investigated: Staff spoke to resident in an inappropriate manner. Staff threatened to withhold resident’s medication.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit for the allegations listed above. LPA met with Administrator Jacqueline Cortez to explain the purpose of the visit. On 9/30/25, LPA Chan obtained copies of the staff and resident rosters and interviewed the administrator and a staff. During the visit today, LPA interviewed an additional four (4) staff and ten (10) residents. The investigation revealed the following: Allegations - Staff spoke to the resident in an inappropriate manner. It is alleged that a staff “screamed her bloody head off, ahh” after observing an extra plate of food on the resident’s walker and “acted like a B.” LPA interviewed staff and residents regarding this allegation. Administrator and Staff stated they are provided training on ways to communicate with residents, and they do not speak to residents inappropriately. Unsubstantiated Staff do not yell at residents or make inappropriate comments. Staff treat residents with dignity and respect. LPA interviewed the administrator, who stated that it was brought to her attention and written statements from staff were provided for this incident. Per the statements, S1 knocked on the door and went inside the room to take out the trash. The resident started to yell, so the staff took out the trash and closed the door. LPA interviewed S1, who denied making any statements/comments to the resident while in the room. The other staff who was present confirmed that S1 did not talk back to the resident. Nine (9) out of ten (10) residents have not been spoken to inappropriately by the staff. Residents stated that staff are respectful and do not put them down. Allegation - Staff threatened to withhold the resident’s medication. It is alleged that the staff threatened to withhold the resident’s medication if the resident did not treat the new girl nicely. LPA interviewed the administrator and staff who had not heard any staff threatening the residents. Staff stated they are not allowed to and do not threaten residents to get them to comply or to treat others kindly. Nine (9) out of ten (10) residents stated they have never been threatened by the staff or seen staff threatening others. 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 with the administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Oct 6, 2025 · control 28-AS-20250922121137

Allegation investigated: Staff did not prevent resident from smoking in the room resulting in a fire. Staff are not responding to residents call button. Staff do not provide adequate food service to residents in care.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to review records and deliver findings on the above allegations. The purpose of the visit was explained to Executive Director Jacqueline Cortez. The investigation consisted of: On 6/17/2025, a physical plant tour of the interior and exterior was conducted, with special focus on medication room, residents' room signal system, kitchen food preparation/servings, and outdoor smoking areas. A total of nine (9) staff and 15 residents were interviewed. LPA reviewed and collected resident (R1 & R2's) file documents; which include Identification and Emergency Information, Physician's Report, Medication Administration Records, Care Plan, June 2025 food menus, alternative food menu, and kitchen resident diet list. LPA interviewed R1's pharmacist and Primary Care Physician's office representative. *Narrative continues next page. Unsubstantiated Allegation: Staff did not prevent resident from smoking in the room resulting in a fire. It is alleged that there was a fire in a resident rooms #143 or #144 and smoke was going into the hallway. Date of incident and resident room number is unknown. A total of 15 residents were interviewed. One (1) out of 15 residents confirmed the allegation. The majority of the residents said that they had no knowledge of any fire in the facility grounds. Residents stated they are allowed to smoke outside in the patio. A total of nine (9) staff were interviewed. All staff denied the allegation. Staff interviewed stated that most of the residents are compliant with smoking rules. The residents are not allowed to smoke in the front of the facility. There are 2 patios in the center area of the facility. During the physical plant inspection, there was no indication of a previous fire in the identified rooms and in other rooms toured. The facility has operable sprinklers. There is insufficient evidence to support the allegation. Allegation: Staff are not responding to residents call button. It is alleged that on 6/15/2025 at approximately 10:30 PM, a resident pressed the call button for incontinence care assistance and staff did not respond to the call, as a result another resident walked to the med-tech room and found the receptionist staff talking instead of responding to the call button request. A total of 15 residents were interviewed. Six (6) out of 15 residents stated they press the call button and often times staff take a long time to respond and/or they do not respond at all. Residents stated they call signal is operable, but the issue is staff response time. According to staff interviews, when residents press the call signal buttons in their room the receptionist communicates through walkie talkies and/or overhead speakers. If caregiver staff are busy, another caregiver is asked to assist with the call signal request. Staff stated staff in all shifts conduct 2-hour checks. Based on interviews conducted, the findings indicate there is a staff person at the front desk 24 hours a day/7 days a week, that monitors call from the signal system. Caregivers are to respond to call requests within a 7 minute time frame, and if they are busy then med-tech staff are to assist with call follow up. The signal system was tested and found to be operational. Staff responded promptly. There is insufficient evidence to support the allegation. Allegation: Staff do not provide adequate food service to residents in care. It is alleged that the facility serves burnt and hard to chew food, over season the food, put onions and peanuts on food of allergic residents, and they run out of bread, coffee, and milk. LPA toured the kitchen and dining room during lunch and dinner meal service. The food supply and cooked was inspected. A resident diet board was posted in the kitchen, meal ticket orders were observed, and the special diet list was reviewed to determine if resident (R1) requires a special diet. Resident (R1) requires a special diet. A total of 15 residents were interviewed, of which 3 residents stated the food is not good and does not meet their dietary requirements. However, most of the residents stated the food is good and a variety of foods are served. Staff interviews revealed that residents may select alternative food if they do not like the food items served during mealtimes. Staff stated they never run out of food and food delivery orders are Mondays and Thursdays. Staff said that some residents are picky eaters, but kitchen staff accommodate their requests. There is insufficient proof to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Jacqueline Cortez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 28-AS-20250616120107

Allegation investigated: Staff had inappropriate interactions with resident Staff does not treat resident with respect

Licensing Program Analyst’s (LPA’s) Christian Gutierrez, and Gabby Castro conducted a subsequent complain visit in regard to the allegations listed above. LPA’s met with Administrator Jackie Cortez and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 09/16/2025, LPA toured the facility and obtained copies of the following documents: staff roster, resident roster. During visit on 09/19/2025 LPA’s Gutierrez, and Castro interviewed: Administrator, staff #1-staff 6, residents #1-residents #10, obtained copies of R1 physician report, identification sheet, resident assessment, service plan, and R1’s intake notes. LPA’s also delivered findings. See 9099C Unsubstantiated In regard to the allegation “Staff had inappropriate interactions with resident”, and ‘Staff does not treat resident with respect”, it is alleged that staff inappropriately touched resident in care and are aggressive. During interviews with Administrator and staff seven (7) out of seven (7) stated that to their knowledge no staff has had any inappropriate interactions with residents. Administrator stated no corrective actions or write ups have been given addressing these concerns. Seven (7) out of seven (7) staff all stated that they treat all residents with dignity and respect and have not been aggressive with residents. During interviews with residents seven (7) out of ten (10) residents stated that staff has not been inappropriate with them and that they are treated with respect. R4 stated that staff should knock on their doors and that it’s disrespectful for them just to come in. 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 Jackie Cortezthe state’s words, verbatim · CDSS document, Sep 19, 2025 · control 28-AS-20250912150740

Allegation investigated: Staff did not seek medical assistance for resident in a timely manner

Licensing Program Analyst (LPA) Glenn Trueman, made an unannounced complaint visit in response to the above mentioned allegation. LPA met with Jacqueline Cortez, Administrator, and explained the purpose of the visit. At today's visit LPA obtained a copy of the staff and resident roster, and Staff Communication Notes. Interviewed Residents 2-8 ( R2-R8) and Staff 1-2 (Staff S1- S2). Administrator also interviewed. File was reviewed for Resident R1 and various documents to be submitted which included Physician's Report, Admissions Agreement and Emergency ID page. In regards to the allegation Staff did not seek medical assistance for resident in a timely manner, based on interviews conducted and information gathered Resident's R2-R5 all stated that they have had to go to the hospital and staff acted appropriately by calling 911 immediately. Stated the whole process of going to the hospital and back to the facility went smoothly. Resident's R6-R8 stated that staff assist with any medical needs. Stated that they have observed residents in need of medical assistance and the staff act quickly and if needed call 911 right away. Unsubstantiated R7 and R8 said they have gone to the hospital and 911 was called immediately and that staff communicates well and the process has gone smoothly. Spoke with Administrator who stated Resident R1 had an unwitnessed fall and was assessed. Stated R1 didn't have a head injury and everything was normal. Said R1 normally has slurred speech. Interview with Staff S1 who stated that R1 fell and was assessed right away and had no head injury, and no wounds. Vitals were normal. Said all was normal with R1. Stated slurred speech is normal. It is baseline. Interview with Staff S2 who stated that if resident had fallen they don't just send them to the hospital. They assess and with R1 didn't have a head injury or wound. Stated R1 was oriented x4 and R1 is self responsible and was fine and didn't want to go to the hospital. Admissions Record dated 2/19/24 lists R1 as responsible party. Staff communication notes state that on 09/09/25 at 12:10 AM that R1 was on the floor. Also said that there were no bumps or bruises and R1 didn't hit head or have any pain. It should be noted that R1 is currently in the hospital. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 28-AS-20250912092956

Allegation investigated: Staff pushed a resident in care. Staff spoke to residents in an inappropriate manner. Staff threatened a resident in care. Staff did not serve a meal to resident in a timely manner. Staff did not ensure that resident's medical needs are being met.

Licensing Program Analyst (LPA) Glenn Trueman, made an unannounced subsequent complaint visit in response to the above mentioned allegations. LPA met with Jacqueline Cortez, Administrator, and explained the purpose of the visit. The initial visit was conducted on 06/19/2025 and the following was done: LPA obtained a copy of the staff and resident roster, Special Incident Report's (SIR's), and Staff Communication Notes. Interviewed Residents 1-4 ( R1-R4) and Staff 1-2 (Staff S1- S2) File was reviewed for Resident R1 and various documents were submitted. At today's visit interviews were conducted with Resident's R5- R10, the Administrator and Staff S3. In regards to the allegations Staff pushed a resident in care, Staff spoke to residents in an inappropriate manner, Staff threatened a resident in care based in interviews conducted and information gathered 9 of 10 residents interviewed stated that staff have not been inappropriate with the residents.All stated that if anything the residents are the aggressors. Unsubstantiated They also stated they have not seen or heard of physical, or verbal abuse and no one has been threatened by the staff. Interview with Resident R10 who stated that R1 has been the aggressor toward Staff S3. Will also call Staff S3 and other staff racist words and seems like R1 has a vendetta toward S3. Said S3 is kind to all the residents. Interview with Staff S2 who said R1 is extremely mean and calls her the B word and she doesn't respond. No one pushed, yelled or threatened R1. If anyone does that it is her. R1 harasses staff and residents. Staff S3 stated R1 is the aggressor and said there has never been pushing, threatening or speaking inappropriately to R1 or any resident. The Administrator stated that Staff S3 didn't push R1. R1 harasses and calls S3 the B word. Said S3 is kind to all the residents. 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. In regards to the allegation Staff did not serve a meal to resident in a timely manner, based on interviews conducted and information gathered 9 out of 10 residents stated the food service is good and that they are all served pretty quickly for all 3 meals. Said the staff organize alot of residents very efficiently. The Administrator stated that there are multiple servers and the system is very good. Staff S1-S3 said the servers are very efficient and the process moves very fast for all 3 meals. Staff S3 stated that there is a red line in front of the kitchen and it says not to cross it because it's only for employees. Said R1 attempted to get in the kitchen 3x and service had just started when R1 said out loud I'm waiting 45 minutes. 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. In regards to the allegation Staff did not ensure that resident's medical needs are being met, based on interviews conducted and information gathered 9 out of 10 residents stated that staff will give immediate attention if it may be urgent and will call 911 right away. Said if they call for help staff come quickly. Said staff will arrange doctor appointments. R1 confirmed that facility arranged for her to go to the hospital after an unwitnessed fall. LPA during initial visit conducted on 06/19/2025 observed R1's call button to be operable. Resident R11 had been treated by Home Health and had gone to the hospital 06/18/2025 and moved out of the facility on 07/03/2025. Resident R6 stated that she had fallen and injured her foot and the staff came immediately after pressing the call button. Staff S1- S3 all stated that residents are helped right away and they call for assistance from the call button in their room. Said they also help immediately if they see the resident in need of medical attention. 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.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 28-AS-20250612164021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i)(1)(A)(B)(C) · Plan of correction due date: Sep 12, 2025

Maintenance and Operation Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Facility failed to have a signal system operable in R7 and R9's room which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Facility to submit by POC due date verification of a scheduled appointment with a company to repair call buttons. Also to submit receipts when the work is completed.

Allegation investigated: Resident was not accorded privacy while in care. Staff yelled at resident. Staff did not administer resident's medication in a timely manner. Facility is not meeting resident's dietary needs.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day investigation visit regarding the above-mentioned allegations. LPA met with Jacqueline Cortez, Executive Director and the reason for the visit was explained. The investigation consisted of the following: LPA obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 – Staff 9 (S1-S9) and Resident 1 – Resident (10), conducted record review for R1 and obtained copies of relevant documentation. Investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Resident was not accorded privacy while in care. It is alleged that staff enter a resident’s room during the night without consent, making it difficult to sleep. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff indicated that staff have to enter rooms to conduct health checks on all residents, particularly those who need assistance with (ADLs) which include doing checks on residents during the night shift. Staff stated that before entering residents’ rooms, they must knock, announce themselves and wait for permission from residents to enter their rooms. Interviews with staff further indicated, staff are respectful of residents’ privacy and will only visit rooms if residents allow staff to enter or if there is a medical emergency and staff need to have access to residents in distress. Interviews with (9) out of (10) residents indicated they are accorded with privacy, and they do not have any concerns. Residents further indicated that staff are respectful when visiting their rooms and understand that staff have to enter their rooms to help meet their needs. Interview with R1 indicated that staff were entering their room during the night shift without R1 requesting staff to come to their side; however, staff are now visiting their room, once before bedtime to get help with personal hygiene and then in the morning to help R1 prepare for their day. Staff and resident interviews do not corroborate the allegation. Regarding: Staff yelled at resident. It is alleged that staff are verbally aggressive and that staff yell at a resident. Interviews with (9) out of (9) deny the allegation. Staff interviews revealed that staff are not verbally aggressive toward residents nor yell at them. Staff also indicated that they have not heard other staff yell at residents. Staff stated they are respectful and use a soft tone of voice when speaking to residents. Interviews with (9) out of (10) residents indicated, staff do not use verbal aggression nor yell at them. Residents indicated, staff are friendly and respectful when talking to residents. Residents further stated staff interactions are appropriate, and they have no concerns. Interview with R1 indicated, staff sometimes do not talk to them calmly and use loud tones of voice when speaking to them; however, the situation has become better, and staff are using more appropriate tones to talk to R1. Staff and resident interviews do not corroborate the allegation. Regarding: Staff did not administer resident's medication in a timely manner. It is alleged that staff are not checking a resident’s vitals nor providing resident with their medication in a timely manner. Staff deny the allegation. Interviews with (6) out of (6) staff indicated, R1has been provided with their medication in a timely manner. Staff indicated that R1 receives all their medication as prescribed by their doctor, and medication is administered on time and documented accordingly. However, R1 has been requesting Acetaminophen 500 mg. tablets (PRN) in between the doctor prescribed doses which are to be given to R1 for pain every six hours. Staff have informed R1, they cannot receive “extra” doses of the Acetaminophen tablets outside of the doctor ordered doses which are given to R1 every six hours for recurring pain. Staff have explained to R1 that over-medication can be harmful to their health and therefore, physician’s orders have to be followed. Staff also indicated, vitals are taken of residents if there is a physician’s order in place or if resident is experiencing a medical emergency. Staff further stated, R1 does not have an order by their physician to have their vitals checked; however, if R1 complains about having a medical emergency, staff will proceed with taking vitals and getting the appropriate medical attention for R1. Record review/eMAR for R1 indicated, R1 is receiving their daily doses of Acetaminophen 500 mg. tablets (PRN) as prescribed by their doctor. Record review for R1 also indicated, R1 does not have an order from their physician for staff to check their vital signs in R1’s facility record. Interview with R1 indicated, they request “extra” Acetaminophen tablets from staff because they want to take it before the recurring pain in her knee and sometimes headaches set in. Interviews with (9) out of (10) residents indicated they have no concerns with receiving their medication in a timely manner. Staff and resident interviews and record review do not corroborate the allegation. Regarding: Facility is not meeting resident's dietary needs. It is alleged that resident is having difficulty eating the food served in the facility. Interviews with (6) out of (6) staff deny the allegation. Interviews with staff indicated, when providing meals to R1, they have to follow the mechanical diet specifications so that R1 can eat their meals conformably. Specifications indicate, R1’s food has to be soft and chopped which is ordered by R1’s doctor. Staff indicated, all kitchen staff follow the dietary needs of all residents who need modifications when preparing their food. ***Continues on LIC 9099-C page 2 When residents want something other than what is on the menu, they can choose something from the alternative menu which will also be modified to meet their dietary needs. Staff further stated, resident allergies, intolerances and type of modifications needed are posted in the kitchen and updated accordingly. Interviews with (9) out of (10) residents stated, facility provides them with adequately prepared food for their dietary needs and have no concerns. Interview with R1 indicated, facility’s kitchen does not prepare their food to their liking and stated that they give R1 the same food every day. LPA observation of R1’s meal services (breakfast and lunch) indicated, items on R1’s plates were observed chopped and served according to physician orders. Review of the facility’s menu indicated there is proper variation of food items throughout the month. Review of R1’s records indicate, resident is to be provided with a mechanical soft diet which should consist of soft, chopped food items. Further record review indicated, kitchen has updated list of resident dietary needs which is referred to when preparing resident meals. Staff and resident interviews, LPA observations and record review do not corroborate the allegation. 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 Jacqueline Cortez, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 8, 2025 · control 28-AS-20250902101443

Allegation investigated: Staff are mismanaging resident's medications.

***This is a corrected version of the original report dated 8/11/25. The purpose of the report is to correct a deficiency issued in error on the LIC 9099-D (section 87465 (b)(3)) which will be dismissed. On today's visit, LPA is issuing a citation under section 87465(c)(3)*** Licensing Program Analyst, Mayra Cota, conducted a subsequent visit to investigate the allegation above. LPA met with Jacqueline Cortez, Exective Director and the reason for the visit was explained. Itnitial 10-day visit was conducted on 6/5/25 by LPA Cota. During initial visit, LPA, obtained a copy of the staff and resident rosters, conducted medication review and obtained medication records for Residents 1-8 (R1-R8). Interviews were also conducted with Staff 1-8 (S1-S8). During today's visit, LPA obtained copies of staff and resident rosters, toured common areas of the facility, interviewed Resident 1 - Resident 8 (R1-R8) and delivered findings. ***Continues on LIC 9099-C Substantiated The investigation revealed the following: Regarding: Staff are mismanaging resident's medications. It is alleged that Medication Administration Record (MAR) had multiple medication errors regarding a medication dose for pain relief. The medication in reference to is Oxycodone. It was reported that medication error is on file at RCFE. QuckMAR reviewed for R1 indicated, medication administration was not recorded on May 2, 2025, for the 2:00 p.m. dose, May 4, 2025, for the 2:00 p.m. dose and May 5, 2025, for the 8:00 p.m. dose of the PRN Oxycodone-Acetaminophen 325 mg tablets. The three days are missing initials from administering staff. Interview with S2 indicated, staff did not "click" on the days which are missing initials, which would indicate that medication was administered correctly to resident. S2 further indicated, most likely, R1 did receive the medication on the days the initials are missing; however, the missing initials on R1's QuickMar are errors made by med-techs for not "clicking" on those specific days after "popping" the medication and giving it to R1. S2 further indicated, R1 would not miss doses of this particular medication because R1 has chronic pain and the medication helps alleviate it. S2-S8 acknowledged during interviews that sometimes, med-techs forget to "click" on the QuickMar after administering medication to residents to indicate that it was provided. Staff also indicated, QuickMar, at times, has connectivity issues and therefore, a "back-up" paper MAR is kept to document the administration of medication like Oxycodone for those residents who are prescribed to take it. At the time of visit, R1's paper MAR for May 2025, was not available for review for the fore mentioned dates. Interview with R1 indicated, staff are administering all their medication correctly and in a timely manner. R1 further stated, med-techs have not missed any dosages of their medication, especially their PRN Oxycodone because they suffer from chronic back pain and therefore, they need it to ease their pain. Interviews with R2-R8 indicated, they have no concerns regarding how the facility manages their medication. It has been found that there is sufficient evidence to corroborate the allegation. Based on record review and staff and resident interviews, the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and the resident's response for May 2, 4 and 5, 2025 for R1. The preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099- D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 28-AS-20250530112753

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Aug 18, 2025

Incidental Medical and Dental Care 87465(c)(3): (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: at the time of visit on 8/11/25, the facility was unable to provide a record of each dose including date and time the PRN medication was taken, the dosage taken, and teh resident's response for May 2, 4 and 5, 2025 for R1.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will ensure med-techs receive additional training regarding proper documentation of medication administration, documenting and reporting documentation errors and notifying physicians of errors by POC due date. Licensee will send training sign-in log and an agenda stating the topics discussed with staff.

