Santa Anita Assisted Living

Allegation investigated: Staff did not prevent residents from assaulting other residents in care Staff not meeting Resident incontinent needs. Staff do not provide proper shower assistance to residents in care Facility is in disrepair Facility is malodorous Residents smoke inside the facility Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial visit to investigate the above allegations. LPA met with William Woods (Assistant Administrator) and discussed the purpose of today’s visit. Maya Mnoyan (Administrator) arrived at approximately 9:05 A.M.. During this investigation, LPA obtained a copy of the staff roster and resident roster, reviewed files for Resident #1 (R-1) through Resident #5 (R-5) and obtained relevant documentation, interviewed Staff #1 (S-1) through Staff #4 (S-4), interviewed Resident #1 (R-1) through Resident #10 (R-10) and conducted a facility tour. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff did not prevent residents from assaulting other residents in care. Per S-1 and S-2, on 05/24/23, R-1 and R-2 were involved in an altercation. Staff intervened and contacted the local police department for assistance. This incident was also reported to Community Care Licensing (CCL). As a result of this incident, both R-1 and R-2 are no longer sharing the same bedroom and R-1 returned back to R-1’s previous roommate (R-3). There has not been additional altercations between R-1 and R-2. Per R-1 and R-2, staff intervened and assisted in a timely manner. Per R-1 and R-2, there has not been additional incidents. Per R-1 and R-3 there has not been any altercations (including physical) with each other. Interviews do not corroborate this allegation. Allegation: Staff not meeting Resident incontinent needs. Per Staff interviews, residents are not left in soiled diapers for several hours and do not wait until the next shift to complete this task. Staff interviews revealed that staff conduct rounds every (2) hours to assist Residents. Per staff interviews, rounds are documented on a log daily (including toileting/incontinence needs). Per Staff interviews, residents are not being double diapered and residents have not developed rashes as a result of incontinence care. Interviewed staff indicated they have not received any complaints/concerns in regards to staff not meeting residents incontinence needs. Resident interviews revealed that staff assist residents with incontinence care on a consistent basis. Per Resident interviews, staff conduct rounds every (2) hours and residents indicated they have not developed any rashes as a result of incontinence care. Interviews and documentation do not corroborate this allegation. Allegation: Staff do not provide proper shower assistance to residents in care. Per Staff interviews, staff assist residents with showers. Interviewed staff indicated staff follow a “shower schedule” for residents. Staff interviews revealed that staff conduct rounds every (2) hours to assist Residents. Per staff interviews, rounds are documented on a log daily (including showering). Interviewed staff indicated they have not received any complaints/concerns in regards to staff not meeting residents showering needs nor reports of residents having bad body odor. Resident interviews revealed that staff assist residents with showers on a consistent basis. Per Resident interviews, staff conduct rounds every (2) hours and residents indicated they have not encountered anyone having bad body odor. Interviews and documentation do not corroborate this allegation. Refer to LIC 9099 for the continuation of this report. Allegation: Facility is in disrepair. (3) out of (4) staff interviews revealed that residents’ sinks are not broken. However, (3) out of (4) staff interviews indicated there was an incident on 06/22/23 at approximately 1:30 A.M regarding the bathroom sink inside room 181 (room vacant at the time of incident and continues to be vacant) leaking. This leak caused water to go into rooms 180 and 175. This incident was reported to S-1 and it was handled immediately. Rooms 181, 180 and 175 have flooring not carpet. Staff mopped and dried the flooring immediately following this incident with no issues noted. LPA conducted a tour of rooms 181, 180 and 175 and observed the rooms to have flooring not carpet and the sink in room 181 (handle) was replaced. Interviews and tour conducted do not corroborate this allegation. Allegation: Facility is malodorous. Per staff interviews, resident rooms are cleaned daily and the facility does not have an odor of urine and/or feces. Interviewed staff indicated they have not received any complaints/concerns in regards to the facility being malodorous. Resident interviews revealed that the facility is kept clean at all times and that the facility does not have an odor of urine and/or feces. LPA toured facility grounds and did not smell an odor of urine and/or feces. Interviews and tour conducted do not corroborate this allegation. Allegation: Residents smoke inside the facility. Staff interviews revealed the facility has designated smoking areas outside (courtyards) of this facility. (3) out of (4) interviewed staff indicated they have not witnessed nor have received any complaints from anyone in regards to smoking inside this facility. Per S-1, R-6 was recently caught smoking inside R-6’s room and S-1 immediately addressed this matter with R-6. S-1 indicated S-1 spoke to R-6 and reminded R-6 about the smoking policy. Per S-1, this was an isolated incident and has not reoccurred with R-6 nor has S-1 witnessed or received complaints/concerns from anyone in regards to residents smoking inside this facility. Resident interviews revealed they have not witnessed anyone smoking inside this facility. Allegation: Staff did not safeguard resident's personal belongings. Staff interviews revealed that they have not received any concerns/complaints in regards to residents items going missing. Per staff interviews, Administrator has not indirectly accused staff of taking residents belongings. Interviewed staff indicated they are trained in Mandated Reporting and Resident Rights. Resident interviews revealed that they do not have items that have gone missing. Interviewed residents did not have any concerns in regards to facility not safeguarding their personal belongings. Interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Based on record review and interviews conducted the findings indicate, although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are UNSUBSTANTIATED. An exit interview conducted, appeal rights and a copy of this report was provided to Maya Mnoyan.the state’s words, verbatim · CDSS document, Jul 21, 2023 · control 28-AS-20230712154816