Allegation investigated: Facility staff do not provide resident with their medications as prescribed. Facility staff do not provide adequate food service to resident in care. Facility staff do not assist residents with clothing.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent investigation visit to deliver findings for the above mentioned allegations. LPA met with Jacqueline Cortez, Executive Director and the reason for the visit was explained. The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, toured the physical plant, inspected 12 resident rooms, interviewed Residents #1-12 (R1-R12) and Staff #1-11 (S1-S11). Medication review was conducted for R1, and copies of medication records for R1 were obtained. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff do not provide resident with their medication as prescribed. It is alleged that staff failed to provide resident with medications as scheduled and ordered by physician. The investigation revealed the following: Facility staff deny the allegation. Interviews with S1-S2 indicated, resident arrived to the facility from skilled nursing hospital with a five-day supply of medication due to R1's new order not being filled till 5/20/25 per pending order status on R1’s physician order documents. Staff stated R1’s family member, delivered medication from pharmacy not contracted with the facility due to R1’s medical insurance being outside of facility’s network before the five-day supply finished. Staff interviews further indicated, family member delivered the medication and staff have been providing the medication to resident as prescribed and without interruption. Interview with R1’s family member (authorized representative) indicated, they brought R1 from the skilled nursing hospital to the facility with a five-day supply of medication. Family member stated, once R1’s pharmacy called family member to pick up the new medication order, it was picked up and promptly delivered to the facility and given to the med-tech staff to store and administer to R1. Family member stated, per their observations during their visits to R1, staff are providing R1 with all their medication as prescribed. LPA's review of resident’s LIC 622/Centrally Stored Medication and Destruction Record indicates, medication was started as of 5/15/25. Review of Medication Administration Record (MAR) for resident also indicates medications were administered as of 5/15/25. Review of resident’s file indicated resident was admitted to the facility on 5/14/25 from skilled nursing hospital. LPA reviewed R1's medication and found all medication prescribed to be present at the facility. Interviews with (10) out of (12) residents indicated, staff provide them with their medication as prescribed. Two (2) residents manage their own medication and therefore, do not get medication from facility staff. Medication and record review, interviews with staff, family member and residents do not corroborate the allegation. Regarding: Facility staff do not provide adequate food service to resident in care. It is alleged that staff have frequently failed to provide resident with meals and water and is often left hungry. Interviews with (7) staff indicated, the kitchen provides food to all residents, daily, whether meals are served in the dining room or delivered to their room. Sufficient food is prepared for residents, and extra food is available for residents who wish to have additional portions. ****Continues on LIC 9099-C page 2 Staff stated, if physician’s orders call for a texture-modified diet, it is prepared accordingly and provided to the resident to ensure they can eat it. Staff follow the resident diet list to ensure residents receive proper meals to meet their needs. Staff also stated, water and other drinks like a variety of juices, milk and coffee are always available for residents throughout the day. Interviews with (10) out of (12) residents indicated, the kitchen provides them with scheduled meals every day and have not missed a meal, whether delivered to their room or served to them in the dining room. Residents stated, kitchen staff make changes to their meal when requested and sufficient food is available. Residents stated, the kitchen has an alternative menu which they can order from if they prefer something different from the regular menu. Residents stated, water and other drinks are available for residents throughout the day. One (1) resident interviewed did not provide information about the facility's food service because they purchase their own food. Interview with R1’s family member indicated, they have observed R1 receiving their meals from staff which they deliver to R1’s room as scheduled. Family member stated, R1 gets food which they can chew, and portions are plentiful. Family member stated, they have observed staff encourage R1 to eat and even help with setting R1 to eat when food is delivered to R1’s room. Family member also stated, staff assist R1 by taking R1 to meal service in the dining area via wheelchair to eat and socialize with other residents. Family member stated, they feel the staff are providing nutritious meals on time and for the ability to be eaten by R1. LPA observation of food preparation and service in the kitchen indicates meals are being provided to meet resident’s dietary needs. Observation also indicated, meals are delivered accordingly to resident’s rooms during scheduled time, along with drinks. Water and other drinks like apple juice and milk were observed during service and are available for residents to take at any time. Staff, resident and family member interviews, and LPA observation do not corroborate the allegation. Regarding: Facility staff do not assist residents with clothing. It is alleged that resident is unable to call for staff for assistance with diapering or getting dressed because her call button is not working, which leaves resident having to complete those tasks by themselves. Interviews with (5) staff indicated, caregiving staff help residents when help is requested, with dressing, personal hygiene and other activities of daily living (ADLs). When assistance is warranted due to health impairments which limit resident’s ability to do things on their own, staff are available to provide care to residents. Staff stated, not only do they follow physician’s orders when providing care to residents per their abilities and limitations but also help in any way even when residents don’t have limitations. Staff are courteous and responsive to all residents. ***Continues on LIC 9099-C page 3 Staff stated, R1 is helped requested and during scheduled rounds to their room. Staff stated, there are times, R1 is offered help with dressing, but has refused to let caregivers assist because R1 states, they can do it themselves. Staff further stated, R1’s requests for assistance from staff are answered and not ignored. Interviews with (10) out of (12) residents indicated, caregivers help with things like dressing, personal hygiene, and other activities of daily living (ADLs) when requested and during caregiver’s rounds when visiting residents who need the assistance. Interview with R1 family member indicated, R1 is alert and can independently take care of their ADLs. R1 stated, they have observed caregivers coming to R1’s room to conduct care; however, R1 refuses to let staff help. R1 family member stated, they observed caregivers be courteous and responsive to R1’s requests. Interviews with residents, staff and R1 family member do not corroborate the allegation. 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 Jacqueline Cortez, Executive Director and a copy of this report was provided. Regarding: Resident call bell is inoperable. It is alleged that resident is unable to call staff for assistance due to call bell now working. LPA inspected (24) call buttons in (12) resident rooms. During inspection, (4) out of (24) call buttons were inoperable. When buttons were pressed on the call speakers, staff did not respond to the call made by LPA during testing for (4) call attempts. LPA conducted observation of the switchboard located in the main office which alerts staff of the calls made by residents and found that the (4) buttons located in the (2) resident rooms, did not trigger an alert. Front desk staff further indicated, they did not get an alert when the call button was pushed for those particular rooms. Interview with S1 indicated, when those call buttons were checked by maintenance staff, they observed that the internal wiring was malfunctioning. LPA tested R1's call button and observed it to be operable during visit. Interview with staff and LPA observations corroborate the allegation. Based on LPA’s observations and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 28-AS-20250527152658

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(A) · Plan of correction due date: Aug 29, 2025

87303 (i)(A) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (A) Operate from each resident’s living unit. This requirement is not met as evidence by: During inspection, (4) out of (24) call buttons were inoperable. Four (4) buttons located in (2) resident rooms, did not trigger an alert to front desk staff.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Licensee will conduct checks to ensure call buttons are working properly in resident rooms. Licensee will log call button inspections for the next five days and provide LPA a copy of the log by POC due date.

Allegation investigated: Staff do not ensure medications are inaccessible to others in care. Staff do not follow proper food handling practices.

Licensing Program Analyst, Mayra Cota, conducted subsequent complaint investigation visit to deliver findings for the above mentioned allegations. LPA met with Jacqueline Corez, Executive Director and the reason of the visit was explained. The investigation consisted of the following: LPA, toured common areas of the facility, including the kitchen and dining room, conducted interviews with Staff 1 - Staff 13 (S1-S13) and Resident 1 - Resident 14 (R1-R14). Unsubstantiated Regarding: Staff do not ensure medications are inaccessible to others in care. It is alleged that staff often leave medications unattended in the dining room. It is alleged that a resident was given medication by Med-Tech staff; however, the resident did not take the medication and the medication remained on the table in the cup for over an hour. It is also alleged that this was not the first instance of medications being left accessible and unattended in the dining area. The investigation revealed the following: Thirteen (13) out (13) staff deny the allegation. Interviews with staff indicated, they have not observed medication left accessible and unattended in the dining room nor have they observed medication left accessible and unattended in any other location in the facility. Eight (8) staff stated that medication administration procedures require medication technicians to provide scheduled medications to residents in a small cup and provide them with drinking water and supervise the residents as they take it. Staff stated technicians cannot walk away from residents until they ensure residents consume their medications whether taken in the dining room, their rooms or anywhere else in the facility. Staff visually check to see if residents swallow medication before moving on to assist the next resident with their medication. If residents want to wait on taking their medication, staff cannot leave scheduled medication with residents. Staff take back medications, lock them in the medication cart and inform residents they will come back to give them their medication when they are ready to take it. Interviews with (12) out of (14) residents indicated they have not observed medication left unattended and accessible to residents in the dining room by staff nor have they observed medication left accessible to residents and unattended in any other location in the facility. Ten (10) residents who need assistance with medication administration stated, staff wait for residents to take their medication before they walk away and take back any medication not taken at the time. One (1) of (14) residents did not provide information regarding this allegation. ****Continues on LIC 9099-C page 2 Regarding: Staff do not follow proper food handling procedures. It is alleged that resident noticed a long black hair in resident’s baked potato and stated that roommate does not have black hair. Staff deny the allegation. Interviews with (13) out of (13) staff indicated that residents have not complained about observing hair in the food prepared and provided by the facility’s kitchen. Interviews with eight (8) staff indicated that it is mandatory for staff handling food during preparation and service to use gloves and hairnets to prevent foreign objects from falling into the food. Staff further stated hand washing practices are always enforced. Food handling gloves are changed between handling different food items to ensure safe food handling practices. Food is covered with plastic film or refrigerated to avoid anything falling into it before it is served. Staff stated cutting boards are specifically assigned for the preparation of all proteins and all surfaces are cleaned and disinfected before and after use. All staff monitor food as it is going out for consumption to ensure freshness. Twelve (12) out of (14) residents indicated, they have never observed hair in their food when taken in the dining room or when it’s delivered to their room by staff. Residents stated the food is well prepared and during visits to the dining room, kitchen staff are observed wearing hair nets and food gloves. One (1) out of (14) residents did not provide information regarding this allegation. During tour of the kitchen and dining area, LPA observed staff wearing hair nets and food handling gloves during food preparation and service to residents. Food which was ready to be served was observed covered before servers brought it out to the residents in the dining area. LPA observation also indicated, meal trays on the kitchen carts which were ready to be delivered to resident's rooms, were also individually covered. Interviews with staff and residents and LPA observations do not corroborate the allegation. 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, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025 · control 28-AS-20250606124958

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit to follow up on a Special Incident Report (SIR) received on 7/30/25. LPA met with Jacqueline Cortez, Executive Director and explained the reason for the visit. Per SIR, Resident 1 (R1) was found in their room on the floor and was observed to be disoriented on 7/28/25. Staff made a 911 call and R1 was transported to the hospital for further treatment and evaluation. SIR also indicated, R1 was displaying signs of possible accidental overdose when found in their room. During today's visit LPA interviewed Executive Director (Staff 1/S1) who stated, R1 was transported to the hospital due to displaying signs of possible accidental overdose from mismanaging their medication. At the hospital, R1 was treated for possible overdose and was released to a skilled nursing facility due to the incident. S1 further stated, R1 will no longer be coming back to the facility due to R1 requiring a higher level of care. Interviews with Wellness Director and med-tech staff 1 (S1) indicated, R1 was managing their own medication and R1 had never experienced a medical emergency like the one experienced on 7/28/25. Review of R1's Clinical Requisition/Physician's Orders documentation indicated, R1 was able to self-administer medication. LPA toured common areas of the facility and no immediate health and safety concerns were observed during time of visit. No deficiencies noted during today's visit. Exit interview held with Jacqueline Cortez and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 18, 2025

Allegation investigated: Staff mismanaged resident's medications.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit for the allegation listed above. LPA arrived unannounced and met with the Business Office Manager, Alisa Dean, to explain the reason for the visit. On 7/25/25, LPA Chan conducted the initial visit and interviewed Staff #1 - #5 and Residents #1 - #10. LPA obtained copies of the staff and resident rosters and reviewed medications for ten residents. Staff #6 - #8 were interviewed via telephone on another date. The investigation revealed the following: Allegation – Staff mismanaged resident’s medications. It is alleged that Resident #1 (R1) needed the Nitroglycerin pill but was told by staff that they had lost it. Substantiated During the visit on 7/25/25, LPA reviewed medications for ten residents. LPA observed all of R1’s medications in the med room, including the Nitroglycerin tablet, and they are managed by the staff. The Nitroglycerin medication is a PRN and is given to the resident upon request. LPA interviewed the medication staff regarding this allegation. One of the staff confirmed that the Nitroglycerin medication could not be found on 7/17/25 when R1 requested it. Staff stated another staff helped search for the medication but could not find it either, so R1 was sent out to the hospital. The staff on the next shift was able to locate the medication. Eight (8) out of ten (10) residents stated that the staff do not give them their medications on time and/or that they were missing. Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided. The meal plan is created with residents’ suggestions and their dietary needs. The cooks stated they include servings from the different food groups and ensure there are alternatives each day. Staff stated they follow any special diets that each resident may have. If a resident’s dietary needs change, the kitchen staff are informed right away. Staff interviewed also stated there are sugar-free drinks and desserts available for residents. Staff provide sugar-free drinks and desserts to those who are diabetic; however, if they choose to get the regular ones, staff will give to them even though they remind them they should not consume sugary items. During the kitchen tour on 7/25/25, LPA observed sufficient food supplies with fresh vegetables and sugar-free drinks and desserts. The kitchen has a list of residents who have dietary needs/restrictions and are diabetic. Two (2) out of (10) residents interviewed feel that the facility does not have sugar-free drinks and desserts, and the food is cooked with lots of sugar. Eight of the residents stated the facility serves sugar-free items and offers a variety of food. 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 via telephone. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 28-AS-20250722152959

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

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview, Staff could not find R1's PRN medication which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2025

Plan of correction: The licensee shall submit a written plan explaining how PRN medications are stored and documented when given. The plan is due to LPA by 8/16/25.

Allegation investigated: Staff does not ensure residents are provided clean towels. Facility has unqualified staff dispensing medications to residents in care. Staff does not ensure medications are dispensed as prescribed. Staff does not ensure residents incontinence care needs are being met in a timely manner. Staff was observed using smoking products while in the facility.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit to investigate the allegations above. LPA discussed the purpose of the visit with Executive Director Jacqueline Cortez/ The investigation consisted of: A physical plant inspection of laundry room, common areas, outdoor designated smoking area, and resident rooms was conducted. Residents (R1- R13) and staff (S1- S12) were interviewed. Resident (R14) is currently at a higher level of care facility and was not interviewed. Copies of relevant documents were obtained. *Narrative continues next page. Unsubstantiated Allegation: Staff does not ensure residents are provided clean towels. It is alleged that over the weekend of Aug. 9, 2025 - Aug. 10, 2025, there were no clean towels for resident use. A total of 13 residents were interviewed, of which all denied the allegation. A total of 12 staff were interviewed. Staff interviews revealed that the facility has a contract with a linen service company that drops off clean linens twice a week. On August 1, 2025, the facility changed linen companies from Mission Linen to Braun Linen. Braun Linen drops off items [sheets/pillow cases, hand/bath towels, blankets, and kitchen linen supplies every Tuesday and Friday. Per staff interviews, there was never a linen/towel shortage during the transition of linen service. Staff denied the allegation and stated all residents were provided clean towels the weekend of 8/9/25- 8/10/25. Residents are provided towels that are to be kept in their bathroom for regular use. Staff interviews revealed that the facility has a large inventory of linens and towels, but has a housekeeping staff shortage, which sometimes causes resident requests i.e. additional towel delivery to rooms to be delayed. LPA inspected the laundry area and observed sufficient towels and linens in the laundry room and 5 large bins outside the laundry area that contained clean linens/towels. Allegation: Facility has unqualified staff dispensing medications to residents in care. It is alleged that due to staff shortages the facility has staff working double shifts, and kitchen staff are also working as med-techs. All the residents interviewed stated they do not know whether med-techs are qualified for the job. Staff interviews revealed that staff (S7) began working at the facility as a server and was promoted to medication technician in March 2025. Based on record review, the findings indicate that staff (S7) completed 8 hours of medication administration training on March 16, 2025. There are 15 med-tech employed at the facility. Record review confirmed all have completed medication administration training. Therefore, the allegation cannot be supported. Allegation: Staff does not ensure medications are dispensed as prescribed. It is alleged that approximately 2 weeks ago a staff tried giving resident (R1) a pink medication pill that is not prescribed to the resident. According to information obtained, the alleged staff was suspended. Staff interviews revealed that on 7/21/25, caregiver staff (S8) entered R1 and R14's room and placed a medication cup near R1, that contained a Tylenol pill that was given to S8 by S11 for personal use. Resident (R1) picked up the medication cup and told staff it is not their medication. Caregiver (S8) stated that they were wearing gloves when they entered R1's room, and placed the medication cup on R1's walker while they removed their gloves and did not administer the medication to R1. Med-tech staff (S11) said they administered to R14 their Rosuvastatin Calcium 20 mg tab. According to S8, they only placed the Tylenol medication there while the gloves were removed. However, staff (S8) is not a med-tech, therefore should not have handled any medications in a resident's room. Neither staff were suspended. This allegation was investigated on a previous complaint control # 28-AS-20250722151911, in which the allegation was substantiated. LPA was provided copies of proof of correction addressing the aforementioned allegation. Therefore, the allegation is not supported because it has been addressed. Allegation: Staff does not ensure residents incontinence care needs are being met in a timely manner. it is alleged that staff leave residents in wet diapers for extended periods of time. The complaint alleges staff do not change incontinent residents as required. A total of 13 residents were interviewed. One (1) out of 13 residents confirmed the allegation. Residents said they are checked and changed often by staff, but on occasion the residents are left wet due to staff shortages and later response times. Staff interviews revealed that residents are checked every 2 hours and are assisted with incontinence care if needed. All staff denied the allegation, and said they have no knowledge of resident concerns pertaining to incontinence care. There is not sufficient proof to support the allegation. Allegation: Staff was observed using smoking products while in the facility. The complaint alleges that facility employees have been seen smoking in the building. Based on staff and resident interviews, the facility has an outdoor patio area designated as the smoking area for residents. All residents and staff denied seeing any staff smoke in the premises. Staff interviews revealed that the facility is a smoke-free workplace for all employees, and prohibits smoking e-cigarettes and vapor cigarettes. Based on interviews, in the past there was a staff person that smoked, but they have not worked at the facility since early 2025. There is insufficient proof to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Executive Director Jacqueline Cortez. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 28-AS-20250811083659

Allegation investigated: Staff are mismanaging resident's medications.

Licensing Program Analyst, Mayra Cota, conducted a subsequent visit to investigate the allegation above. LPA met with Jacqueline Cortez, Exective Director and the reason for the visit was explained. Itnitial 10-day visit was conducted on 6/5/25 by LPA Cota. During initial visit, LPA, obtained a copy of the staff and resident rosters, conducted medication review and obtained medication records for Residents 1-8 (R1-R8). Interviews were also conducted with Staff 1-8 (S1-S8). During today's visit, LPA obtained copies of staff and resident rosters, toured common areas of the facility, interviewed Resident 1 - Resident 8 (R1-R8) and delivered findings. The investigation revealed the following: ***Continues on LIC 9099-C Substantiated Regarding: Staff are mismanaging resident's medications. It is alleged that Medication Administration Record (MAR) had multiple medication errors regarding a medication dose for pain relief. The medication in reference to is Oxycodone. It was reported that medication error is on file at RCFE. QuckMAR reviewed for R1 indicated, medication administration was not recorded on May 2, 2025, for the 2:00 p.m. dose, May 4, 2025, for the 2:00 p.m. dose and May 5, 2025, for the 8:00 p.m. dose of the Oxycodone-Acetaminophen 325 mg tablets. The three days are missing initials from administering staff. Interview with S2 indicated, staff did not "click" on the days which are missing initials, which would indicate that medication was administered correctly to resident. S2 further indicated, most likely, R1 did receive the medication on the days the initials are missing; however, the missing initials on R1's QuickMar are errors made by med-techs for not "clicking" on those specific days after "popping" the medication and giving it to R1. S2 further indicated, R1 would not miss doses of this particular medication because R1 has chronic pain and the medication helps alleviate it. S2-S8 acknowledged during interviews that sometimes, med-techs forget to "click" on the QuickMar after administering medication to residents to indicate that it was provided. Staff also indicated, QuickMar, at times, has connectivity issues and therefore, a "back-up" paper MAR is kept to document the administration of medication like Oxycodone for those residents who are prescribed to take it. At the time of visit, R1's paper MAR for May 2025, was not available for review for the fore mentioned dates. Interview with R1 indicated, staff are administering all their medication correctly and in a timely manner. R1 further stated, med-techs have not missed any dosages of their medication, especially their Oxycodone because they suffer from chronic back pain and therefore, they need it to ease their pain. Interviews with R2-R8 indicated, they have no concerns regarding how the facility manages their medication. It has been found that there is sufficient evidence to corroborate the allegation. Based on record review and staff and resident interviews, staff did not ensure that QuickMar for R1 for was adequately completed and thus the preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099- D. An exit interview was conducted with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 28-AS-20250530112753

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(b)(3) · Plan of correction due date: Aug 18, 2025

Incidental Medical and Dental Care (b) If resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: QuickMAR has multiple medication errors regarding a medication dose for pain relief for May 2, 4 and 5, 2025 for R1.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Licensee will ensure med-techs receive additional training regarding proper documentation of medication administration, documenting and reporting documentation errors and notifying physicians of errors by POC due date. Licensee will send training sign-in log and an agenda stating the topics discussed with staff.

Allegation investigated: Staff does not ensure resident's door lock is in good repair.

Licensing Program Analyst, Mayra Cota, conducted a 10-day complaint visit today and met with Jacqueline Cortez, Executive Director. The reason for the visit was explained. The investigation consisted of the following: During today’s visit, LPA, obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 – Staff 4 (S1-S4) and Resident 1 – Resident 9 (R1-R9), inspected (9) resident rooms with a focus on inspecting the locks on the doors, leading into their rooms. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff does not ensure resident's door lock is in good repair. It is alleged that the lock in resident's room is broken and door had to be forced open by maintenance. It is also alleged, maintenance tried to fix it but were unable to. Interviews with S1-S4 revealed that R1's door lock malfunction was reported to maintenance staff on 8/2/25. S2 indicated, they contacted the locksmith the facility regularly hires, on the same day the issue was reported by R1. Locksmith was scheduled to come out on 8/4/25; however; S1-S3 stated, locksmith did not come out as they had scheduled to do so, because the door lock ordered to replace R1's had not yet arrived to the locksmith’s shop. S1 indicated, they talked to S2 and S3 to see if something else could be done to repair the lock for R1's room while they waited for the locksmith to come out. S1-S3 stated that the facility had an extra door lock from a vacant room which was installed on R1's door on 8/7/25 while staff wait for the locksmith to deliver and install the new door lock and to ensure R1 could lock their door, accordingly. S1-S4 revealed, after the malfunctioning door lock was checked and removed for replacement, staff found that the doorknob had glue inside the keyhole. Staff stated, in the past, they had an issue with a resident putting "Gorilla" glue in the key holes of some residents doors as a type of "prank" which they believe caused R1's door lock to malfunction. Staff further indicated that they did not forcefully open R1’s door; however, they had to wiggle the key to soften the glue which was still not completely dry. S1-S3 also stated, they did not ignore R1’s concern for their malfunctioning doorknob. They kept R1 in communication and resolved the issue as best as they could. Interview with R1 indicated, they are glad the doorknob was replaced by a new one. R1 stated, "It was fixed and now my door works. I was given a new shiny key and they tested it and I also tested it myself." R1 indicated, staff installed the new lock and made sure the door locked and unlocked appropriately. R1 further indicated, they have no more concerns regarding their door lock because staff were able to fix it as fast as they could. Inspection of (9) out of (9) resident rooms, including R1's indicated, doors can lock and unlock properly. LPA inspected the (9) locks on each door and found them to be in good repair. Interviews with (8) out (9) staff indicated, their door locks work properly and have not had any issues. Nine (9) out of (9) residents stated, they know they can report to administrative and maintenance staff if they need repairs of any kind done in their room. LPA also, received confirmation of delivered door locks which will be kept on hand if replacement is needed, via photo from S2. Staff and resident interviews and LPA observations do not corroborate the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted,with Jacqueline Cortez, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 28-AS-20250806113019

Allegation investigated: Staff administered the incorrect medication to resident.

***This is an amendment of the original report. The purpose of the amendment is to correct an error on the LIC 9099-D (citation). There is no change in the findings. The findings remain the same.*** Licensing Program Analyst (LPA), Mayra Cota, conducted unannounced 10-day investigation visit regarding the above mentioned allegation. LPA Cota, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained. The investigation consisted of the following: LPA Cota, obtained copies of staff and resident rosters, toured the common areas of the facility, with a focus on inspecting the medication room and medication for Resident 1 (R1), interviewed Staff 1 - Staff (S1-S5) and Resident 1- Resident 5 (R1-R5) and obtained copies of relevant documentation. ***Report continues on LIC-9099 Substantiated Regarding allegation: Staff administered the incorrect medication to resident. It is alleged that caregiving staff gave R1 medicine on 7/21/25 at around 8:00 p.m., which is not prescribed to R1 and was told to take it. It is alleged that when R1 told staff the medication wasn’t theirs, caregiving staff told R1 “You gotta take it.” The investigation revealed the following: Interviews with Staff 1 – Staff 6 (S1-S6) revealed, caregiving staff are not allowed to administer medication to residents at any time. S1-S6 stated, the only staff who are allowed and qualified to administer medication are medical technicians per education training, facility policy and procedures. However, interview with S3 (caregiver) indicated, they were asked by S5 to please give R2 (R1’s roommate) a medication as S5 waited outside R2’s room with medication cart during medication pass, due to R1 not allowing S5 to enter R1’s room. S3 stated, they took the cup with a “pink” pill from S5 because S5 asked S3 to please give R2 the medication, even though S3 is aware that only medical technician staff are allowed to do so, which S3 is not. S3 stated, they proceeded to enter R1/R2’s room, and once in the room, S3 placed the cup with the medication on R1’s walker table. S3 stated, the medication was meant for R2 and not for R1 which at that time, S3 was able to retrieve the cup with the medication from R1 and proceeded to give it to R2. S5, denies the allegation; however, record review of R2’s medication administration record (QuickMar) for July 2025 indicates, S5 signed off on administrating R2’s bedtime routine medication at 8:00 p.m. on 7/21/25, which S5 does admit to being the staff who passed R2’s medication on that day. Interview with R1 indicated, S3 gave them the cup of medication with a “pink” pill which they did not take due to medication not being part of their regular routine medication prescribed by their doctor. R1 further indicated, they do not take any “pink” pills with their routine medication and can identify exactly which medication R1 takes, daily. Review of R1’s medication indicated, R1 does not take any medication fitting the description of the pill given to them by S3 on 7/21/25. Further review of R2’s medication revealed, R2 takes medication which includes a pink pill of Rosuvastatin Calcium 20mg tab which was administered on 7/21/25 at 8:00 p.m. by S5. R2 was unable to be interviewed due to being hospitalized at the time of visit. LPA observation, record review, and staff and resident interviews, corroborate the allegation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2025 · control 28-AS-20250722151911

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Jul 29, 2025

87411(d)(4) Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met as evidenced by: based on observation, staff and resident interviews and record review, licensee did not ensure that caregiving staff who are not qualified to administer medication to residents refrain from administering medication to a resident.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee will conduct training with caregiving and medical technician staff regarding medication administration policies and precedures. Licensee will submit proof of training by POC due date in a form of sign-in log of staff in attendance and topics discussed via an agenda of training.

Type of visit: POC

Licensing Program Analyst, (LPA), Mayra Cota, conducted a Plan of Correction (POC) visit today. LPA met with Jacqueline Cortez, Executive Director, and explained the reason for the visit. During today’s visit, Civil Penalties were assessed for Sections CCR 87555(b)(27), 87555(b)(29), 87303(e)(3), 87303(e)(4) and 87465(a)(4) for deficiencies issued on 7/17/25 for Failure to Correct by Plan Of Correction (POC) due date of 7/18/25. Civil Penalties which were assessed today for $1000 each deficiency not corrected, total to $5000. LPA Cota, received POCs during today’s visit of 7/28/25 by means of obtaining photo of repair of the grab bar in resident's bathroom, purchase receipt for container lids replaced in the food pantry, photo of water temperature warining sign above the kitchen dishwashing sink, service receipt for pest control conducted on 7/25/25 and in-service training sign-in log which took place on 7/21/25 for medication administration policy and procedures. POCs have now been corrected, per documentation received during today’s visit of 7/28/25. Exit interview conducted with Jacqueline Cortez, Executive Director and copies of this report, Civil Penalty Assessments - Failure to Correct, and Appeal Rights provided at the time of visit.the state’s words, verbatim · CDSS document, Jul 28, 2025

Allegation investigated: Resident missed medication.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation regarding the allegations listed above. LPA met with Alisa Dean, the Business Office Manager, and explained the purpose of the visit. The investigation consisted of the following: On 6/19/25, LPA Chan conducted the initial visit and obtained copies of the resident and staff rosters. LPA toured the kitchen, dining room, and medication room. Interviews were held with the administrator, Staff #1 - #5, and Residents #1 - #5. During the visit today, LPA interviewed an additional four Staff and five Residents and reviewed medications for residents. (continue on LIC9099C) Substantiated The investigation revealed the following: Allegation - Resident missed medication. It is alleged that residents have missed medications due to medications not being refilled on time. LPA interviewed Staff and Residents for this allegation. Three of the med techs stated that residents may have missed their medications due to pending physician’s approval for the refills. Staff stated they would order refills about 7-10 days prior to medications running out. Staff noted that self-managed medications are refilled by the residents themselves. Residents interviewed stated that the facility manages their medications and do not believe they have missed any. LPA reviewed medications for ten residents. Two out of the ten residents have at least one of their medications for which they have a physician’s order to self-manage. Staff stated they would assist with ordering refills if residents asked. LPA reviewed Resident #3’s medications with the medication administration record (MAR). It appeared that the medication Alendronate Sodium 70 MG tablet was prescribed once a week in June 2025 and was indicated on the MAR log with the staff’s initials. However, the medication could not be located in the med room/cart. LPA confirmed with the staff that the medication was not available in June because the refill has not been obtained by the family member. There were no staff notes available for this medication to follow up on a refill. Based on LPA observation and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report, a plan of correction, and appeal rights were provided. The administrator and staff stated they do not retaliate and have not observed any staff mistreat residents for filing complaints. The alleged staff denied showing any form of retaliation against the resident who contacted the police and alleged that the staff pushed the resident. LPA interviewed ten residents and nine out of ten do not feel that staff retaliate against anybody filing complaints. The majority of the residents feel that the staff are respectful and assist them when needed. Allegation - Staff spits in the resident's food. LPA interviewed the administrator and staff. All the staff denied spitting in the resident’s food, and they have not seen any staff do so. Kitchen staff interviewed stated they treat residents with respect and would not do such a thing. LPA interviewed ten residents, and nine out of ten have not seen any staff spit in their food. Allegation - Staff is unsanitary when handling food. It is alleged that a staff does not change their gloves after wiping their nose or face and will continue serving the food with the contaminated gloves. It is also alleged that residents have been getting sick due to salads containing mayonnaise being left out of the refrigerator for 4-5 hours until they are served to residents. LPA conducted interviews with the administrator, kitchen staff, and residents. The kitchen staff stated they have received training on the appropriate handling of food and etiquette toward residents. Staff stated they are required to wear hair nets and gloves while preparing and serving food. When they need to sneeze, wipe their noses or faces, they will use a tissue or another part of their arm. Afterwards, they will discard the gloves, wash their hands, and put on a new pair. Staff have not witnessed other staff using a contaminated glove and serving food to residents. Staff also do not prepare food many hours ahead of mealtime and leave them unrefrigerated. Nine out of the ten residents interviewed stated that they have not seen staff being unsanitary or have not gotten ill from food served at the facility. 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 with A. Dean. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 28-AS-20250613170613

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 19, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, Resident #3 did not take the medication Alendronate Sodium 70 MG once a week in June which poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: The licensee shall ensure medications are refilled timely and that residents do not miss any dosage. An in-service training for medication staff shall be conducted and the log to be submitted to LPA by 7/19/25.

Type of visit: Required - 1 Year

***This is an amendment of the original report. The purpose of the amendment is to add identifiers in the Deficient Practice Statement on the LIC 9099-D (citation). There citations stands and remains the same.*** Licensing Program Analyst (LPA), Mayra Cota, conducted the required annual inspection visit. LPA arrived unannounced and met with Jacqueline Cortez, Executive Director. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. Facility is operating within the scope of its license. The facility is located in a residential area of Temple City and the building consists of: (89) resident rooms with bathroom included in each room, main entry lobby/lounge, (5) administrative office, medication room, kitchen, (2) dining rooms, (2) patios/courtyards, movie theater room, activities room, (6) staff/visitor restrooms, garden room, staff break room, (2) maintenance/housekeeping storage rooms, chemical room, record room and parking lot. LPA toured the facility inside and out. LPA, randomly selected (10) resident rooms to inspect as well as the common areas. Hot water temperature in resident bathrooms were tested and measured within the range of 105-120 degree F. Each resident room has the required furniture, closet space, and lighting. However, LPA observed a safety grab bar in (1) resident shower breaking off the wall. The rooms have call buttons located by the resident's beds which were tested and operating during visit. A fireplace was observed and was adequately covered. There are no items nor debris obstructing the walkways. There are no swimming pools or other bodies of water on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department. Several fire extinguishers were also observed throughout the facility and were observed charged. The kitchen was inspected however, several live cockroaches were observed in the dishwashing area, the kitchen sink did not have the hot water warning sign posted by the sink, two dry food containers for rice and oatmeal's lid observed broken and content was exposed and two kitchen staff observed without a hair net during food preparation were observed during visit. ***Continues on LIC 809-C Adequate food supplies of 2 day perishable and a week of nonperishable were observed. Ten (10) staff and (10) resident records were randomly chosen and reviewed. Records reviewed had the required documents in place. Staff are fingerprint cleared and associated to the facility. Resident files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, pre-appraisal form, and care plan. Medication review was conducted. Resident medication is centrally stored in the medication room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed (10) resident medications; however, medication errors were observed. LPA observed a medication present in the bubble pack and not given to a resident which should have been administered on 7/8/25 (Famotidine 20 mg) Staff interview indicated, they forgot to give the resident the medication at the time it was due for administration. Also, an evening medication was administered too early on 7/17/25. LPA observed missing medication in the evening slot for 7/17/25 (Quetiapine Fumarate 25 mg). Deficiencies are noted on LIC 809-D. Exit interview was conducted with Alisa Dean, Business Office Manager due to administrator leaving for a prior engagement, and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Allegation investigated: Staff are mismanaging resident's medications.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-Day complaint visit to investigate the allegation listed above. The purpose of the visit was explained to Executive Director Jacqueline Cortez. The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on medication room, residents' room signal system, kitchen food preparation/servings, and outdoor smoking areas. A total of nine (9) staff and 15 residents were interviewed. LPA reviewed and collected resident (R1 & R2's) file documents; which include Identification and Emergency Information, Physician's Report, Medication Administration Records, Care Plan, June 2025 food menus, alternative food menu, and kitchen resident diet list. LPA interviewed R1's pharmacist and Primary Care Physician's office representative. *Narrative continues next page. Substantiated Allegation: Staff are mismanaging resident's medication. The complaint alleges that resident (R1) did not receive blood pressure medications Furosemide 20 mg or Hydrochlorothiazide 25 mg for three days, and when med-techs were asked about the non-filled medications they had no idea why the medications were not filled. Resident (R1) stated in the past staff have given the resident another resident's medications, but the error was caught by the resident. A total of 15 residents were interviewed, of which 2 residents stated they have not been administered medications as directed by their physician. A total of nine staff were interviewed. Med-tech and Administration staff acknowledged that on June 14, 2025, resident (R1) ran out of the two aforementioned medications but did not contact R1's doctor or pharmacy until Saturday June 15, 2025. LPA called the facility pharmacy and R1's Primary Care Physician's office. The findings indicate that med-tech staff contacted the pharmacy and doctor until after the resident ran out of the medications. Based on record review of Medication Administration Records, med-tech staff did not communicate to Wellness Director or Executive Director that the pharmacy did not have a physician order for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg. The pharmacist stated that on Sat. June 14, 2025 they delivered an emergency 3-day supply of medications. However, the QuickMar MAR states the medications were not dispensed, and notes indicate the medications are still pending. In addition, the pharmacy sent all the routine medications to the facility on June 11, 2025, with the exception of the two medications. Staff did not observe the two medications were not delivered. Therefore, there is sufficient evidence to corroborate the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to Title 22. See LIC 9099D. Exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 17, 2025 · control 28-AS-20250616120107

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Jun 18, 2025

Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement was not met evidenced by: Based on record review and interviews conducted, on June 14m, 2025 R1 ran out of 2 medications [ Furosemide 20 mg or Hydrochlorothiazide 25 mg]. Facility does not have a current physician order for the medications and they have not been filled as of today. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Executive Director agreed to submit 1. A written statement on medication administration protocols, and a plan that addresses the medications errors. 2. All med-tech staff shall obtain medication training from a medical professional 3. Physician orders for medications Furosemide 20 mg or Hydrochlorothiazide 25 mg.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted a subsequent complaint visit to conduct additional interviews regarding the above mentioned allegation. LPA met with Jacqueline Cortez, Administrator and explained the reason for the visit. The investigation consisted of the following: LPA, Cota, obtained copies of resident and staff rosters and conducted interviews with Resident 15 (R15) and Staff 11 (S11). Regarding: Staff hit resident. It is alleged, that two months ago, staff walked past a resident and hit resident on the shoulder in the dining area. ***Continues on LIC 9099-C*** Unsubstantiated Interviews with (11) out of (11) staff indicated, they have not received information regarding incident in which staff hit a resident on the shoulder in the dining room two months ago nor have they been involved in incidents in which staff hit residents. Staff stated, staff have not observed other staff hit nor treat residents with any form of aggression. Staff stated, they are respectful towards residents and they are trained in mandated reporting. Interviews with (13) out of (15) residents indicated, they have not been hit by staff nor have they witnessed any staff hit residents. Residents stated, staff are courteous, helpful and caring. Residents stated, staff treat them with dignity and have not heard other residents state that staff are hitting them. Interviews with staff and residents do not corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 28-AS-20250605125710

Allegation investigated: Staff do not ensure that residents' dietary needs are met. Staff hit resident.

Licensing Program Analyst (LPA), Mayra Cota, conducted an initial unannounced complaint visit to investigate the above allegations. LPA met with Jacqueline Cortez, Administrator 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 including the dining room and kitchen, conducted record review for R1 and facility menus and special dietary needs postings, and interviewed Staff 1-Staff 10 (S1-S10) and Resident 1 – Resident 14 (R1-R14). Regarding: Staff do not ensure that residents' dietary needs are met. It is alleged, that resident is being served fish products even though they are allergic to fish. It is also alleged that facility staff, fries all foods in the same oil that they fry fish or foods containing fish residue, staff are not preparing enough food for residents to eat, and staff are eating the meals prepared for residents. ***Continues on LIC 9099C Unsubstantiated The investigation revealed the following: Interviews with eight (8) staff revealed, it is mandatory for staff handling food to use gloves and hairnets to serve the food provided to the residents. Staff further stated hand washing practices are always enforced. Food handling gloves are changed between handling different food items to prevent cross-contamination. Food is covered with plastic film or refrigerated to avoid anything falling into it before it is served. Staff stated, food like fish is prepared separately from food prepared for individuals who are allergic to fish. Cutting boards are specifically assigned for the preparation of all proteins. There is also enough food for residents and food is never short. Staff stated that although kitchen staff follow healthful portion guidelines, extra food is prepared for residents who may ask for a second helping. Furthermore, snacks and other alternative food items are available to accommodate for food allergies, intolerance, religious customs, and preferences. Staff stated fish is hardly ever fried. Fish is baked in the oven and the oil in the fryer is changed constantly. Staff stated, they do not eat the food prepared for residents. Record review revealed, kitchen staff are informed by administrative staff of resident’s food allergies, intolerances, religious food customs and preferences. Staff have meetings to incorporate meal plans for residents with special dietary needs. Interviews with (13) out of (14) residents indicated, they don’t have concerns with meals not meeting their dietary needs. Residents stated, they observe kitchen staff use gloves and hairnets when serving their food. Residents stated, they have enough food to eat, and a variety of snacks are available in the front office like fruit and sandwiches after kitchen is closed. Residents stated, they like the food, and they know there is an alternate menu they can resort to when they don’t like the meal on the menu for the day. Residents stated, fried food is not served often, and fish is backed or grilled. Residents stated, if there is a change in their dietary needs, the kitchen staff will make the accommodations they need to get the appropriate food in their diet. LPA conducted tour of the dining room and kitchen and observed all staff wearing gloves and hairnets during food preparation. LPA also observed, staff practicing hand washing and glove replacement after contact with different food items. Food preparation and cooking areas were observed, and stove tops, grills, griddles and fryers were also observed clean. Food was observed covered appropriately before being served and portions met the nutritional guidelines. At the time of visit, LPA did not observed staff eating resident’s food, nor any other food items during their work shift. Staff and resident interviews, record review and LPA observation, do not corroborate the allegation. Record review indicated, there is a standard menu in place in addition to a menu with alternative food choices which are available daily. Record review and interview with R1 do not indicate a reactions has occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. ****Contines on LIC 9099-C Exit interview conducted with Alisa Dean, Business Office Manager due to Administrator leaving the facility for a prior engagement, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 28-AS-20250605125710

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control #28-AS-20250522124740). During the visit, LPA reviewed files for Resident #1 (R1) and observed that the facility did not submit an incident report for R1 who fell on 04/25/2025 and sustained an injury. The Administrator, Jacqueline Cortez searched through the files and confirmed that the facility failed to submit the incident report (SIR) and will be faxing the incident report to CCL today. Deficiency is noted on LIC 809D. Exit interview, a copy of this report and Appeals Rights were provided to Jacqueline Cortez, Administrator.the state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 30, 2025

87211(a)(1) 87211 Reporting Requirements: (a) Each licensee shall furnish..: (1)A written report shall be submitted to the licensing agency... within seven days of the occurrence...(D)Any incident which threatens the welfare, safety or health of any resident.... This requirement is not met as evidence by: LPA observed that the facility did not submit an incident report for Resident #1 (R1) who fell on 04/25/2025 and sustained an injury which poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Administrator agreed to conduct in-service training for staff and create the incident report for R1 and submit it to CCL/LPA by POC due date.

Allegation investigated: Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Sanjay Vaid conducted an initial 10-day complaint visit to investigate the listed allegation. The purpose of the visit was explained to Administrator- Jacqueline Cortez and Wellness Director- Ruth Villa. LPA Vaid conducted a tour of the facility and did not observe any health and safety concerns. The investigation consisted of the following: Requested, obtained and reviewed ten (10) residents face sheets and identification, physicians’ reports, physician orders and MARs January 2025 to present (5/21/25), staff and resident roster, staff rosters by department. List of residents with medication insurance issues, list of self-medicating residents. Regarding the allegation: Facility is not properly managing resident's medication. It is alleged that the staff are not administering prescribed medications to the resident, staff have failed to give the residents their medications as ordered. Continued on 9099C.................. Unsubstantiated Five (5) out of five (5) staff interviewed deny this allegation. According to the staff, the medications are administered to residents as ordered from their physicians. The staff stated they keep watchful eye over the medications management to the residents, staff are following and managing protocols for administering medications. Staff contacts the physicians and pharmacy when the physician orders are not clear or missing vital information. Medications to the residents are administered by medication management and protocols; staff locates the resident, opens resident profiles in the MARs (medication administered record), matches names to the bubble packed meds, checks the time and dosage, matches the pills to picture shown on screen, some residents will inquire of new medications. Discontinued medications will appear in the MARs, and the medications is disposed. Medication refusal is entered into MARs to communicate to next shift of the residents’ medications issues. Ten (10) out of fourteen (14) residents interviewed could not corroborate this allegation, residents interviewed stated that their medications are available after prescribed by the doctor and processed through the pharmacy. A few residents stated they like to see the medication before they take it. A few residents interviewed stated they self-administer their own medication. Eight (8) out of fourteen (14) residents stated that the facility is correctly managing their medications and have not had issues with receiving their medications. Based on records reviewed, interviews conducted, and observations made, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. A copy of this report was given to Wellness Director Ruth Villa.the state’s words, verbatim · CDSS document, May 22, 2025 · control 28-AS-20250516122852

Allegation investigated: Licensee did not provide notice of rate increase to residents in care. Staff did not dispense medications as prescribed. Staff do not ensure residents medications are properly managed. Staff do not ensure residents are treated with dignity and respect by others residents in the facility. Staff did not ensure residents personal belongings were kept safely secured. Staff did not provide resident with copy of requested records.