Allegation investigated: Facility staff are not providing residents with keys to lock their room door.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 07/17/23 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 #2 - 5 interviews(S2 – S5), Resident #1 – 7 interviews (R1 – R7) 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 #2 and 3(R2, R3) Medication Administration Record (MAR) for May, June and partial month July of 2023, 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 physical plant tour. Substantiated The investigation revealed the following. Regarding Allegation(s): Facility staff are not providing residents with keys to lock their room door- It is alleged that facility staff are not providing residents with keys to lock their room door. Two (2) out of five (5) staff interviewed acknowledged that not all residents have keys to their rooms due to some locks on residents’ doors to be is disrepair or not the keys themselves are not working correctly. Seven (7) out of the seven (7) residents interviewed currently do not have keys to lock their room door. Interviews and record review revealed three (3) out of seven (7) residents have been at the facility under 60 days and never received a key to their room. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited. Exit interview was conducted. A copy of this report, 9099-D, and appeals rights was provided. Facility staff are not re-filling medications in a timely manner. It is alleged facility staff are not re-filling resident medications in a timely manner. Four (4) out of four (4) staff interviewed deny this allegation. LPA Ramirez reviewed three (3) resident MAR for the months May, June and partial of July 2023. LPA Ramirez could not locate and discrepancy to suggest facility did not attempt to refill prescriptions. LPA Ramirez did locate notes in R1 file that indicated facility staff made several attempts to contact physician for prescription refill however, the physician’s office was delaying response. 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 are not safeguarding residents’ personal belongings. It is alleged the facility staff are not safeguarding residents’ personal belongings. Four (4) out of four (4) staff interviewed deny this allegation. Four (4) out of the seven (7) residents interviewed revealed they had items missing from their room in the past however, they did not notify facility staff because some stuff was of nominal value. Residents interviewed could not recall if they misplaced some items of if they were stolen from their room. R2 stated a new cellphone was stolen from their room several weeks ago. R2 revealed they did not notify the facility when the alleged theft occurred. LPA Ramirez could not locate a cell phone listed in R2’s itemized inventory list. 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. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2023 · control 28-AS-20230710131509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 31, 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: Seven out of the seven residents interviewed do not have keys to lock their rooms. 3 out of the seven residents are have been at the facility less than 60 days and never received a key to their room.the state’s words, verbatim · CDSS document, Jul 17, 2023

Plan of correction: Licensee will develop a plan to address how facility will record lost keys and replacements, how facility will record new residents receiving keys to room. Facility staff provided majority of residents replacement keys to their rooms after report was drafted. Licensee will send list of all residents awaiting replacement keys 7/31/23.