***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegations and to deliver complaint investigation findings. Met with Ruth Villa, Wellness Director and explained purpose of the visit. LPA Vaid and Wellnesses Director toured the facility and did not observe any health and safety concerns. The investigation conducted on 01/06/25, consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7) and clients 1-14 (C1-C14). LPA requested, collected, and reviewed documents from C1's face sheet, physicians reports, service plan, needs and services, medication file, and copies of six (6) random clients: face sheet, medication list, written physicians’ orders, physician reports. Facility Plan of Operations regarding controlled substance management, copy of posted flyer for pharmacy change, letter sent to SSI recipients regarding rate increase. Continued on 9099C..... Unsubstantiated ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Licensee did not provide notice of rate increase to clients in care. It is alleged that facility owners increased the monthly rent on all the clients without proper notification. Seven (7) out of seven (7) staff deny this allegation. According to business office staff, increase in the rental room rate is increased per year, as per Admissions Agreement. Notice of increase is communicated by letter to the residents’ and their POA. Higher needs and services require skilled nursing. Notice of new room rate increase and personal needs allowance was communicated to all the residents. According to the business office staff and records residents who were assessed by August Health(third party health point system) and determined an increased/decreased in level of care, was communicated to the residents and their POAs, by the business office staff. Resident was at Level 2 from January 2024 thru October 2024. Resident was reassessed by August Health in October 2024 to level 1, decreasing the monthly care rate. Statement of notice was delivered to Resident, by business office staff. Records for October 2024 thru January 2025 shows rent increase and level of care rate decreased. Resident has been paying 2024 rent rates for the year 2025 and thus is behind in rental payments. The business office is attempting to work with resident to collect the balance. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Interviews with residents reveals that rate increase occurs when care and need levels increase, when a resident is determined unable to perform self-ADL’s like continence care an increase occurs, and are informed by staff before charge is made to the clients account. Several residents stated, they have been notified by staff when an increase is made in their level of care and yearly rental increases. Several other residents stated they receive SSI (Social Security Income), and they were given statement of notice for the rate increase for new rooms and increase in monthly personal needs expenses, by the business office staff. Based on interviews conducted and records reviewed, there is insufficient evidence to support this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Continued on 9099C...... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did not dispense medications as prescribed. It is alleged that the medication technicians (Med-Techs) are not dispensing the correct medication to residents. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Residents stated they are receiving their medications daily. Seven (7) out of seven (7) staff interviewed deny this allegation and stated that they have not observed the med-tech staff mismanaging the resident’s medication. The Med-techs interviewed, stated that medication is administered as prescribed by physician orders and logged into the Medication Administration Record. LPA's review of five (5) random residents medications, and medication administration records, observed that medication are administered by staff as prescribed. During the afternoon, LPA observed AM-shift med-techs performing medication count before the PM shift was assigned the mobile medication carts. The PM shift med-tech then also make a pill count before next round of late afternoon/evening medications administration. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Regarding the allegation: Staff do not ensure residents medications are properly managed. It is alleged that Medications is not being ordered in timely manner causing medication shortages for the residents. Thirteen (13) out of fourteen (14) residents interviewed stated they have not had interruptions in medications they receive. New prescriptions are filled and started within a few days of the doctors’ visit. Seven (7) out of seven (7) staff interviewed deny this allegation. Med-techs interviewed stated, through the electronic medication management system, notification of low medication supply is electronically sent to the pharmacy who can restock the medications without interruptions for the residents. The med-techs works closely with the pharmacy to ensure medications re-ordered by the facility and new medication prescribed by the physicians are readily available to the residents. 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. Continued on 9099C..... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff do not ensure residents are treated with dignity and respect by other residents in the facility. It is alleged that facility staff is not ensuring that all residents get along with one another and that residents treat each other with dignity and respect. Seven (7) out of seven (7) staff interviewed deny this allegation. Staff stated they treat all the residents in their care with respect and dignity. Staff request all residents to treat each other with kindness and mutual respect. However, the staff cannot control the attitudes and views of all residents. Thirteen (13) out of fourteen (14) residents interviewed stated they get along with each other, sometimes there are disagreements between residents. One resident stated, sometimes residents have a heated exchange of words and sometimes gets loud, and fights break out, however, staff quickly intervene and redirect the residents. Another resident stated, people here don’t always get along, I don’t need to be nice and friendly to everyone, only civil. Based on interviews conducted 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. There was a concern regarding a resident being harassed by another resident. It appears they had a personal relationship based on resident interviews. However, it could not be determined this was due to facility’s lack of supervision, based on interview with Administrator Joel Niblett. Resident was advised that the other resident has right to reside at the facility. Administrator advised both residents to respect each other’s right to privacy and keep distant from one another. Continued on 9099C..... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** Regarding the allegation: Staff did not ensure residents personal belongings were kept safely secured. It is alleged Staff are taking items from residents’ room while resident are not in resident’s room. Seven (7) out of seven (7) staff deny this allegation. The residents’ rooms are lockable and the keys for each room are assigned to resident(s) of the room. Staff keeps spare room key for housekeeping and emergencies to ensure residents safety when needed. Housekeeping cleans and sanitizes the rooms and have set time parameters for each room. Staff always ensures to remind residents to lock their rooms when leaving, even for a few minutes. Staff reported that R1 has a room and shares the room with another resident who also has a room key. Thirteen (13) out of fourteen (14) residents interviewed stated, the staff is respectful of their belongings, housekeeping helps to keep rooms clean. Resident reported, they have not had items missing from their rooms. One resident stated people are respectful of other resident’s personal property. Another resident stated, they keep their room keys with themselves whenever leaving the room and hope their roommates do the same. Another resident stated, keeps their belongings locked, because some people have greedy eyes. Interview with R1 revealed that R1 was unable to report what items were removed from R1 room and the investigation did reveal that items were removed from R1’s room or that staff do not safeguard resident belongings. Based on interviews conducted and observations made, 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. Regarding the allegation: Staff did not provide resident with copy of requested records. It is alleged that the business office staff did not provide a resident with monthly rent records in a timely manner, however staff asked resident to pay rent based on the amount previously charged and staff would reconcile the payment at a later date. Seven (7) out of seven (7) staff interviewed deny this allegation. Business office staff stated computers were not operating the entire day for one day only due to telecommunications interruption and were up the next day. Requests for records are completed via written request from the residents stating: type of record(s), the date range of the request. Staff stated all requests are completed within 1-2 days. Continued on 9099 C....... ***This report supersedes the report delivered on 04/07/2025. The reason for the supersede is to add information not listed on the initial report. The findings will remain unsubstantiated. *** A verbal request to staff requesting lengthy records is not permitted to ensure correct information is provided to the requestor. A written request such as a copy of vaccine record or copy of a medication list can be facilitated immediately. Thirteen (13) out of fourteen (14) residents interviewed were not able to corroborate this allegation. Residents interviewed stated their request for records is completed by staff in a reasonable amount of time. Other residents interviewed stated they have not had issues with requesting and receiving records and/or receive information within 2-3 days, depending upon the size of the request. Interview with R1 confirmed that staff provided R1 with the requested record in a timely manner. Based on interviews conducted and observations made, 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. Exit interview was conducted and copy of this report was provided to Ruth Villa -Welness Director.the state’s words, verbatim · CDSS document, May 7, 2025 · control 28-AS-20241230090004

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sanjay Vaid conducted an unannounced Case Management Visit at 1210PM to follow up on a clients’ drug overdose. LPA met Administrator Joel Niblett and explained the reason for the visit. Per Unusual Incident Report received on 03/31/2025, on 03/29/25 at 12pm resident was found by staff conducting usual check on the residents. Staff found R1 in their room with a syringe in their neck unresponsive and called 911 and was taken to USC Arcadia. R1 was treated and release on 03/30/25 with diagnosis of substance abuse disorder. R1 was prescribed OTC and prescription medicines only as ordered by the hospital physician. On 03/30/25 after R1 had returned to the facility, at approximately 0940AM staff heard thumping noise coming from R1’s room, staff found R1 confused with swelling and discoloration over their eyes and head. 911 was called. EMS and staff noticed a white substance sprawled over R1’s clothing and found syringe and spoon along with white powdery substance. Temple City Sherriff deputies confiscated the syringe, spoon and white substance. R1 was transported to USC Arcadia for further evaluation and treatment. Upon release from the hospital, R1 was placed into a skilled nursing facility for higher level of care. R1 will remain at the skilled nursing until R1’s POA can locate a facility that R1 can be placed. Staff spoke with R1’s POA and R1 was discharged from Santa Anita Assisted Living and transferred to the skilled nursing facility on 04/01/25. No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 14, 2025

Allegation investigated: Licensee did not provide notice of rate increase to residents in care. Staff did not dispense medications as prescribed. Staff do not ensure residents medications are properly managed. Staff do not ensure residents are treated with dignity and respect by others residents in the facility. Staff did not ensure residents personal belongings were kept safely secured. Staff did not provide resident with copy of requested records.

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegations and to deliver complaint investigation findings. Met with Ruth Villa, Wellness Director and explained purpose of the visit. LPA Vaid and Wellnesses Director toured the facility and di not observe any health and safety concerns. The investigation conducted on 01/06/25, consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7) and clients 1-14 (C1-C14). LPA requested, collected, and reviewed documents from C1's face sheet, physicians reports, service plan, needs and services, medication file, and copies of six (6) random clients: face sheet, medication list, written physicians’ orders, physician reports. Facility Plan of Operations regarding controlled substance management, copy of posted flyer for pharmacy change, letter sent to SSI recipients regarding rate increase. Continued on 9099C..... Unsubstantiated Regarding the allegation: Licensee did not provide notice of rate increase to clients in care. It is alleged that facility owners increased the monthly rent on all the clients without proper notification. Seven (7) out of seven (7) staff deny this allegation. According to business office staff, increase in the rental room rate is increased per year, as per Admissions Agreement. Notice of increase is communicated by letter to the residents’ and their POA. Higher needs and services require skilled nursing. Notice of new room rate increase and personal needs allowance was communicated to all the residents. According to the business office staff and records residents who were assessed by August Health(third party health point system) and determined an increased/decreased in level of care, was communicated to the residents and their POAs, by the business office staff. Resident was at Level 2 from January 2024 thru October 2024. Resident was reassessed by August Health in October 2024 to level 1, decreasing the monthly care rate. Statement of notice was delivered to Resident, by business office staff. Records for October 2024 thru January 2025 shows rent increase and level of care rate decreased. Resident has been paying 2024 rent rates for the year 2025 and thus is behind in rental payments. The business office is attempting to work with resident to collect the balance. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Interviews with residents reveals that rate increase occurs when care and need levels increase, when a resident is determined unable to perform self-ADL’s like continence care an increase occurs, and are informed by staff before charge is made to the clients account. Several residents stated, they have been notified by staff when an increase is made in their level of care and yearly rental increases. Several other residents stated they receive SSI (Social Security Income), and they were given statement of notice for the rate increase for new rooms and increase in monthly personal needs expenses, by the business office staff. Based on interviews conducted and records reviewed, there is insufficient evidence to support this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Continued on 9099C...... Regarding the allegation: Staff did not dispense medications as prescribed. It is alleged that the medication technicians (Med-Techs) are not dispensing the correct medication to residents. Thirteen (13) out of fourteen (14) residents interviewed could not corroborate the allegation. Residents stated they are receiving their medications daily. Seven (7) out of seven (7) staff interviewed deny this allegation and stated that they have not observed the med-tech staff mismanaging the resident’s medication. The Med-techs interviewed, stated that medication is administered as prescribed by physician orders and logged into the Medication Administration Record. LPA's review of five (5) random residents medications, and medication administration records, observed that medication are administered by staff as prescribed. During the afternoon, LPA observed AM-shift med-techs performing medication count before the PM shift was assigned the mobile medication carts. The PM shift med-tech then also make a pill count before next round of late afternoon/evening medications administration. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Regarding the allegation: Staff do not ensure residents medications are properly managed. It is alleged that Medications is not being ordered in timely manner causing medication shortages for the residents. Thirteen (13) out of fourteen (14) residents interviewed stated they have not had interruptions in medications they receive. New prescriptions are filled and started within a few days of the doctors’ visit. Seven (7) out of seven (7) staff interviewed deny this allegation. Med-techs interviewed stated, through the electronic medication management system, notification of low medication supply is electronically sent to the pharmacy who can restock the medications without interruptions for the residents. The med-techs works closely with the pharmacy to ensure medications re-ordered by the facility and new medication prescribed by the physicians are readily available to the residents. 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. Continued on 9099C..... Regarding the allegation: Staff do not ensure residents are treated with dignity and respect by other residents in the facility. It is alleged that facility staff is not ensuring that all residents get along with one another and that residents treat each other with dignity and respect. Seven (7) out of seven (7) staff interviewed deny this allegation. Staff stated they treat all the residents in their care with respect and dignity. Staff request all residents to treat each other with kindness and mutual respect. However, the staff cannot control the attitudes and views of all residents. Thirteen (13) out of fourteen (14) residents interviewed stated they get along with each other, sometimes there are disagreements between residents. One resident stated, sometimes residents have a heated exchange of words and sometimes gets loud, and fights break out, however, staff quickly intervene and redirect the residents. Another resident stated, people here don’t always get along, I don’t need to be nice and friendly to everyone, only civil. Based on interviews conducted 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. There was a concern regarding a resident being harassed by another resident. It appears they had a personal relationship based on resident interviews. However, it could not be determined this was due to facility’s lack of supervision, based on interview with Administrator Joel Niblett. Resident was advised that the other resident has right to reside at the facility. Administrator advised both residents to respect each other’s right to privacy and keep distant from one another. Continued on 9099C..... Regarding the allegation: Staff did not ensure residents personal belongings were kept safely secured. It is alleged Staff are taking items from residents’ room while resident are not in resident’s room. Seven (7) out of seven (7) staff deny this allegation. The residents’ rooms are lockable and the keys for each room are assigned to resident(s) of the room. Staff keeps spare room key for housekeeping and emergencies to ensure residents safety when needed. Housekeeping cleans and sanitizes the rooms and have set time parameters for each room. Staff always ensures to remind residents to lock their rooms when leaving, even for a few minutes. Staff reported that R1 has a room and shares the room with another resident who also has a room key. Thirteen (13) out of fourteen (14) residents interviewed stated, the staff is respectful of their belongings, housekeeping helps to keep rooms clean. Resident reported, they have not had items missing from their rooms. One resident stated people are respectful of other resident’s personal property. Another resident stated, they keep their room keys with themselves whenever leaving the room and hope their roommates do the same. Another resident stated, keeps their belongings locked, because some people have greedy eyes. Interview with R1 revealed that R1 was unable to report what items were removed from R1 room and the investigation did reveal that items were removed from R1’s room or that staff do not safeguard resident belongings. Based on interviews conducted and observations made, 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. Regarding the allegation: Staff did not provide resident with copy of requested records. It is alleged that the business office staff did not provide a resident with monthly rent records in a timely manner, however staff asked resident to pay rent based on the amount previously charged and staff would reconcile the payment at a later date. Seven (7) out of seven (7) staff interviewed deny this allegation. Business office staff stated computers were not operating the entire day for one day only due to telecommunications interruption and were up the next day. Requests for records are completed via written request from the residents stating: type of record(s), the date range of the request. Staff stated all requests are completed within 1-2 days. Continued on 9099 C....... A verbal request to staff requesting lengthy records is not permitted to ensure correct information is provided to the requestor. A written request such as a copy of vaccine record or copy of a medication list can be facilitated immediately. Thirteen (13) out of fourteen (14) residents interviewed were not able to corroborate this allegation. Residents interviewed stated their request for records is completed by staff in a reasonable amount of time. Other residents interviewed stated they have not had issues with requesting and receiving records and/or receive information within 2-3 days, depending upon the size of the request. Interview with R1 confirmed that staff provided R1 with the requested record in a timely manner. Based on interviews conducted and observations made, 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. Exit interview was conducted and copy of this report was provided to Administrator Joel Niblett.the state’s words, verbatim · CDSS document, Apr 7, 2025 · control 28-AS-20241230090004

Allegation investigated: Staff physically abused resident, resulting in resident sustaining a bruise

*** This licensing report issued on 4/17/25 supersedes that licensing report dated 4/4/25, LPA Vaid obtained additional information, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegation and to re-deliver complaint investigation finding. Met with Joel Niblett-Administrator and explained purpose of the visit. Requested and obtained staff and client rosters. Conducted a tour of the facility and did not observe any health and safety concerns. On 02/03/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 24-hour complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#8 (S1-S8) and residents #1-#10 (R1-R10). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential appraisal-individual service plan. CONTINUED 0N 9099C............... Unsubstantiated Caregiver sign-in for month of January. Residents census and resident roster, caregiver staff roster (01/20/25-01/31/25), S4 employee file-caregiver duties and disciplines. Regarding the allegation: Staff physically abused resident, resulting in resident sustaining a bruise. It is alleged that resident #1 (R1) was punched in the arm by a caregiver who changes residents’ diapers during NOC shift. Eight (8) out of eight (8) staff interviewed deny the allegation. All staff interviewed deny physically abusing the R1 or any residents. Nine (9) out of ten (10) residents interviewed were not able to corroborate the allegation. Residents interviewed stated; they have not encountered issues with staff during continence care. Interview with R1 revealed that R1 is does not recall how R1 sustained the bruising. The investigation revealed that S4 recalled an incident that occurred between R1 and S4 on 01/23/25, S4 reported that S4 explained to R1 that the color of the adult brief was the correct size, however R1 did not want S4 to use that color and preferred a different color, which per S4 was the incorrect size for R1. S4 proceeded to change R1 into the correct size adult brief. Per S4, R1 became upset regarding the color of the adult brief that S4 was using to change R1, resulting in R1 hitting S4 with R1’s arms. S4 reported holding up S4’s arms and hands in a cross formation to block R1 from hitting S4 during the altercation. S4 does not recall R1 sustaining any injury during the incident. It was also reported that on 01/26/25, S7 recalls observing R1 with a bruise on R1’s upper inside left arm while bathing R1. S7 recalls R1 reporting that R1 was unsure of how the injury/bruise occurred. Additionally, according to R1’s Physicians Report dated 2/28/23 and R1s Individualized Service Plan dated 09/07/2022, R1 is prone to bruising due to prescribed medications. On 02/03/25 while LPA Vaid interviewed R1, LPA did not observe any visible bruising on R1s arm. The investigation did not reveal any evidence to support that staff physically abused R1 and/or that staff caused R1 injury which resulted in R1 sustaining a bruise. Based on interviews conducted, observations made, and documents reviewed. Although the allegation 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 conducted with Administrator Joel Niblett.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 28-AS-20250131145836

Allegation investigated: Staff physically abused resident, resulting in resident sustaining a bruise

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit today regarding the listed allegation and to re-deliver complaint investigation finding. Met with Joel Niblett-Administrator and explained purpose of the visit. Requested and obtained staff and client rosters. Conducted a tour of the facility and did not observe any health and safety concerns. On 02/03/25, Licensing Program Analyst (LPA) S Vaid conducted an initial 24-hour complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff #1-#8 (S1-S8) and residents #1-#10 (R1-R10). LPA requested, collected, and reviewed documents from R1's face sheet, physicians reports, residential appraisal-individual service plan. CONTINUED 0N 9099C............... Unsubstantiated Caregiver sign-in for month of January. Residents census and resident roster, caregiver staff roster (01/20/25-01/31/25), S4 employee file-caregiver duties and disciplines. Regarding the allegation: Staff physically abused resident, resulting in resident sustaining a bruise. It is alleged that resident #1 (R1) was punched in the arm by a caregiver who changes residents’ diapers during NOC shift. Eight (8) out of eight (8) staff interviewed deny the allegation. All staff interviewed deny physically abusing the R1 or any residents. Nine (9) out of ten (10) residents interviewed were not able to corroborate the allegation. Residents interviewed stated; they have not encountered issues with staff during continence care. Interview with R1 revealed that R1 is does not recall how R1 sustained the bruising. The investigation revealed that S4 recalled an incident that occurred between R1 and S4 on 01/23/25, S4 reported that S4 explained to R1 that the color of the adult brief was the correct size, however R1 did not want S4 to use that color and preferred a different color, which per S4 was the incorrect size for R1. S4 proceeded to change R1 into the correct size adult brief. Per S4, R1 became upset regarding the color of the adult brief that S4 was using to change R1, resulting in R1 hitting S4 with R1’s arms. S4 reported holding up S4’s arms and hands in a cross formation to block R1 from hitting S4 during the altercation. S4 does not recall R1 sustaining any injury during the incident. It was also reported that on 01/26/25, S7 recalls observing R1 with a bruise on R1’s upper inside left arm while bathing R1. S7 recalls R1 reporting that R1 was unsure of how the injury/bruise occurred. Additionally, according to R1’s Physicians Report dated 2/28/23 and R1s Individualized Service Plan dated 09/07/2022, R1 is prone to bruising due to prescribed medications. On 02/03/25 while LPA Vaid interviewed R1, LPA did not observe any visible bruising on R1s arm. The investigation did not reveal any evidence to support that staff physically abused R1 and/or that staff caused R1 injury which resulted in R1 sustaining a bruise. Based on interviews conducted, observations made, and documents reviewed. Although the allegation 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 conducted with Administrator Joel Niblett.the state’s words, verbatim · CDSS document, Apr 4, 2025 · control 28-AS-20250131145836

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the amended report and substantiated findings for the investigated complaint. Explained the purpose of the amended report is to clear state the findings regarding the substantiated allegation.the state’s words, verbatim · CDSS document, Dec 20, 2024

Allegation investigated: Staff are mismanaging resident's medications.

*** This licensing report issued on today’s visit, 12/06/2024 supersedes that licensing report dated 10/11/2024, LPA Vaid is reissuing the report and citations, however, the investigation findings will remain the same*** Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegation listed above to reissue the report and to reissue citation for the investigated complaint findings. Regarding the allegation: Staff are mismanaging residents’ medication. It is alleged that staff give residents day and evening medication together. The investigation consisted of interviews with staff and residents, including resident #20 (R#20) and review of R#20 Medication Administration Record. The investigation revealed, on 08/08/24, staff #21 gave R#20 the afternoon blood pressure (name medication) a dosage of 10 mg in the morning. This medication error was observed by Staff 10 (S10) during the medication audit conducted during the Med Tech staff shift change. The protocol for shift change is for each med-tech to audit the medications in the medication carts before starting their shift. S10 reported the medication error former administrator Maya Mnoyan, who contacted R#20 physician and placed S#21 on suspension during the facility’s internal investigation. Based upon the facility’s investigation S#21 was terminated from employment. Therefore, S#21 did not properly administer R#20 blood pressure medications. Substantiated Based on interviews conducted, and records collected and reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. Deficiencies are being cited according to California Cade of Regulations, Title 22. Citation is on 9099-D page. Exit interview was conducted and copy of report and appeals were given to the Administrator Aaron Khodorkovsky. Regarding allegation: Staff are overdosing residents. It was alleged that staff are overmedicating residents with a Narcotic called Avitan used to treat adults with insomnia caused by anxiety and can cause drowsiness. Staff S1-S14 interviewed denied the allegation. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed med-tech staff overmedicating any of the residents. The Med-techs have stated that the medication is administered as prescribed as needed. Each residents’ medication that is administered is logged into the MARs. The medication cart and the medication room is audited each month, by management. LPA's review of five (5) random residents’ medication, and medication administration records, observed medication to be administered as prescribed by physician’s orders. All medications are accounted, as shown in the MARs log, LPA performed pill count of medications in the bubble packs. LPA reviewed residents that are prescribed Avitan, the MARs indicate that the Avitan has been administered sparingly, administered when needed to specific residents with attributing health conditions. Resident R1-R20 interviewed were unable to corroborate the allegation. Based upon records 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. Regarding the allegation: Staff are administering unprescribed medications to residents. It is alleged that the staff had administered unprescribed medications to the residents who misbehave during the night, by logging incorrect information of medication administered. Covering up the pill count. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the medication technician staff administer unprescribed medication to residents. The Med-techs stated that medication is administered as prescribed. The narcotics log used to record time, date and dosage administered to the resident(s). The narcotics medication(s) are audited randomly each month for each resident using medications containing heavy narcotics. Medication audits are performed monthly by the Wellness Director to ensure medications are being administered as prescribed by the physician orders, constant communications with the pharmacy via eMARs (electronic medication administered records) ensure consistent supply of all medications continues. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed by physician orders and pharmacy orders. Resident R1-R20 interviewed were unable to corroborate the allegation. Based upon records 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. con't 9099C... Regarding the allegation: Staff do not answer the resident’s call button in a timely manner. It is alleged that staff are not answering the call button in a timely manner when residents call for assistance. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the staff not answering the call button switchboard in a timely manner. LPA observed a call come into the office by a resident asking for assistance, within 1-2 minutes a caregiver answered the office to acknowledge the call being handled, the call was answered by a staff person from the resident’s room. Residents R1-R15 interviewed stated that the caregivers come within 2-3 minutes after call is made on the residents’ call box, someone always answers. Based upon observations made 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. Regarding the allegation: Staff do not ensure residents’ showering needs are being met. It is alleged that staff are not ensuring residents showering needs are being met. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Caregiver staff and direct person staff(DSP) interviewed state, the caregivers staff assist the Home Health Aides with bathing the residents 2-3 times per week as noted in the resident’s needs/services plan. When residents refuse bathing, a note is made for bath refusal in the ADL (assisted daily living) clinical notes. Basic ADLs like brushing teeth, washing face, and combing hair, dressing is applied daily. Fifteen (15) out of fifteen (15) residents interviewed stated the staff gives baths twice a week, some residents stated they were given bathes three times a week by the home health agencies, the caregiver staff provides the rest. Based upon records 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. Con't 9099C... Regarding the allegation: Staff do not ensure facility has adequate food supply. It is alleged that the staff is not ensuring adequate food supply for residents. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Kitchen staff interviewed state, grocery list is planned and ordered on Sunday and Wednesday for delivery of food on Monday and on Thursday. The kitchen was observed to have enough foods to feed all the residents, during tour of the kitchen LPA observed delivery being made, many boxes and bags of fruit and vegetable along with canned and dry food items being delivered. Fifteen (15) out of fifteen (15) residents interviewed state they like the food served and have never experienced food shortage at the facility. Based upon records 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. Regarding the allegation: Staff do not ensure residents attend scheduled medical appointments. It is alleged that a staff person is cancelling residents’ medical and other important appointments. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The residents with medical appointments, relay information to the caregivers and the care coordinator, who then logs in the appointments in the transportation log to ensure the drivers are aware of resident’s appointments. The protocol for the appointment scheduling is verified by the care coordinator to ensure all necessary paperwork and insurance paperwork is ready for the residents. Fifteen (15) out of fifteen (15) residents interviewed stated they are happy with the transportation protocols and have not had any problems with keeping their appointments. Based upon records 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. con't 9099C.... Regarding the allegation: Staff do not ensure residents’ air conditioner is in good repair. It is alleged that the staff is not ensuring that the air conditioner system is not in good repair. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The air conditioner units are maintained by the maintenance staff, all air-conditioner systems are operational. When a unit breaks down or needs service, a work order is issued for maintenance to repair, repairs are handled within 24 hours unless parts are needed ordering. Accommodations for the residents are made if repair takes longer than anticipated. Regarding maintenance all work orders are logged to ensure completion of the projects in timely manner. Fifteen (15) out of fifteen (15) residents interviewed stated they have no concerns of the A/C units, staff is always fixing and are repairing things around the facility. Based upon records 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. LPA did not observe any Health and Safety concerns during the visit, an exit interview was held and copy of this report was given to the Administrator Aaron Khodorksky.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 28-AS-20240815132940

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 13, 2024

87465 Incidental Medical and Dental Care.(c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Title 22, Division 6 Chapter 8 This requirement was not met as evidenced by: On 08/08/24, staff #21 gave R#20 the afternoon blood pressure medication, a dosage of 10 mg in the morning.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: Administrator will provide staff with medication administering training by 12/13/24.

The state marks this report as 16 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Staff hit resident resulting in a bruise Staff do not ensure that resident's personal items are safeguarded Staff did not prevent resident from inappropriately touching other residents Staff do not speak to residents in a respectful manner Staff did not ensure resident medications are properly managed Staff do not provide residents with a sufficient amount of food.

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complaint visit in regard to the allegations listed above. LPA met with Wellness Director Ruth Villa and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 11/12/2024, LPA interviewed Staff #1- Staff #7, Resident #1 -Resident #10, and toured the facility’s kitchen. LPA obtained copies of the following documents: staff roster, resident roster, identification and emergency information, Individual service plans, physician report for R1, food invoices, food menu, physicians order for R9 and staff records. SEE 9099C Unsubstantiated In regard to the allegation that “Staff hit resident resulting in a bruise” the department previously investigated this allegation on 09/23/2024 and it was found to be unsubstantiated. LPA reviewed records, interviewed residents, and staff and no additional information was given. In regard to the allegation that “Staff do not ensure that resident's personal items are safeguarded” it is alleged that R3 goes into residents’ room and steals money. During interviews with residents seven (7) out of ten (10) residents state they have not had any items missing from their rooms. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. R5 stated that his/her roommate steals their clothes to sell. During interviews with staff four (4) out of seven (7) staff have not heard about items missing from resident’s room. S6 and S7 state that one resident was missing wallet but was unsure of where wallet was left. S6 states that R3 doesn’t steal and is very helpful to residents. In regard to the allegation that” Staff did not prevent resident from inappropriately touching other residents ‘it is alleged that a resident goes into females’ rooms and touches them and has forced residents to kiss them. During interviews with residents eight (8) out of ten (10) residents state they have never witnessed any inappropriate touching between residents or been touched. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. During interviews with staff six (6) out of seven (7) staff indicate they have never witnessed any inappropriate touching between residents. S6 stated that there are couples in the facility and that they do hang out like boyfriend and girlfriend. S7 stated there is holding hands between couples but it is consensual. In regard to the allegation that “Staff do not speak to residents in a respectful manner” it is alleged that staff does not treat residents with respect and are mean to them. During interviews seven (7) out of ten (10) residents stated that staff talks to them with respect. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. R9 stated “some do some don’t”. During interviews with staff six (6) out of seven (7) staff stated that staff speak to residents with respect. S5 stated that one staff was let go for not speaking to residents with respect. SEE 9099C In regard to allegation that “Staff did not ensure resident medications are properly managed” it is alleged that medications are not being ordered and that medicated shampoo for R9 is not available. During interviews with residents seven (7) out of ten (10) residents stated they get their medication when needed. One (1) resident R7 was in hospital at time of interview and one (1) resident R1 was confused at time of interview. R9 stated sometimes medication are late but that he/she has medicated shampoo in his/her room. Interviews with Four (4) staff reveled that only MedTech’s handle medication so they would not have any knowledge of medication. Interviews with two (2) staff stated that all medication is given and ordered on time and that the only delay would be if Drs. Approval is needed for refills. LPA conducted random check on five residents’ medication and no errors were observed at time of visit. In regard to the allegation that “Staff do not provide residents with a sufficient amount of food” it is alleged that residents are given small portions of food and that residents are always hungry. During interviews with residents seven (7) out of ten (10) residents state there is enough food. One (1) resident R7 was in hospital and one (1) resident R1 was confused at time of interview. R9 stated” there is enough food, but I really don’t like it” R10 stated “There is enough for me. I can ask for more”. During interviews with staff five (5) out of seven (7) stated there was enough food. S2 had no knowledge of food supply. S3 stated that “we have never not had enough food”. S5 stated that they even get food to take to their rooms. LPA toured kitchen and food supply during time of visit and sufficient food supply was observed. 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 copy of this report was left with the Wellness Director Ruth Villa.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 28-AS-20241104144910

Allegation investigated: Staff did not take appropriate steps to prevent the spread of communicable disease.

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegation listed above to deliver findings for the investigated complaint. Met with Wellness Director Ruth Villa. LPA didnot observe any health and safety concerns. On 10/31/2024, LPA Vaid conducted a 10-day complaint visit to the facility. The investigation consisted of the following: LPA obtained and reviewed staff schedule and client roster, client list of names that are being tracked and isolated, copy of In-Service staff training for Scabies, PPE-gown, and handwashing. LPA interviewed fourteen (14) clients and seven (7) staff. Five (5) Four Tech Laboratory reports for the affect clients. The investigation revealed the following. Regarding Allegation: Staff did not take appropriate steps to prevent the spread of communicable disease. Seven (7) out of seven (7) staff interviewed stated that one resident had been diagnosed with scabies and three other clients are being tracked for the illness, all the clients have been isolated to their rooms. Continued on 9099C....... Unsubstantiated The affected clients were educated about the scabies rash and physician and family were informed of the resident’s communicable disease and of the precautions taken, isolation until scabies rash is gone. Four (4) residents were tracked for scabies starting on 10/16/24, 10/17/24 and 10/23/24 for rash and were given Permethrin cream to apply to rash. Staff explains the details of the isolation procedures that are followed to ensure that the Scabies is not spread to other residents. Gowns, gloves, and masks are worn when servicing the isolated clients, PPE are constantly changed after each resident is visited. Fourteen (14) out of fourteen (14) residents interviewed have said that they have observed the staff use gowns, gloves and masks when making their rounds and visiting the isolated residents. Residents interviewed also state that they were told to stay in their rooms if they developed a rash, but some do not listen and wander all around the facility. Clients interviewed state that the staff is doing their very best to keep the facility clean and free from illnesses in the facility. LPA Vaid observed caregivers and Med-tech staff taking extra precautions when delivering services to infected residents. Scabies skin scraping and testing was conducted on 11/04/24. Out of one hundred forty-seven (147) residents, one hundred six (106) residents were tested, fifteen (15) residents refused testing, twenty six (26) residents were out of the facility. From all the residents that were tested only one resident was diagnosed by the physician to have scabies. Based upon the investigation, interviews conducted with residents and staff, documents collected and reviewed, and observations made by LPA the investigation did not reveal any evidence to support that staff did not take appropriate steps to prevent the spread of communicable disease. 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 allegation is unsubstantiated. An exit interview was conducted and copy of this report was left with the Wellness Director Ruth Villa.the state’s words, verbatim · CDSS document, Dec 3, 2024 · control 28-AS-20241023134312

Allegation investigated: Staff mishandled a resident's medication

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit on 11/14/24 regarding the listed allegation and to deliver complaint investigation findings. Met with Ruth Villa, Wellness Director and explained purpose of the visit. Toured the physical plant and did not observe any Health and Safety concerns. On 11/12/24, Licensing Program Analyst (LPA) S Vaid conducted an initial 10-day complaint investigation visit for the above allegation. LPA met with Ruth Villa, Wellness Director and the purpose of the visit was discussed. The investigation consisted of the following: LPA toured the physical plant. LPA Interviewed staff 1-7 (S1-S7) and residents 1-14 (C1-C14). LPA collected and reviewed documents from C1's medication file, and copies of four (4) random residents: medication list, written physicians’ orders. Facility Plan of Operations regarding medication administration. Continued on 9099C....... Unsubstantiated Regarding the allegation: Staff mishandled a resident's medication. It is alleged that the medication technician staff do not distribute the residents’ medications in a timely fashion. It is also alleged that six (6) medications pills were disposed by a new nurse (name not given), one hour later. Seven (7) out of seven (7) staff interviewed deny this allegation. The medication is administered to the residents at the correct times, AM, Noon, evening, PM, and bedtime. The medication is given to the residents within one hour before or one hour after the initial times. It is also confirmed by the physicians whom subscribe the medications and dosages, the morning medications are given between the hours of 6am to 8am for residents requiring morning medication. Noon medication is given between 11am to 1pm, evening medication is given between 5pm to 7pm and this occurs throughout the day. Med-techs also monitor residents who require medication administration every four (4) to six (6) hours. The medication that is refused by the residents is logged in the electronic medications administration record (EMAR) the refused medication is then properly disposed. Refused medications cannot be administered at any other times. Protocols for administering medications are being followed as per Plan of Operation regarding medications: delivery procedures for medications, section B thru section H: facility policies and procedures regarding, new medication order for current residents, medication direction changes, PRN medications, residents refusing medications, charting of medications. Thirteen (13) out of Fourteen (14) residents interviewed stated they have gotten their medication daily and could not corroborate the allegations. Thirteen (13) residents stated, the med-techs speak to them while administering their medications and answer questions regarding their medication. Seven (7) out of fourteen (14) residents know the shape and size of their medications and are aware of the medications they are given. Based on interviews conducted, observations made, and documents reviewed, residents’ medication list, written physicians’ orders, facility Plan of Operations regarding medication administration. 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 allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was given to Ruth Villa, Wellness Director.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 28-AS-20241106101156

Allegation investigated: Personal Rights/Resident sustained an unexplained injury while in care.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced visit to interview Resident #3 (R-3) through Resident #7 (R-7) and deliver findings. LPA met with Jacqueline Cortez and explained the purpose of this visit. On 09/23/24, LPA Irra conducted the initial investigation visit. 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 (R-1's) and Resident #2 (R-2) files and obtained relevant documentation. Additionally, LPA obtained a copy of the staff roster and a copy of the Resident roster. During the course of this investigation, Investigator Christine Ferris (Department of Social Services- Investigative Bureau/IB) interviewed R-1, R-2, Staff #1 (S-1), Staff #2 (S-2), Staff #3 (S-3), Staff #4 (S-4) and Staff #5 (S-5). Investigator Ferris also obtained documentation from Los Angeles County Sheriff-Temple City Station pertaining to this allegation. On 10/21/24, LPA interviewed R-3 through R-7. ***Refer to LIC 9099C for the continuation of this report** Unsubstantiated Allegation: Personal Rights/Resident sustained an unexplained injury while in care. It has been alleged that a bruise was observed on R-1’s right rib area. Per Investigator Ferris’ investigation, R-1 did not disclose how R-1 sustained the bruise nor did R-1 disclose abuse or concern for neglect. Per Investigator Ferris’ investigation, staff interviewed denied knowledge of how R-1 sustained the bruise. Additionally, the Los Angeles County Sheriff’s Department determined no crime was committed. The investigation revealed no evidence to support abuse or neglect. R-3 through R-7 interviews revealed that they do not have any concerns, they have not heard of anyone complaining about this matter and that they feel safe residing at this facility. Interviews and police documentation do not corroborate this allegation. Although the allegation may have happened or are 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, appeal rights and a copy of this report was provided to Jacqueline Cortez.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 28-AS-20240920160331

Allegation investigated: Staff are overdosing residents. Staff are mismanaging resident's medications. Staff are administering unprescribed medications to residents. Staff do not answer residents’ call button in a timely manner. Staff do not ensure residents’ showering needs are being met. Staff do not ensure the facility has an adequate food supply. Staff do not ensure residents attend scheduled medical appointments. Staff do not ensure residents’ air conditioner is in good repair.

Licensing Program Analyst (LPA) S Vaid conducted a subsequent complaint visit regarding the above allegations. LPA conducted the initial complaint visit on 08/19/2024, this is a residential care facility for the elderly, a housing arrangement for persons, 60 years old and over. 24-hour non-medical care and supervision is provided. During today’s visit LPA met with Administrator Maya Mnoyan and explained the purpose of today’s visit. On today’s visit LPA Vaid conducted a physical plant tour with Admin Mnoyan and did not observe any health and safety concerns. Staff and home health agencies were observed assisting residents. The investigation consisted of the following: LPA Vaid interviewed Administrator, staff, and residents and toured the physical plant with Administrator and observed staff assisting residents with ADL (assisted daily living). LPA Vaid interviewed Administrator, staff #S2-S14 and residents #R1-R15. Continued on 9099C..... Unsubstantiated LPA Vaid requested and obtained the following documents: Staff and resident rosters, maintenance log for A/C repairs and call box signal repairs and installation for 2024, five random residents EMARS and other pertinent documents regarding this investigation. Regarding allegation: Staff are overdosing residents. It was alleged that staff are overmedicating residents with a Narcotic called Avitan used to treat adults with insomnia caused by anxiety and can cause drowsiness. Staff S1-S14 interviewed denied the allegation. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed med-tech staff overmedicating any of the residents. The Med-techs have stated that the medication is administered as prescribed as needed. Each residents’ medication that is administered is logged into the MARs. The medication cart and the medication room is audited each month, by management. LPA's review of five (5) random residents’ medication, and medication administration records, observed medication to be administered as prescribed by physician’s orders. All medications are accounted, as shown in the MARs log, LPA performed pill count of medications in the bubble packs. LPA reviewed residents that are prescribed Avitan, the MARs indicate that the Avitan has been administered sparingly, administered when needed to specific residents with attributing health conditions. LPA did not perform pill count as the medication is bottled. Resident R1-R15 interviewed were unable to corroborate the allegation. Based upon records 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. Regarding the allegation: Staff are mismanaging residents’ medications. It is alleged that staff are mismanaging residents’ medication by giving out one residents’ medication to another when first residents’ medication runs out. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the med-tech staff mismanaging the resident’s medication. The Med-techs and staff interviewed, stated that medication is administered as prescribed and logged into the Medication Administration Record. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed. During the afternoon, LPA observed AM-shift med-techs performing medication count before the PM shift was assigned the mobile medication carts. The PM shift med-tech then also make a pill count before next round of late afternoon/evening medications administration. Resident R1-R15 interviewed were unable to corroborate the allegation. Residents have no knowledge of this incident. Based upon records 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. Con't 9099C.... Regarding the allegation: Staff are administering unprescribed medications to residents. It is alleged that the staff had administered unprescribed medications to the residents who misbehave during the night, by logging incorrect information of medication administered. Covering up the pill count. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the medication technician staff administer unprescribed medication to residents. The Med-techs stated that medication is administered as prescribed. The narcotics log used to record time, date and dosage administered to the resident(s). The narcotics medication(s) are audited randomly each month for each resident using medications containing heavy narcotics. Medication audits are performed monthly by the Wellness Director to ensure medications are being administered as prescribed by the physician orders, constant communications with the pharmacy via eMARs (electronic medication administered records) ensure consistent supply of all medications continues. LPA's review of five (5) random resident medication, and medication administration records, shows that medication appears to be administered as prescribed by physician orders and pharmacy orders. Resident R1-R15 interviewed were unable to corroborate the allegation. Based upon records 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. Regarding the allegation: Staff do not answer the resident’s call button in a timely manner. It is alleged that staff are not answering the call button in a timely manner when residents call for assistance. Fourteen (14) out of fourteen (14) staff interviewed stated that they have not observed the staff not answering the call button switchboard in a timely manner. LPA observed a call come into the office by a resident asking for assistance, within 1-2 minutes a caregiver answered the office to acknowledge the call being handled, the call was answered by a staff person from the resident’s room. Residents R1-R15 interviewed stated that the caregivers come within 2-3 minutes after call is made on the residents’ call box, someone always answers. Based upon observations made 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. Continued on 9099C...... Regarding the allegation: Staff do not ensure residents’ showering needs are being met. It is alleged that staff are not ensuring residents showering needs are being met. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Caregiver staff and direct person staff(DSP) interviewed state, the caregivers staff assist the Home Health Aides with bathing the residents 2-3 times per week as noted in the resident’s needs/services plan. When residents refuse bathing, a note is made for bath refusal in the ADL (assisted daily living) clinical notes. Basic ADLs like brushing teeth, washing face, and combing hair, dressing is applied daily. Fifteen (15) out of fifteen (15) residents interviewed stated the staff gives baths twice a week, some residents stated they were given bathes three times a week by the home health agencies, the caregiver staff provides the rest. Based upon records 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. Regarding the allegation: Staff do not ensure facility has adequate food supply. It is alleged that the staff is not ensuring adequate food supply for residents. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. Kitchen staff interviewed state, grocery list is planned and ordered on Sunday and Wednesday for delivery of food on Monday and on Thursday. The kitchen was observed to have enough foods to feed all the residents, during tour of the kitchen LPA observed delivery being made, many boxes and bags of fruit and vegetable along with canned and dry food items being delivered. Fifteen (15) out of fifteen (15) residents interviewed state they like the food served and have never experienced food shortage at the facility. Based upon records 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. Regarding the allegation: Staff do not ensure residents attend scheduled medical appointments. It is alleged that a staff person is cancelling residents’ medical and other important appointments. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The residents with medical appointments, relay information to the caregivers and the care coordinator, who then logs in the appointments in the transportation log to ensure the drivers are aware of resident’s appointments. The protocol for the appointment scheduling is verified by the care coordinator to ensure all necessary paperwork and insurance paperwork is ready for the residents. Fifteen (15) out of fifteen (15) residents interviewed stated they are happy with the transportation protocols and have not had any problems with keeping their appointments. Continued on 9099C.... Based upon records 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. Regarding the allegation: Staff do not ensure residents’ air conditioner is in good repair. It is alleged that the staff is not ensuring that the air conditioner system is not in good repair. Fourteen (14) out of fourteen (14) staff interviewed denied the allegation. The air conditioner units are maintained by the maintenance staff, all air-conditioner systems are operational. When a unit breaks down or needs service, a work order is issued for maintenance to repair, repairs are handled within 24 hours unless parts are needed ordering. Accommodations for the residents are made if repair takes longer than anticipated. Regarding maintenance all work orders are logged to ensure completion of the projects in timely manner. Fifteen (15) out of fifteen (15) residents interviewed stated they have no concerns of the A/C units, staff is always fixing and are repairing things around the facility. Based upon records 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. LPA did not observe any Health and Safety concerns during the visit, an exit interview was held and copy of this report was given to the Administrator Maya Mnoyan.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 28-AS-20240815132940