Type of visit: Case Management - Deficiencies

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, Jul 17, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1)(2) · Plan of correction due date: Jul 18, 2023

87465(a)(1) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. 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. Facility 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, Jul 17, 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.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Continuation Visit on 07/7/2023 at 9:20Am, stemming from initial Annual Required Visit on 06/12/23 and Annual Continuation on 6/13/23. LPA was met by Staff #1 (S1) and explained the purpose of the visit. LPA Ramirez conducted eight(8) residents interviews. LPA Ramirez requested facility liability insurance, facility will email proof of required liability insurance no later than 7/14/23. No deficiencies are being cited at this time. LPA Ramirez conducted exit interview and a copy of this report will be emailed due to printer problem.the state’s words, verbatim · CDSS document, Jul 7, 2023

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Continuation Visit on 06/13/2023 at 1:22pm, stemming from initial Annual Required Visit on 06/12/23. LPA was met by Administrator Mnoyan and explained the purpose of the visit. Records Review: LPA reviewed nine (9) staff personnel files, nine (9) resident files, and conducted nine (9) staff interviews. No deficiencies were cited during file review. LPA requested and obtained a copy of facility liability insurance. Due to time constraints, LPA will return to complete resident interviews at a later day. A copy of this report will be emailed to Administrator Mnoyan due to printer problems.the state’s words, verbatim · CDSS document, Jun 13, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/12/2023 at 1:300 Pm. LPA was met by Administrator Mnoyan and explained the pupose of the visit. Staff #9 (S9) assisted in tour of facility. Facility is licensed to serve residents over the age of 60 years old. The facility has a fire clearance for 130 non-ambulatory, 20 bedridden and is currently approved for 20 hospice residents. LPA requested and obtained a copy of Personnel Report, and Resident Roster. Observations: The facility is located on a residential street and is a single-story building. LPA toured physical plant and selected random residents rooms for inspection. LPA toured TV room, medication room, activities room, laundry room, theater room, and kitchen/dinning room area. LPA observed kitchen staff cleaning up kitchen after lunch service and observed several kitchen staff preparing dinner service. LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7-day supply on non-perishables. Walk in freezer thermostat was observed to read 0 degrees F and walk in refrigerator thermostat was observed to read 40 degrees F. Dinning room area was observed to be clean and free from hazards. LPA observed dinning room tables to have seating charts. TV room, activities room, laundry room and theater room were all observed to be clean and free of hazards. LPA observed staff conducting a cooking class with residents in activities room. LPA selected rooms 116, 115, 120, 128, 136, 161 and 153 for inspection. Selected rooms all contained the required furnishings, linens and were observed to be clean with plenty of closet space. Water temperature in resident bathroom #153 was recorded as 109.7 degrees F. LPA observed and tested emergency call assist cord in resident bedroom # 120. Emergency assist cord was pulled at 3:05 pm and staff responded at 3:07 pm. LPA observed fist aid kit located in medication. LPA observed several fully charged fire extinguishers throughout the facility. Due to time constraints, LPA will return at a later date to complete annual inspection. No deficiencies are being cited at this time. Exit interview was conducted with S9. A copy of this report will be emailed due to printer problems.the state’s words, verbatim · CDSS document, Jun 12, 2023