Allegation investigated: Staff do not ensure infection control guidelines are being followed Staff do not ensure changes in residents health conditions are being monitored

Licensing Program Analyst (LPA) Vaid conducted an unannounced initial 10 day complaint visit regarding the above allegations. LPA met Maya Mnoyan (Administrator) and explained the reason for the visit. During today's visit, LPA reviewed and obtained client and staff roster, client admissions agreement, face sheet, physician order. LPA toured the physical plant with Administrator Mnoyan and did not observe any deficiencies or health and safety concerns. LPA Vaid interviewed Staff 1-6 (S1-S6). LPA interviewed residents 1-14(R1-R14). Regarding the allegation: Staff do not ensure infection control guidelines are being followed. It is alleged the facility staff are not following the infection control guidelines. Six (6) out of (6) staff deny the allegation. Fourteen (14) out of (14) residents interviewed could not corroborate this allegation. LPA reviewed the facilities Infection Control plan. ...... CONTINUED ON 809 C......... Unsubstantiated Last reviewed and updated by Administrator on 03/28/24. LPA observed the staff using PPE’s through out the facility, no reported cases of COVID-19 at the facility. Based on documents reviewed, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED. Regarding the allegation: Staff do not ensure changes in residents health conditions are being monitored. It is alleged that the facility is not monitoring the residents’ health conditions. Six (6) out of (6) staff interviewed deny this allegation. Fourteen (14) out of (14) residents could not corroborate the allegation. The residents who are with serious medical issues are monitored every two hours, some residents are monitored every hour depending upon their medical conditions. Caregivers and med-techs communicated with one another via communication logs, to alert the next shift caregivers and med-techs of any medical issues, residents are experiencing and level of monitoring that needs to be administered. There have not been any reported, no serious incident reports(SIR) of residents hospitalized for excessive cough have been filed. Based on documents reviewed, observations made, and interviews conducted. 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 allegation is UNSUBSTANTIATED. An exit interview was conducted and copy of this report was left with the Administrator, Maya Mnoyan.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 28-AS-20240827135724

Allegation investigated: Licensee did not provide responsible party with a refund.

***This licensing report supersedes licensing report (LIC 9099) dated 07/30/24.*** Licensing Program Analyst (LPA) Vaid conducted a follow complaint visit to the facility. Upon arriving at the facility, LPA met with Wellness Director Yumi Ludwig, Administrator Maya Mnoyan arrived shortly after to assisted with the visit. LPA discussed and explained the purpose of today’s visit, which was to reissue the findings issued on/07/30/24. On todays, visit LPA spoke and toured the physical plant along with Maya Mnoyan and did not observe any Health and Safety concerns. During today’s visit LPA obtained resident/ staff roster, complete admissions agreement. CONTINUED ON 9099 A...... Substantiated ***This licensing report supersedes licensing report (LIC 9099) dated 07/30/24.*** On 07/30/24 LPA Vaid conducted an initial complaint visit, during visit, LPA Vaid obtained resident/ staff roster, admissions agreement, and email correspondence showing responsible party’s email with facility officers. LPA also interviewed administrator Maya Mnoyan. 7 out 0f 7 residents could not corroborate the allegation and 5 out of 5 staff deny the allegation. Based on interviews conducted and documents review the findings indicate the facility was notified on 04/13/24 by the responsible party that the belongings of R1 were being moved to the rehab center where R1 would be residing for the remainder of their rehabilitation after being discharged from the hospital. On 04/16/24 R1 passed away, and on 04/17/24 responsible party notified the administrator via email correspondence, to start the prorated refund. The business office notified the responsible party the refund needed to go thru the corporate office, the corporate office would close out all outstanding accounts and the refund would be sent directly to the responsible party. R1’s responsible party (RP) contacted facility staff S1 and S2 via email correspondence to inquire of the refund on 05/17/24, 06/09/24, 06/17/24, 07/14/24, and 07/23/24. R1’s RP was assured the by facility staff S1 and S2 the refund was being handled. The facility failed to refund the prorated funds to R1’s responsible party within 15 days after property was removed on 04/13/24. Notification by the responsible party on 04/17/24 of R1’s death on 04/16/24 via email correspondence, as agreed to in the admissions agreement section VIII -termination and section C-death, dated 02/03/24. Therefore, based on LPA’s observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Exit interview was conducted and copy of this report and appeals rights were discussed and given to the Administrator.the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 28-AS-20240725105346

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(c) · Plan of correction due date: Aug 1, 2024

Admission Agreements 87507(5) Refund conditions.(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility... the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement not met as evidence by: Based on interviews and record review, licensee failed to refund monies with 15 days after R1's belonging were removed and after R1's death. California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Administrator produced the proof of refunded monies to R1's responsible party on 07/29/24. Proof of correction has been satisfied.

Allegation investigated: Licensee did not provide responsible party with a refund

On 07/30/24 at 08:45 a.m., Licensing Program Analyst (LPA) S Vaid conducted an ten day unannounced complaint visit to the facility. Upon arrival LPA met with Alyssa Morales (Business Officer) and explained the purpose of the visit. Maya Mnoyan(Administrator) arrived shortly after. During today’s visit LPA obtained resident/ staff roster, admissions agreement, physicians report, facesheet and email correspondence showing responsible party’s email with facility officers. LPA also interviewed administrator Maya Mnoyan. Toured the physical plant with the Administrator and did not observe any health and safety concerns. Based on interviews conducted and documents reviewed the findings indicate the facility was notified on 04/13/24 by the responsible party the belongings of R1 were being moved to the rehab center where R1 would be residing for the remainder of their rehabilitation after being discharged from the hospital. Continued on 9099C... Unsubstantiated On 04/16/24 R1 passed away at the hospital, on 04/17/24 responsible party notified the administrator via email correspondence to start the prorated refund. 7 out of 7 residents were not aware of the refund process. 5 out of 5 staff interviewed denied the allegation. The administrator notified the responsible party the refund needed to go thru the corporate office, the corporate office would close out all outstanding accounts and the refund would be sent directly to the responsible party. On 07/14/24 the Business Office Manager informed the responsible party that the corporate office had completed the refund request and will be mailing the prorated refund. On 07/26/24, check in the amount of $699.07 was sent to the responsible party via USPS mail. The process for refunds depends upon corporates Accounts Payable department and their due diligence by Social Security and insurance payments according to the business officer. Based on interviews conducted and documents obtained, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Administrator Maya Mnoyan and copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 28-AS-20240725105346

Allegation investigated: Illegal eviction

Licensing Program Analyst(LPA) S Vaid conducted an unannounced 10 day complaint investigation visit for the allegation listed above. LPA met with Executive Director Maya Mnoyan to discuss the purpose for today’s visit. LPA toured the facility, interviewed the Administrator, staff #2-#5, interview residents #1-#5, and requested a copy of the staff roster, resident roster, face sheet, admission agreement, physicians report, needs and services. Regarding allegation: illegal eviction. On 07/04/24 R1 was taken by paramedics to Arcadia USC due to shortness of breath, R1 was under the impression they would return to the facility upon being discharged from the hospital. On 07/05/24, facility administrator spoke to the Social Worker regarding R1 state of health and suggested that higher level of care was needed, both the social worker and facility administrator agreed. On 07/09/24, R1 family collected R1 personal belongings and medication for safe keeping, not knowing the protocols of the facility. CONTINUE ON 9099C... Substantiated There was no exchange in communications by the family nor the facility on whether R1 would be returning. No notice was given by resident(R1) to the facility of their plans to leave the facility, as indicated in the admissions agreement a 30-day notice is expected by the facility for anyone moving out of the facility. The administrator is refusing to allow the resident back into the facility citing no beds available. The capacity of the facility is 150 beds and todays census is 146, therefore the facility has room for four more residents until full to capacity. Administrator stated that four beds were reserved for new residents, however the facility is taking new residents when exsisting residents are still admitted to facility. The facility is in direct violation of the admissions agreement. R1 is ready to be discharged from the hospital however facility does not have room available, R1 room was given to another resident. Based on interviews, records reviewed and obtained, 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, Chapter 8, is being cited on the attached LIC 9099D. En exit interview was conducted and a copy of this report was provided to the along with the appeals rights.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 28-AS-20240722134903

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Jul 25, 2024

87224 Eviction Procedures...(a) The licensee may evict a resident.. Thirty (30) days written notice to the resident is required.... This requirement is not met as evidenced by: The facility did not comply with regulation of evictions procedures. R1 is ready to be discharged from the hospital however facility does not have room available for R1, facility gave away room to other resident. R1 did not given 30 day notice to facility about leaving.the state’s words, verbatim · CDSS document, Jul 25, 2024

Plan of correction: Within 24-48 hours facility will send nurse to hospital and perform an assesment and then R1 will continue residing at the facility until more skilled nursing home is found for the resident.

Allegation investigated: Facility staff does not meet residents grooming needs. Staff don't answer facility phone.

*This is a corrected version of previous report dated 6/14/24. LPA Ramirez corrected number of residents interviewed. LPA Ramirez met with Barbara Lopez and explained the purpose of the visit. LPA Ramirez redelivered this report on 7/6/24 with no changes to the findings.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/14/2024 regarding the above allegations. LPA Ramirez was met by Receptionist Tyryse Robinson. Administrator Maya Mnoyan, arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 6 interviews (S1 – S6), Resident#1 – 10 (R1 – R10), copies of Resident#1 (R1)- Physician’s Report (LIC 602), Identification and Emergency Information form, Admission Agreement, Medication Administration Record (MAR), Facility resident progress notes, Caregiver assignment log for R1, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegations: Facility staff does not meet residents grooming needs- It is alleged staff do not assist R1 with grooming. R1 arrived at the facility on 02/03/2023. Per R1’s Physician Report dated 3/4/24, R1 needs assistance with grooming. Six (6) out of the six (6) staff interviewed deny this allegation. Eight (8) out of the ten (10) residents interviewed deny this allegation. LPA Ramirez reviewed the facility Caregiver Assignment Logs for R1 which indicated R1 was assisted with grooming on different days R1 was present at the facility for the months of May and June 0f 2024. Staff interviews revealed R1 would leave the facility for days at a time. Staff revealed they would assist R1 with grooming when he returned. During facility tour and interviews with residents, LPA Ramirez observed residents to tidy in appearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff don’t answer facility phone- It is alleged staff do not answer the facility phone when family members call the facility. On 6/12/ 2024, at 11:15 am, LPA Ramirez dialed facility phone number and was greeted by facility staff. On 6/13/2024, at 4:45 pm, LPA Ramirez dialed facility phone number and was greeted by facility staff. During facility tour, LPA Ramirez observed facility phone ringing and staff answering calls. Six (6) out of the six (6) staff interviewed deny this allegation. Nine (9) out of the ten (10) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this investigation complaint. Exit interview conducted with Administrator Mnoyan. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 6, 2024 · control 28-AS-20240610162952

Allegation investigated: Staff did not provide adequate supervision to resident resulting in fall. Staff physically abused resident in care.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Administrator, Maya Mnyoyan who assisted with the visit. Regarding the allegation that : Staff did not provide adequate supervision to resident #1 resulting in fall. The investigation consisted of interviews with Administrator, staff #1 - staff #3, and resident #2 - resident #11. LPA also reviewed resident #1's file, and obtained copies of specific documents, including incident report dated 6/9/24. The investigation revealed the following : Administrator and staff interviewed stated that on 6/9/24, resident #1 experienced a fall at 10:42am while a caregiver was assisting resident #1 from a chair to her bed. Resident #1 was assessed and not found to have any injuries. Resident #1 experienced a second fall at 1:40pm, which was unwitnessed. Staff #2 assessed resident #1 and observed that resident #1 stated they were not in pain, and there were no visible injuries. Administrator stated that the doctor advised the facility to send resident #1 to the hospital for a more thorough assessment. Resident #1 is currently hospitalized. Unsubstantiated Administrator and staff interviewed denied the allegation. Four out of four staff interviewed stated that staff do provide adequate supervision to residents in care. Staff interviewed stated that if a resident experiences a fall, they are immediately assessed for injuries. Residents interviewed were unable to corroborate the allegation. Nine out of ten residents interviewed stated that staff provide adequate supervision to residents in care. Resident #1 is currently hospitalized and was unable to be interviewed. Although resident #1 did sustain a fall, the preponderance of evidence does not show that any Title 22 regulations were violated. Regarding the allegation that : Staff physically abused resident #1 in care. The investigation consisted of interviews with Administrator, staff #1 - staff #3, and resident #2 - resident #11. Administrator and staff interviewed denied the allegation. Four out of four staff interviewed stated that they have not observed any staff physically abuse any of the residents in care. Staff interviewed stated that they have not had any resident(s) report any physical abuse. Resident(s) interviewed were unable to corroborate the allegation. Ten out of ten residents interviewed stated that they have not observed any staff physically abuse any resident(s) in care. Resident #1 is currently hospitalized and was unable to be interviewed. 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 conducted, and a copy of the report was provided to Administrator.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 28-AS-20240611084216

Allegation investigated: Facility staff does not meet residents grooming needs. Staff don't answer facility phone.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 06/14/2024 regarding the above allegations. LPA Ramirez was met by Receptionist Tyryse Robinson. Administrator Maya Mnoyan, arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 6 interviews (S1 – S6), Resident#1 – 10 (R1 – R10), copies of Resident#1 (R1)- Physician’s Report (LIC 602), Identification and Emergency Information form, Admission Agreement, Medication Administration Record (MAR), Facility resident progress notes, Caregiver assignment log for R1, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegations: Facility staff does not meet residents grooming needs- It is alleged staff do not assist R1 with grooming. R1 arrived at the facility on 02/03/2023. Per R1’s Physician Report dated 3/4/24, R1 needs assistance with grooming. Six (6) out of the six (6) staff interviewed deny this allegation. Two (2) out of the ten (10) residents interviewed deny this allegation. LPA Ramirez reviewed the facility Caregiver Assignment Logs for R1 which indicated R1 was assisted with grooming on different days R1 was present at the facility for the months of May and June 0f 2024. Staff interviews revealed R1 would leave the facility for days at a time. Staff revealed they would assist R1 with grooming when he returned. During facility tour and interviews with residents, LPA Ramirez observed residents to tidy in appearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Staff don’t answer facility phone- It is alleged staff do not answer the facility phone when family members call the facility. On 6/12/ 2024, at 11:15 am, LPA Ramirez dialed facility phone number and was greeted by facility staff. On 6/13/2024, at 4:45 pm, LPA Ramirez dialed facility phone number and was greeted by facility staff. During facility tour, LPA Ramirez observed facility phone ringing and staff answering calls. Six (6) out of the six (6) staff interviewed deny this allegation. One (1) out of the ten (10) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this investigation complaint. Exit interview conducted with Administrator Mnoyan. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 28-AS-20240610162952

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 06/14/2024, stemming from initial complaint investigation conducted on 06/14/2024. LPA Ramirez was greeted by Administrator Maya Mnoyan. Case Management-Deficiencies findings: Resident#1 (R1) was admitted into the facility on 2/3/2023 and has an admission agreement dated 2/3/2023. LPA Ramirez discovered R1 and facility representative signed a document indicating the following “R1 has agreed to stay in this community here at Santa Anita Assisted Living under the following conditions: Stays in the building every day without leaving overnight. (Building closes at 10pm). Pay rent every single month on the 5th, starting June 5th, 2024, with no missed payment. If these conditions are not followed and being done, resident has agrees to leave facility and discharge themselves.” This document is dated 5/31/2024. Review of R1’s Physician Report (LIC 602) dated 3/4/2024, indicates R1 may leave the facility unassisted. R1 is self-responsible and is not conserved. Per Title 22, Division 6, Chapter 8- 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights. Interview with R1 revealed R1 left the facility on 6/7/24. On 6/10/24, Administartor Mnoyan phoned R1 to advise R1. they broke their agreement signed on 5/31/24 and could not return to the facility. As of 6/14/2024, R1 has not returned to the facility. LPA Ramirez and Administrator Mnoyan phoned R1 and R1 was told they may return to the facility. R1 agreed to phone the facility to get transportation arrangements. Facility staff violated R1’s personal rights by asking R1 to sign above referenced document; which violates R1's right to leave the facility freely, interfere and retaliate against R1 for exercising their rights. One deficiency was cited during this visit. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Jun 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(3) · Plan of correction due date: Jun 28, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.the state’s words, verbatim · CDSS document, Jun 14, 2024

Plan of correction: This requirement was not met as evidence by: R1 was asked to sign a document violating thier right to leave the facility freely, interfere and retaliate against R1 for exercising their rights. Licensee will retrain staff on this regulation and send proof of re-training by 6/28/24. Licensee will recind this notice by 6/17/24 and send proof to LPA Ramirez via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 5/21/24. LPA arrived unannounced and met with Administrator, Maya Mnoyan. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool. The following were observed: Infection Control: The facility is continuing to follow their Infection Control Plan. Staff are using gloves to assist residents and performing adequate hand hygiene. Staff are receiving annual in-service training on Infection Control. Operational Requirements: The facility is operating within the approved fire clearance. Facility accepts and retains residents with dementia. The liability insurance is current and has the sufficient amount covering the injury of residents and guests. Physical Plant & Environment Safety: The single story facility is located in the residential area. LPA randomly selected 12 rooms to inspect as well as the common areas. The hot water temperature in the rooms was measured within the range of 105-120 degree F. The common areas are clean and furnished. Each resident room has the required furniture, closet space, and lighting. The rooms have a call cord located by the residents bed and in the bathrooms. The fireplace is not in use and adequately screened. There are no items obstructing the walkways. There is no swimming pool on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department. Food Service: Adequate food supplies of 2 day perishable and a week of nonperishable were observed. The kitchen area is clean and free of rodents and insects. Food is properly covered to avoid contamination. Planned Activities: Facility has a full-time Activity Director providing activities to residents. There are planned daily activities and are posted on the bulletin board. Staffing: Per the administrator, there is sufficient staffing on each shift. The overnight shift staff are all awake and providing supervision to residents. There is at least one staff who is CPR & First Aid certified on each shift at all times. Personnel Records-Training: LPA reviewed 6 personnel records. The administrator's (Maya Mnoyan) certificate expires on 10/9/25. Staff are fingerprint cleared and associated to the facility. Staff have appropriate dementia care training and ongoing training. Resident Rights/Information: Information for appropriate reporting agencies are posted at the facility. Residents' rights are respected and implemented by staff. Resident Records/Incident Reports: LPA reviewed 14 resident files. Resident files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, pre-appraisal form, and care plan. Incidental Medical and Dental: Medications are centrally stored in the medication room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed 14 residents' medications and did not find any discrepancies. Disaster Preparedness: The facility has the updated LIC610E Emergency Disaster Plan posted. Annual training is provided to staff. The facility conducts monthly disaster drills for different shifts and are documented. Residents with Special Health Needs: Residents utilizing oxygen tanks have the proper sign posted outside their doors. Staff are ensuring that incontinence residents are changed often and the facility remains free of odor from incontinence. There are no deficiencies observed during the visit today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, May 21, 2024

Allegation investigated: Staff allow residents to use illegal drugs in the facility. Staff sell illegal drugs to residents in care. Staff do not ensure that the facility is clean. Staff do not ensure that resident is provided transportation to medical appointments.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of contiunuing the investigation of the above-allegations. LPA met with Business Office Manager, Alyssa Morales, and explained the purpose for the visit. Administrator Maya Mnoyan arrived shortly after to assist with the visit On 09/25/23, LPA Maldonado conducted an initial visit to the facility. The visit consisted of the following: LPA obtained a copy of resident/staff rosters, conducted a tour of physical plant and common areas with Administrator, Maya, and obtained the following documents for Residents# 1-4 (R1-R4): Facesheet, Physician's Report, Pre-Placement Appraisal, and Needs and Services Plan. LPA observed food supplies and random resident rooms. The residents were also observed to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns during today's visit. (Report continued on LIC9099-C...) Unsubstantiated The following allegation: Staff sell illegal drugs to residents in care, was investigated by the Department. The departments investigation consisted of the following: Interviews conducted with Staff#1-9 (S1-S9), Resident#1 (R1), Residents#5-10 (R5-R10), and Former Resident#1 (FR1). IB also obtained records from R5-R11's files, facility incident reports, Charting notes, SOC341 records completed by the facility, and documented staff encounters to incidents of possible drug use by residents. The investigation revealed the following: Regarding allegation: Staff sell illegal drugs to residents in care. It is alleged that residents are buying illegal drugs, such as methamphetamines, from S1. Per IB's interviews conducted with staff, (9) of (9) staff denied selling illegal drugs, including methamphetamines, to residents. Staff stated to have witnessed some residents showing signs of being under the influence of methamphetamines (staring off, talking to themselves, and dilated pupils). Staff also stated that S2 met with the suspected dealer, R1, to stop selling at the facility. Facility was unable to evict R1 due to lack of evidence to formally evict R1. Per S2, facility staff were instructed to notify S2 and document any suspicious activity on facility grounds. Incident Reports obtained by IB reflected the facility has reported these incidents to the licensing agency. The incident reports documented residents reporting to staff that R1 was selling drugs to other residents. SOC341's were also completed and incidents were reported directly to law enforcement, by the facility. Per the interview conducted with S1, S1 denied ever being in possession of any drugs or selling them to residents at the facility. Per interview with R1, R1 denied S1 to have sold methamphetamine's to R1 or other residents. R1 also denied selling drugs to residents. Therefore, this allegation is Unsubstantiated. During today's visit, LPA Maldonado, continued the investigation regarding the following allegations: Staff allow residents to use illegal drugs in the facility. Staff do not ensure that the facility is clean. Staff do not ensure that resident is provided transportation to medical appointments. LPA obtained a copy of the resident and staff rosters and a copy of Admission's Agreement for R1. LPA also conducted interviews with Staff#2-5 (S2-S5), Staff#10-11 (S10-11), Residents#1-2 (R1-R2), and Residents #11-14 (R11-R14). The laundry room/services were also inspected and observed. The investigation revealed the following: (Report Continued on LIC9099-C...) Regarding allegation: Staff allow residents to use illegal drugs in the facility. It is alleged that several residents at the facility were using methamphetamine with staff and Administrator knowledge, and allowed it. Per staff interviews, (6) of (6) staff denied allowing residents to use illegal substances on facility premises. Staff stated that any suspicious activity observed that may depict residents using illegal substances or being under the influence are to be reported to the Administrator immediately and to document the observation. Per resident interviews, (5) of (6) residents denied the allegation. Residents stated using illegal drugs/substances is prohibited as part of the house rules and staff do not allow it. If staff believed someone was under the influence, law enforcement is called. Per SOC341's obtained by IB, it was documented that the facility reported the incidents directly to law enforcement. Incident reports also obtained by IB indicate that the facility documented and reported known incidents of residents observed under the influence of illegal substances. Therefore this allegation is Unsubstantiated. Regarding allegation: Staff do not ensure that the facility is clean. It is alleged that facility staff do not wash resident's bedding and do not vacuum. Upon entry to the facility, LPA Maldonado observed (3) different housekeeping staff pushing carts with clean and folded linens, taking out trash from resident rooms, and sweeping and mopping resident rooms and hallways. During resident interviews, LPA observed housekeepers exiting rooms 119 with trash, observed the laundry room to be operating and fully stocked with clean folded clothes. LPA observed laundry staff delivering clean clothes on a hangar to room#145. The facility was free from odors and appeared to be clean and sanitary. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that housekeeping staff is on facility grounds (7) days a week and regularly clean resident rooms. Per S10, housekeeping change linens (2) to (3) times a week and as needed, laundry for all residents is done daily, and resident rooms are vacuumed once a week, unless a resident refuses housekeeping services on a certain day. Per resident interviews, (5) of (6) residents denied the allegation. Residents stated their rooms are cleaned daily, laundry is done daily and as needed, sheets are changed often and as needed, and rooms are vacuumed. Regarding allegation: Staff do not ensure that resident is provided transportation to medical appointments. It is alleged that facility staff are not assisting with taking R1 to R1's medical appointments due to being too far, although they are taking other residents to appointments that are further. Per staff interviews, (6) of (6) staff denied the allegation. Staff stated that S4 and S5 assist residents with making medical appointments when needed, and the receptionist will schedule the transportation for the medical appointments via the facility vehicle or a company contracted service. (Report continued on LIC9099-C...) Residents also have the option of requesting transportation services provided through their insurance. Staff also stated that if a resident's appointment is far, they will assist with finding a physician closer to the area, if the resident chooses. Per R1, R1 has been taken to medical appointments before by the facility van. However, they facility did not want to give R1 a ride to the liquor store and R1 had to pay for a taxi to take R1. (6) of (6) residents interviewed denied the allegation. Per interview with R13, R13's medical appointments are far and facility staff accommodate R13 to get R13 to their medical appointments. 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. Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit. An exit interview was conducted with Administrator, Maya Mnoyan, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 28-AS-20230922131350

Allegation investigated: Staff did not provide adequate food service for resident.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegation. LPA Maldonado met with Administrative Assistant, William Woods, and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff rosters, a copy of the food menu, conducted a tour of the physical plant with special focus on the kitchen and food services, and obtained the Facesheets and Physician's Reports for Residents# 1-8 (R1-R8). LPA also conducted interviews with Staff# 1-5 (S1-S5) and R1-R8. The investigation revealed the following: (Report continued on LIC9099-C...) Unsubstantiated Regarding allegation: Staff did not provide adequate food service for resident. It is alleged that on 1/23/24, a resident was denied breakfast upon their return from a medical appointment, due to them being out of the facility during the meal time, although they were promised breakfast upon their return. Per interviews conducted, (5) of (8) residents denied the allegation. Residents stated that snacks are provided to take with them to their appointments, and a meal is provided upon their return. Residents also stated that they have not had any issues with receiving a meal upon their return from their appointments. (2) of (8) residents interviewed could not corroborate the allegation as they stated they do not leave for regular medical appointments. (5) of (5) staff interviewed denied the allegation. They stated that it is the facility's policy to hold a meal for the residents any time they are out for a medical appointment. And if the meal is not held, the kitchen staff will personally prepare a fresh meal for the resident upon their return the facility. Staff state to be unaware of any resident being denied a meal upon their return from their medical appointment in the last 2 weeks. 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 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 28-AS-20240123134117

Allegation investigated: Staff did not prevent resident from attacking another resident resulting in injuries Staff did not notify resident's authorized representative of incident Staff did not notify residents authorized representatives of COVID outbreak

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Assistant Administrator, William Woods who assisted with today's visit. Regarding the allegation that : Staff did not prevent resident from attacking another resident resulting in injuries. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. The investigation revealed the following : Assistant administrator stated that on 10/28/23, resident #1 and resident #13 had a disagreement, and resident #1 pushed resident #13. Assistant administrator stated that the incident happened in the lobby area of the facility, and a special incident report was submitted to Community Care Licensing. Staff interviewed stated that resident #13 was assisted and assessed for injuries. Assistant administrator and staff interviewed stated that staff do try to intervene and prevent altercations between residents from occurring. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents interviewed stated that staff do try to intervene and prevent alteracations from occurring. Unsubstantiated Regarding the allegation that : Staff did not notify resident's authorized representative of incident. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. Assistant administrator and staff interviewed stated that the facility does notify residents' authorized representative(s) of incident(s). Staff #1 stated that he contacted the authorized representative(s) listed on resident #13's contact list, and was able to contact resident #13's son. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents stated that they were not sure if the facility contacts residents authorized representative(s) of incident(s). Regarding the allegation that : Staff did not notify residents authorized representatives of COVID outbreak. The investigation consisted of interviews with Resident #1 - Resident #12, Assistant Administrator, and staff #1 - staff #4. Assistant administrator and staff interviewed stated that the facility did notify the resident(s) who have authorized representatives of the Covid outbreak at the facility. Residents interviewed were unable to corroborate the allegation. 12 out of 12 residents interviewed stated that they are self responsible. They stated that they don't know if the facility notified residents authorized representatives of COVID outbreak. 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 conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20231030142152

Allegation investigated: Staff did not prevent the spread of scabies

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegation. LPA met with Assistant Administrator, William Woods who assisted with today's visit. On today's visit, LPA interviewed Assistant Administrator and Staff #1- Staff #3, reviewed Resident #1's file and interviewed Resident #2 - Resident #12. LPA also requested and obtained copies of specific documents from resident #1's file. The investigation revealed the following : Regarding the allegation that staff did not prevent the spread of scabies. Assistant administrator and staff interviewed denied the allegation. They stated that resident #1 lived at the facility from 1/23/23 - 7/1/23. Staff interviewed stated that resident #1 did not have scabies. Staff interviewed stated that resident #1 did have a rash and did complain of being itchy. Review of resident #1's file indicated that resident #1 was diagnosed with shingles on 6/17/23. LPA did not observe a scabies diagnosis during review of resident #1's file. Unsubstantiated Residents interviewed were unable to corroborate the allegation. 11 out of 11 residents interviewed stated that there has not been a scabies outbreak in the facility to their knowledge. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20231206084832

Allegation investigated: Staff mismanaged residents medications. Staff did not ensure faciltiy was free from bed bugs.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced initial complaint investigation regarding the above allegations. LPA met with Maya Mnoyan - Executive Director and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of Staff and Resident Roster’s, copies of Resident #1 (R1): Face Sheet, Current Physician Report, Discharge Paperwork from Hospital (of most recent visit), and Medical Documents. LPA conducted facility tour and inspected 6 client bedrooms. LPA conducted Staff #1 - 5 interviews (S1 – S5) and Resident #1-10 interviews (R1 – R10). Continued on 809-C Unsubstantiated The investigation revealed the following: Allegation: Staff mismanaged residents’ medications. It is alleged that R1 was given medication that was not needed. Medication in question was a 1% topical lotion, R1 states that S2 was giving them the wrong medication as it should have been 5%. LPA reviewed discharge paperwork from R1’s file and medication that was prescribed by doctor was a 1% topical lotion, this error was not done due to staff changing a medication. R1 cancelled the medication, and a new order was given by doctor for the correct 5% topical lotion. Interviews with S1 and S2 revealed that staff are not able to make any adjustments to resident medications and all medications are prescribed by doctor and administered per doctor’s orders. Interview with S2 revealed that S2 followed up with a phone call to doctor as medication prescribed is usually used to treat scabies and as precaution wanted confirmation as isolation protocols would follow if this was the case, doctor stated that the medication is provided to help cure mild skin allergies/irritations and did not confirm nor deny this was caused by bed bugs. LPA interviewed 10 Residents and 8 out of 10 Residents denied the above allegation and state they are confident that the facility manages their medication correctly and they are administered their medication per doctor’s orders. Allegation: Staff did not ensure facility was free from bed bugs. It is alleged that R1 has bed bugs in their room. LPA toured facility, inspected R1’s bedroom along with 5 other resident bedrooms, Rooms inspected were #’s 126, 145, 171, 177, 178, 186. LPA inspected the mattresses linens and carpets in each room and did not observe bed bugs or insects in any of the bedrooms. LPA reviewed R1 medical records and observed that R1 was provided with medications to cure a skin disorder, R1 was provided with Bed Bug Information Sheets at discharge, however, the diagnosis of skin condition did not identify that it was due to bed bug bites. LPA reviewed R1’s medical records and there are records showing R1 has had minor cuts/abrasions and skin tear treatment since 2/29/2023. LPA interviewed 5 staff and 5 out of 5 staff stated that no other resident besides R1 has brought the concern of bed bugs to their attention. 5 out of 5 staff stated that although they have not seen the bed bugs R1 claims to have in their room, there have been precautionary measures taken to ensure resident does not have bed bugs. Mattress has been switched out on three different occasions in R1’s room, housekeeping cleans regularly using a steamer on resident rooms twice weekly and weekly laundry is done where sheets are washed and replaced. LPA interviewed 10 Residents and 9 out of 10 Residents stated that their rooms are cleaned daily, sheets are washed weekly and they have never had any issues with bed bugs in their rooms. Continued on LIC 9099-C Based on statements and interviews conducted with staff and Residents and review of Resident #1 files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Executive Director Maya Mnoyan.the state’s words, verbatim · CDSS document, Nov 20, 2023 · control 28-AS-20231117101225

Allegation investigated: Facility grounds are littered with trash and cigarette buds. Resident was given incorrect medication by staff. Facility emergency call button in resident room is in disrepair all.

**This is corrected version of previous report dated 10/17/23. Verbiage on 9099-C was corrected from " Three (3) out of the four (4) staff interviewed deny this allegation" to " Three (3) out of the four (4) residents interviewed deny this allegation." No changes to findings.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegations. LPA Ramirez was met by Assistant Administrator William Woods and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Face Sheet, Physician Report Dated 08/25/21, Medication Administration Record (MAR) for the months of September and October, Physicians Orders dated May 2023, current medications as of 10/17/23, review of medical file, and physical plant tour. See 809-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Facility grounds are littered with trash and cigarette buds.- At 11:17 am, LPA Ramirez toured indoor and outdoor of the facility grounds. LPA Ramirez did observe several discarded cigarette buds in planter located on the outside main entry walkway of the facility. LPA Ramrez observed staff inspecting front grounds with a broom and scoop pan, and removing discarded cigarette buds from front grounds. LPA Ramirez did not observe trash scattered around facility grounds. 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. Resident was given incorrect medication by staff.- It is alleged facility staff gave R1 incorrect medication. Four (4) out of four (4) staff interviewed deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez reviewed R1’s Medication Administration Record for the months of September and October. LPA Ramirez did not observe and discrepancies. LPA Ramirez reviewed R1’s medical file and could not locate any medical records indicating R1 was sent to the hospital or treated for being over medicated or under medicated. LPA Ramirez did not observe and Special Incident Reports (SIRs) for R1 indicating medication was given incorrectly or missed. 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. Facility emergency call button in resident room is in disrepair.- It is alleged the facility emergency call button in R1’s bathroom is in disrepair. LPA Ramirez toured R1’s room (159) and tested emergency call button located in bathroom. Initially call button was not working properly however, this was due to call button not being reset. After second attempt and reset, emergency call button functioned accordingly. LPA Ramirez tested emergency call buttons in bathrooms: 120 and 132. LPA Ramirez observed these to be in working order. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. No deficiencies were cited during this visit. A copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Nov 14, 2023 · control 28-AS-20231011133210

Allegation investigated: Illegal eviction Facility is retaliating against resident

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint investigation visit for the allegation(s) listed above. LPA met with Executive Director Maya Mnoyan and Administrative assistant William Woods to discuss the purpose for todays visit. LPA toured the front of the facility, interviewed the Executive Assistant, staff #1-#2, interview residents, and requested a copy of the staff roster, resident roster, face sheets and eviction notices issued within the last 30 days. Regarding allegation: illegal eviction. There were roomers that resident #1 and resident #2 were selling drugs, but the administrator has no evidence. She said she called the Temple City Police Special assignment deputy's but they wouldn't go inside resident #1 and resident #2's room without them being present. Residents who were interviewed 1 out of 3 said they had knowledge resident #1 selling drugs in the facilty, Unsubstantiated but no proof was provided. On September 19, 2023, Executive Director Maya Mnoyan issued a 30 day eviction to the resident based on hearsay of other residents. On October 17, 2023, LPA Kimberly Ramirez requested that the Executive Director Maya Mnoyan rescind the 30 day notice for resident #1 and the Executive Director rescinded the 30 day notice on October 25, 2023. LPA Wesley was unable to interview resident 1 because they are not in the facility and based on the text conversation from the resident, they will not be returning. Regarding allegation: Facility is retaliating against resident. Based on the pictures provided the condition that resident #1 room was altered, the sprinklers, the call box was not working, the closet doors contained graffiti on them, and the room was thrashed. When the resident came back to the facility after being gone for a number of days, the administrator place her in room 122 which was a better kept room and the resident had a roommate that she got along with. There was no reason for resident to feel that she wasn't issued the same room because she contacted Community Care Licensing Division, as she was given the room assignment prior to her contacting Community Care Licensing Division as the room she was in was altered and there was no way of the resident using the call button and the sprinklers in her room were not operable. 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.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 28-AS-20231020154831

Allegation investigated: Facility staff hit resident in care. Facility staff did not safeguard resident's personal belongings. Facility staff did not ensure resident's record was completed accurately.

**This is a corrected version of previous report dated 8/25/23. No changes in findings. Verbiage on 9099 was corrected to reflect correct staff identifier (S1). ** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/25/23 regarding the above allegations. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R3, R5),attempted interview of Resident#4 (R4), copies of Resident #4 (R4): Admission agreement, Emergency and identification, Preplacement Appraisal Information dated 1/19/23, Physician’s Report 1/24/23, other pertinent documents and physical plant tour. Unsubstantiated Regarding allegation(s): Facility staff hit resident in care. It is alleged an unknown staff member hit Resident #4 (R4). Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez attempted to interview R4 in R4’s accommodation. R4 denied entry to LPA Ramirez and refused to be interviewed. LPA Ramirez reviewed R4’s medical file and did not observe and Special Incident Reports (SIR) indicating R4 sustained any injures within the last 2 weeks. 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. Facility staff did not safeguard resident's personal belongings. It is alleged facility staff stole R4’s wallet and jewelry. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. During the interview of R5, it was revealed that R5 found R4’s wallet in the dining room couch on 8/24/23. According to Administrator Mnoyan, R5 stated they found the wallet and the facility returned it back to R4. R4 refused to be interviewed. 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. Facility staff did not ensure resident's record was completed accurately. It is alleged that facility staff are not ensuring R4’s medical records are current. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. R4 was admitted into the facility on 1/19/23. Physician’s Report dated 1/24/23 and Preplacement Appraisal Information dated 1/19/23 both indicate R4 is ambulatory and does not require assisted devices to get around the facility. Four (4) out of the four (4) staff interviewed confirm R4 is ambulatory without assisted devices. R5 revealed that R4” accidentally left their wallet on dinning room couch and walked away.” LPA Ramirez could not find any discrepancies while reviewing R4’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator Mnoyan.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 28-AS-20230823112141

Allegation investigated: Facility grounds are littered with trash and cigarette buds. Resident was given incorrect medication by staff. Facility emergency call button in resident room is in disrepair.all

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegations. LPA Ramirez was met by Assistant Administrator William Woods and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Face Sheet, Physician Report Dated 08/25/21, Medication Administration Record (MAR) for the months of September and October, Physicians Orders dated May 2023, current medications as of 10/17/23, review of medical file, and physical plant tour. See 809-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Facility grounds are littered with trash and cigarette buds.- At 11:17 am, LPA Ramirez toured indoor and outdoor of the facility grounds. LPA Ramirez did observe several discarded cigarette buds in planter located on the outside main entry walkway of the facility. LPA Ramrez observed staff inspecting front grounds with a broom and scoop pan, and removing discarded cigarette buds from front grounds. LPA Ramirez did not observe trash scattered around facility grounds. 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. Resident was given incorrect medication by staff.- It is alleged facility staff gave R1 incorrect medication. Four (4) out of four (4) staff interviewed deny this allegation. Three (3) out of the four (4) staff interviewed deny this allegation. LPA Ramirez reviewed R1’s Medication Administration Record for the months of September and October. LPA Ramirez did not observe and discrepancies. LPA Ramirez reviewed R1’s medical file and could not locate any medical records indicating R1 was sent to the hospital or treated for being over medicated or under medicated. LPA Ramirez did not observe and Special Incident Reports (SIRs) for R1 indicating medication was given incorrectly or missed. 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. Facility emergency call button in resident room is in disrepair.- It is alleged the facility emergency call button in R1’s bathroom is in disrepair. LPA Ramirez toured R1’s room (159) and tested emergency call button located in bathroom. Initially call button was not working properly however, this was due to call button not being reset. After second attempt and reset, emergency call button functioned accordingly. LPA Ramirez tested emergency call buttons in bathrooms: 120 and 132. LPA Ramirez observed these to be in working order. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. No deficiencies were cited during this visit. A copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 28-AS-20231011133210

Allegation investigated: Resident is being illegally evicted.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/17/23 regarding the above allegation. LPA Ramirez was met by Assistant Administrator William Woods and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews(S1 – S4), Resident #1-4 interviews (R1 – R4 ), copies of Resident #1 (R1): Face Sheet, proof of service dated 09/19/23, signed Admission Agreement, signed Facility House Rules, 30-Day to Terminate dated 09/19/23, and physical plant tour. See 809-C for continuation. Substantiated The investigation revealed the following. Regarding Allegation: Resident is being illegally evicted.- It is alleged R1 is being illegally evicted. On 9/19/23, LPA Ramirez received notification of R1’s 30-Day to Terminate. The eviction alleged R1 failed to comply with the general policies of the community, R1’s conduct poses a danger to themselves or others at the community, R1 was disruptive and created unsafe conditions, and R1 engaged in conduct that violated federal, State or local laws, or ordinances. Facility staff could not provide LPA Ramirez with a police report or arrest report from local law enforcement that indicates R1 violated federal, State, local laws or ordinances. LPA Ramirez could not locate any Special Incident Report (SIRs) indicating R1 was found with illegal drugs in their persons or in their accommodation. On 09/22/23, LPA Ramirez reviewed R1 30-Day to Terminate and contacted Administrator Mnoyan. LPA Ramiez advised Administrator Mnoyan against eviction for R1 based on lack of criminal evidence of R1 allegedly selling illegal drugs in the facility. Administrator Mnoyan advised LPA Ramirez that local law enforcement refused to search R1’s room and advised the facility to seek a warrant so that local law enforcement may search R1’s room. Interviews with staff revealed R1 has never been found with illegal drugs in R1’s possession or found in R1’s room. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Exit interview conducted. One (1) deficiency is being cited. A copy of this report, 809-D, and appeals rights was provided. Resident is being harassed by staff- It is alleged R1 is being harassed by staff. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents interviewed deny this allegation. LPA Ramirez viewed signs posted in facility main reminding all residents, staff and visitors of Residents’ Rights and how to report any types of abuse or harassment. LPA Ramirez toured R1’s room and did not observe any hazards. LPA Ramirez toured facility grounds and observed several staff providing care and supervision. LPA Ramirez did not observe any staff harassing residents during visit. 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. Facility has bed bugs and insects- It is alleged the facility has bed bugs and insects in R1’s room. Four (4) out of four (4) staff deny this allegation. Three (3) out of the four (4) residents deny this allegation. LPA Ramirez toured rooms: 120, 123, 132, 145,153 and 159. LPA Ramirez inspected mattresses, linens and carpets in each room. LPA Ramirez did not observe bed bugs or insects in any of the rooms. LPA Ramirez did not locate any medical records treatment for R1 receiving treatment for bed bug bites. LPA Ramiez did not locate any work orders to treat any resident rooms for bed bugs. 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.the state’s words, verbatim · CDSS document, Oct 17, 2023 · control 28-AS-20231011091749

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Oct 25, 2023

(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidence by: Licensee did not provide R1 in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.the state’s words, verbatim · CDSS document, Oct 17, 2023

Plan of correction: Licensee will rescind eviction. Licensee could not provide factual evidence that resident failed to comply with state or local law and received written notice of the alleged violation.

Allegation investigated: Facility staff hit resident in care. Facility staff did not safeguard resident's personal belongings. Facility staff did not ensure resident's record was completed accurately.

**This is a corrected version of previous report dated 8/25/23. No changes in findings. Verbiage was corrected.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/25/23 regarding the above allegations. LPA Ramirez was met by Staff #1 (S1) and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R3, R5),attempted interview of Resident#4 (R4), copies of Resident #4 (R4): Admission agreement, Emergency and identification, Preplacement Appraisal Information dated 1/19/23, Physician’s Report 1/24/23, other pertinent documents and physical plant tour. See 9099-C for continuation. Unsubstantiated Regarding allegation(s): Facility staff hit resident in care. It is alleged an unknown staff member hit Resident #4 (R4). Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez attempted to interview R4 in R4’s accommodation. R4 denied entry to LPA Ramirez and refused to be interviewed. LPA Ramirez reviewed R4’s medical file and did not observe and Special Incident Reports (SIR) indicating R4 sustained any injures within the last 2 weeks. 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. Facility staff did not safeguard resident's personal belongings. It is alleged facility staff stole R4’s wallet and jewelry. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. During the interview of R5, it was revealed that R5 found R4’s wallet in the dining room couch on 8/24/23. According to Administrator Mnoyan, R5 stated they found the wallet and the facility returned it back to R4. R4 refused to be interviewed. 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. Facility staff did not ensure resident's record was completed accurately. It is alleged that facility staff are not ensuring R4’s medical records are current. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. R4 was admitted into the facility on 1/19/23. Physician’s Report dated 1/24/23 and Preplacement Appraisal Information dated 1/19/23 both indicate R4 is ambulatory and does not require assisted devices to get around the facility. Four (4) out of the four (4) staff interviewed confirm R4 is ambulatory without assisted devices. R5 revealed that R4” accidentally left their wallet on dinning room couch and walked away.” LPA Ramirez could not find any discrepancies while reviewing R4’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator Mnoyan.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 28-AS-20230823112141

Type of visit: Case Management - Deficiencies

**Please note this is corrected version from previous report dated 7/17/23. Deficiency issued on 7/17/23 has been changed from Type A to Type B. Please see new LIC 809-D page.** Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management VISIT DEFICIENCIES on 7/17/23 at 10am, stemming from initial complaint investigation on 7/17/23. LPA Ramirez gained entry into the facility at 9:25 am. LPA Ramirez requested and obtained copies of Resident #1 (R1): Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 3/23/23, Order Summary Report dated 4/5/2023, Individual Service Plan (ISP) dated 3/20/2023, Medication Administration Record (MAR) for May, June and partial month July of 2023, Resident #2 (R2) Face sheet, Physician’s Report dated 5/23/23, Resident #3 (R3) Face sheet, Physician’s Report, Resident #8(R8) Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 6/01/23, Order Summary Report dated 6/12/2023, and facility Blood Sugar Log for June 26, 2023. Case Management-Deficiencies findings: · LPA Ramirez conducted four (4) record reviews of Resident #1, 2,3, and 8 (R1, R2, R3, R8) medical file. · LPA Ramirez discovered that R1 seen their physician on 6/15/23 and R1’s physician ordered R1 blood sugar to be checked before breakfast, lunch and bedtime. Individual Service Plan (ISP) dated 3/20/2023 states Assisted Living Facility (ALF) will monitor blood sugar 3x/day and will report high or low glucose to MD. LPA Ramirez could only locate documentation for 6/26/23 that indicates facility staff checked R1’s blood sugar. LPA Ramirez could not locate documentation that facility staff checked R1 blood sugar from 6/16/23 to 6/25/23 3x per day as ordered by R1’s physician. · LPA Ramirez discovered that R8 seen their physician on 6/15/23. R8’s physician ordered R8’s blood pressure to be monitored and logged for seven (7) days. R8’s Physician Report dated 6/1/23 indicates R8 should “hold” on taking a certain prescribed medication if R8’s blood pressure is under 100. Facility staff could not provide proof of log to LPA Ramirez. Deficiencies are being cited. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Sep 28, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(13) · Plan of correction due date: Sep 28, 2023

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. This requirement is not met as evidence by: R1 physican ordered R1 have blood sugar monitored and recorded 3x a day, R8 physican ordered R8 have blood pressure monitored and recorded. Staff only recorded 1 day of R1's blood sugar and no proof of monitoring or logging of R8 blood pressure.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Licensee will certify plan to re-train staff on providing assistance in meeting medical needs of residents and following the physicans orders in regards to medical needs. Licensee will provide proof of staff training attendance sheet by 7/25/23. *No further action required*

Allegation investigated: Facility did not seek resident timely medical attention.

Licensing Program Analyst (LPA) Erik Zaragoza conducted a follow up complaint investigation regarding the allegation listed above. LPA met with the Tyreese Robinson the receptionst of the facility and explainedt the reason of the visit. Assistant Administrator William Woods and Administrator Maya Mnoyan arrived shortly thereafter. The investigation consisted of the following: during the initial visit conducted on 08/05/2022, LPA Alberto Lopez interviewed three (3) Staff Members and also obtained Resident #1's (R1's) file, including R1's FACE Sheet, Physician Report, Emergency contacts, appraisal Needs and Services Plan, and incident reports.During today's visit, LPA Zaragoza reviewed these documents and also obtained an updated Staff and Resident Roster list, along with a Physician's Report for R1. LPA Zaragoza also interviewed S1 - S7, and also Residents #2 - 12 (R2 - R12). LPA attempted to interview R1, however R1 no longer lives in the facility. Substantiated The investigation revealed the following: in regards to the allegation "Facility did not ensure that resident was adequately fed while in care", it is alleged that the resident had stopped eating and lost a lot of weight which led her family to call an ambulance to take her to a hospital over fears of malnutrition. During interviews with the residents, none of them corroborated the allegation that the facility does not ensure they are adequately fed. All of them indicated that they offer breakfast, lunch, dinner, and snacks to all the residents, and R8 indicated that they also accommodate her vegetarian diet as well and therefore believes they offer a good variety of food as well. During interviews with the staff members, none of them corroborated the allegation that residents are not adequately fed while in care. All staff explained that residents are fed breakfast lunch and dinner at the facility, and S2 along with S6 explained that if a resident is determined to be failing in death due to no longer eating, then they immediately report the issue to the resident's physician for further guidance. In regards to the allegation "Facility did not ensure that resident was adequately hydrated while in care", it is alleged that once R1 was admitted into the hospital, it was determined by the doctors at the hospital through testing that the resident was suffering from extreme dehydration along with malnutrition. During interviews with the residents, none of them corroborated the allegation that residents are not adequately hydrated while in care. All residents interviewed indicated that water and juice is available for them at all hours of the day whenever they ask for it. During interviews with the residents, none of them corroborated the allegation that they do not ensure that residents are adequately hydrated. They all explained that water and juice is provided to the residents every day, and S4 explained that if a resident is displaying signs of failing to hydrate themselves, the facility makes sure to elevate the situation to the Med Techs and the resident's physician to determine the next course of action. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. Regarding the allegation "Facility did not seek resident timely medical attention", it is alleged that R1's deteriorating health condition due to malnutrition and dehydration was not properly addressed by the staff of the facility, which forced her family to call an ambulance to take her to a local hospital. During interviews with the residents, seven (7) out of eleven (11) residents interviewed corroborated the allegation that they have not received appointments with doctors and specialists after they have asked for assistance in scheduling appointments, others have said delays in receiving medical care have forced them to admit themselves to the emergency room, and others explain that they are still waiting for medical care as they have not received a full physical since being admitted to the facility despite having health concerns. During interviews with the staff, none of them corroborated the allegation that the facility does not seek timely medical attention for the residents, however S6 did explain that R1 did not want to eat during their quarantine due to COVID and it was perhaps overlooked that R1's condition may have been declining at this time and did not seek medical attention for R1. The facility initially notified R1's family of the facility's concern that R1 had not been eating on 7/26/2022, and this report along with the family's concern that they had not had contact with R1 in the recent days led the family to call an ambulance and paramedics to take R1 to the hospital on 7/31/2022. R1 did not return to the facility after this hospitalization. Based on LPAs interviews conducted with the residents 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, and Chapter 8 are being cited on the attached LIC9099D. Exit interview held and a copy of the report and appeal rights was provided to the administrator Logan Harrison.the state’s words, verbatim · CDSS document, Sep 22, 2023 · control 28-AS-20220801102037

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Sep 23, 2023

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement is not met evidenced by: Based on interviews, LPA determined that facility staff noticed R1's health was declining on 7/26/2022, however medical care was not obtained until 7/31/2022 after R1's family called for an ambulance, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Sep 22, 2023

Plan of correction: Administrator shall ensure that all residents are afforded timely medical care. Administrator is to submit a written plan indicating how the facility will meet regulation 87468.1(a)(16) in a timely manner for all residents moving forward.

Allegation investigated: Facility staff hit resident in care. Facility staff did not safeguard resident's personal belongings. Facility staff did not ensure resident's record was completed accurately.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/25/23 regarding the above allegations. LPA Ramirez was met by Staff #1 (S5) and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R4), copies of Resident #4 (R4): Admission agreement, Emergency and identification, Preplacement Appraisal Information dated 1/19/23, Physician’s Report 1/24/23, other pertinent documents and physical plant tour. See 9099-C for continuation. Unsubstantiated Regarding allegation(s): Facility staff hit resident in care. It is alleged an unknown staff member hit Resident #4 (R4). Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. LPA Ramirez attempted to interview R4 in R4’s accommodation. R4 denied entry to LPA Ramirez and refused to be interviewed. LPA Ramirez reviewed R4’s medical file and did not observe and Special Incident Reports (SIR) indicating R4 sustained any injures within the last 2 weeks. 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. Facility staff did not safeguard resident's personal belongings. It is alleged facility staff stole R4’s wallet and jewelry. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. During the interview of R5, it was revealed that R5 found R4’s wallet in the dining room couch on 8/24/23. According to Administrator Mnoyan, R5 stated they found the wallet and the facility returned it back to R4. R4 refused to be interviewed. 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. Facility staff did not ensure resident's record was completed accurately. It is alleged that facility staff are not ensuring R4’s medical records are current. Four (4) out of the four (4) staff interviewed deny this allegation. Four (4) out of the four (4) residents interviewed deny this allegation. R4 was admitted into the facility on 1/19/23. Physician’s Report dated 1/24/23 and Preplacement Appraisal Information dated 1/19/23 both indicate R4 is ambulatory and does not require assisted devices to get around the facility. Four (4) out of the four (4) staff interviewed confirm R4 is ambulatory without assisted devices. R5 revealed that R4” accidentally left their wallet on dinning room couch and walked away.” LPA Ramirez could not find any discrepancies while reviewing R4’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator Mnoyan.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 28-AS-20230823112141

Allegation investigated: Facility is not providing residents with keys to lock bedroom door. Facility is not serving meals in a timely manner. Food being served is of poor quality. Staff do not prohibit resident from harassing other residents. Staff allow residents use illegal drugs and drink alcohol in the facility. Facility staff is not ordering resident medication on time.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a subsequent complaint investigation visit to deliver findings on 08/25/23 regarding the above allegation(s). LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit. The investigation consisted of the following: Initial complaint investigation was conducted on 8/22/23 by LPA Ramirez. LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #1 - 4 interviews (S1 – S4), Resident #1-4 interviews (R1 – R4), copies of Resident #2 (R2): current Physician’s Orders as of 8/22/23, Physician Visit dated 7/27/23, Physician Visit dated 6/15/23, Acknowledgement of receipt of room key, and physical plant tour. See 9099-C for continuation. Unsubstantiated The investigation revealed the following. Regarding Allegation(s): Facility is not providing residents with keys to lock bedroom door. It is alleged the facility is not providing residents with keys to lock their accommodations due to the locks being in disrepair. On 7/17/23, LPA Ramirez, cited facility for not providing at least seven (7) residents with keys to lock their accommodation. The facility did not provide keys due to the facility locks being in disrepair. Plan of correction (POC) was submitted on 7/25/23 for deficiency. Although the facility submitted POC, it was noted that additional parts would be required to repair or replace some locks and the locksmith would return and repair or replace the locks. On 08/22/23, LPA Ramirez observed locksmith replacing and repairing locks to resident accommodations. As of 8/22/23, Administrator Mnoyan revealed most locks have been rekeyed and all residents that requested a key received a key and signed an acknowledgment of receiving key. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Facility is not serving meals in a timely manner. It is alleged that kitchen servers are taking thirty (30) minutes to bring out meals during dinning hours. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. Interviews with staff revealed that although the dinning room is open at 7:30 am, residents can arrive early and wait for their breakfast to be served. According to staff, residents that arrive early before meals times are served, may feel like their meals are taking longer than usual. Staff revealed to that most meals are brought out within 10 minutes of placing order. LPA Ramirez toured kitchen and dining room area during breakfast and lunch. At 11:41 am LPA Ramirez observed staff serving meals within 8 minutes at 1 table with 2 residents during lunch. Although the allegation 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 allegation is UNSUBSTANTIATED. Food being served is of poor quality. It is alleged the facility is serving poor quality foods to residents in care. On 8/22/23, LPA Ramirez observed kitchen area and dinning room during breakfast and lunch hours. LPA Ramirez observed facility walk in refrigerator thermostat to read 39 degrees F. LPA Ramirez observed perishable food inside walk in refrigerator to be sealed in containers. LPA Ramirez did not observe any deficiencies. Containers were labeled with date of expiration. LPA Ramirez observed facility cook heating spiral cut ham for lunch. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. Although the allegation 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 allegation is UNSUBSTANTIATED. See 9099-C for continuation. Staff do not prohibit resident from harassing other residents. It is alleged facility staff do not stop resident from harassing another resident. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. Three (3) of the residents interviewed revealed R5 will repeatedly ask residents and staff for cigarettes. Three (3) out of the four (4) residents interviewed reported R5 is annoying but not harassing or violent. Although the allegation 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 allegation is UNSUBSTANTIATED. Staff allow residents use illegal drugs and drink alcohol in the facility. It is alleged facility staff allow residents to use illegal drugs and drink alcohol in the facility. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. LPA Ramirez toured four (4) resident accommodations. No health and safety risks were observed. Residents interviewed revealed that although they have never seen illegal drugs being used in the facility, they believe other residents go out of the facility and return intoxicated. Although the allegation 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 allegation is UNSUBSTANTIATED. Facility staff is not ordering resident medication on time. It is alleged that the facility is not ordering residents medications on time. Three (3) out of the four (4) residents interviewed deny this allegation. Four (4) out of the four (4) staff interviewed deny this allegation. LPA Ramirez reviewed R2’s medication record and medical file. Records review revealed that on 06/15/23, R2 saw their physician and the physician ordered 30 tablets of a pain reliever. However, once the order was received and processed by the pharmacy, the physician changed the prescription to the pharmacy and decreased the number of pills to fourteen (14). LPA Ramirez reviewed original prescription request for 30 tablets of pain medication on 6/15/23 and electronically revised prescription for 14 tablets that was sent to the pharmacy on 6/16/23. Although the allegation 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 allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Mnoyan. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 28-AS-20230816101140

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 8/22/23 at 9am, stemming from initial complaint investigation on 8/22/23. LPA Ramirez gained entry into the facility at 9:03 am. LPA Ramirez was greeted by Staff #1 (S1). LPA Ramirez conducted facility tour with S1. Case Management-Deficiencies findings: · LPA Ramirez toured eight (8) resident accommodations. Resident accommodation #129 carpet was observed to be heavily stained with black and brown spotted and scattered stains throughout accommodation. Bathroom was observed to be dirty. LPA Ramirez observed to have hairs and grime around tub. LPA Ramirez observed grime and dirt on floor near toilet. Per R1, carpet has been in disrepair and not clean since R1 moved into the facility in May of 2023. · Facility was cited on 7/17/23 for 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Facility resident door locks were in disrepair which resulted in several residents not receiving keys to lock their accommodation. · Based on today’s observations, LPA Ramirez is issuing Civil Penalties in the amount of $250 for repeat violations. Thereafter, a civil penalty of $100 per violation per day will be assessed until the violation is corrected. Deficiencies are being cited. Exit interview was conducted. A copy of this report, 809-D, LIC 421FC and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 5, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Resident accommodation carpet is disrepair and not clean. Room 129 bathroom tub and floor was observed to be dirty.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: Licensee will replace carpet or remove stains. Licensee will send picture proof of replaced carpet or invoice of professional carpet cleaning services for room 129. Licensee had staff clean bathroom during visit. No further action required for bathroom correction.

Allegation investigated: Resident has severe case of scabies

***Please note: This LIC9099 report supersedes the LIC9099 report dated 11/18/2022 to clarify and correct the citation on the deficiency page (LIC9099D), however, the finding will remain the same. *** Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with receptionist Tyryse Robinson and explained the reason of the visit. Shortly after, LPA met with Wellness Directot Yumi Ludwig and assisted with the visit. The investigation consisted of the following: On 09/07/2022, LPA Wong conducted a health and safety check. LPA toured the facility with LVN Mia Cody and observed that the facility is clean and in good repair. (See LIC 9099C for continuation) Substantiated LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, hand washing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. The following documents were collected which included: staff and resident roster. Resident#1-#3 (R1-R3) LIC601, physician report, resident appraisal, and admission agreement. On today's date, LPA interviewed five staff (S1-S5) and six residents (R1-R6) and families, facility in house doctor and obtained copy of physician communication report. The investigation revealed of the following: In regards to the allegation of "Resident has severe case of scabies" LPA interviewed the facility regional nurse on 09/07/2022 and reported that residents were not diagnosed with scabies and residents only had suspicious rashes from July to August 2022. Medical treatment was sought for residents in question as required and the issue was had been resolved but residents were treated prophylactically as a preventive measure. LPA also reviewed the residents' physician communication report and indicated for rashes and itching. LPA contacted the medical professional on 11/18/2022 and it was confirmed the facility did have scabies infection about two to three months ago (July to September 2022). The medical professional reported he did not remember how many residents got infected but for sure it’s more than two residents. Affected residents were treated and the issue was resolved. In regards to Resident #1, she was admitted to the hospital on 09/01/2022 and diagnosed with an advanced case of scabies which had not been properly treated and/or required medical treatment had not been obtained per emergency personnel. R1 did not get proper treatment at the facility while the facility had a scabies outbreak. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Wellness Director Yumi Ludwig along with the Appeals Rights.the state’s words, verbatim · CDSS document, Jul 28, 2023 · control 28-AS-20220902163645

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 4, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. The requirement was not met as evidenced by interviews conducted and records reviewed which indicated the facility failed to obtain additional medical care for R1 as required which resulted in the advancement of her scabies diagnosis which posed a potential risk tor resident in care.the state’s words, verbatim · CDSS document, Jul 28, 2023

Plan of correction: Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date