Allegation investigated: Facility door is in disrepair. Staff do not prohibit residents from smoking.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Maya Mnoyan (Administrator) and explained the purpose of the visit. During today's visit, LPA obtained/reviewed a copy of the Staff/Resident rosters and smoking policy, toured (R#1) Resident #1's bedroom, interviewed Staff #1 to #4 in the conference room, interviewed Resident #1 in the bedroom and interviewed Residents #2 to #7 in the conference room. In regards to the allegation: Facility door is in disrepair. It was alleged that the sliding door in R#1's bedroom is in disrepair. LPA toured R#1's bedroom and observed the sliding door to be in good repair. Interview with R#1's indicate the sliding door was not in disrepair but difficult to slide. Interviews with Staff also indicate the sliding door was not in disrepair but was hard to slide. Facility made adjustments to the sliding door as soon as Staff was made aware. Continue to LIC9099C...... Unsubstantiated In regards to the allegation: Staff do not prohibit residents from smoking. LPA reviewed the facility smoking policy and observed that smoking is allow in designated areas of the facility. Interviews with 4 of 4 Staff also indicate there are areas designated for smokers and have never witness anyone smoking in the back of the facility which is not a designated smoking area. Interviews with 7 of 7 Resident indicate they don't smoke in the back area of the facility and have never witnessed anyone smoking in the back area of the facility. Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Maya Mnoyan and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 21, 2023 · control 28-AS-20230313143928

Allegation investigated: Staff does not safe guard resident's personal items.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Maya Mnoyan (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 2 (S1 – S2), Resident 1 - Resident 7 (R1 – R7), R1's Family Member and R1's Power of Attorney (POA). LPA also toured R1's room and reviewed R1's file. The investigation revealed the following: regarding the allegation "staff does not safe guard resident's personal items”, it is alleged that R1's personal belongings had been stolen. The following belongings were allegedly stolen: 4 watches, a bag of about 15-20 pairs of earrings, sunglasses and water bottle. (Continued to LIC 9099C) Unsubstantiated Administrator and staff interviewed stated that R1 did report these items missing, however, when R1 moved in R1 threw a lot of personal belongings to the trash. One of the staff took a bag of jewelry out of the trash, but R1 told the staff it was trash, therefore the staff gave it to the administrator to store just in case. They also stated that R1 refused to file a police report. Administrator stated that R1 found some of the earrings in the bag of jewelry that was recovered from the trash and she assisted R1 in searching R1's entire room for the other items, but could not find them. R1, R1's family member, and R1's power of attorney confirmed that R1 did threw things away when R1 moved in, but claimed that the items reported missing were not things that were thrown away. It was confirmed that R1 did refuse to file a police report. Interviewed with R1 revealed that these items went missing on different dates: sunglasses went missing on 12/03/2022, earrings went missing on 01/02/2023, the 4 watches went missing on 02/02/2023, and the water bottle went missing on 02/11/2023. However, R1 did not report these items missing to the facility until 02/13/2023. Residents interviewed revealed that 5 out of the 7 residents could not corroborate with 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 held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Feb 22, 2023 · control 28-AS-20230215160926

Allegation investigated: Resident sustained pressure injuries while in care

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 finding. LPA met with receptionist Frances CDeVaca and explained the reason of the visit. Shortly after, LPA met with administrator Maya Mnoyan 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. LPA also observed supplies of nonperishable food for a minimum of one week and perishable food 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. (See LIC 9099C for continuation) Unsubstantiated On 11/18/22, LPA interviewed five staff (S1-S5) and six residents (R1-R6) and families, facility in house doctor and obtained copy of physician communication report. On today's date, LPA obtained more documents for R1. The investigation revealed of the following: In regard to the allegation of “Resident sustained pressure injuries while in care.” The staff denied the allegation and reported R1’s wound/blister had been there for a long time and even since she's admitted to the facility three years ago and it's been healing and clean. LPA spoke to home health agency and reported they already discharged R1’s services as there’s no more swelling or redness for R1's blister/wound on her right leg and they reported R1’s thickens skin on hands and foot had been there for a long time and they cannot wash it off. Based on LPA's observation, interviews conducted with staff and residents, 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 is UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Administrator Maya Mnoyanthe state’s words, verbatim · CDSS document, Feb 7, 2023 · control 28-AS-20220902163645

Allegation investigated: Resident has severe case of scabies

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 Ruben Reyes and explained the reason of the visit. Shortly after, LPA met with administrator Maya Mnoyan 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. 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 familes, facility in house doctor and obtained copy of phyician communication report. Substantiated The investigation revealed of the following: In regards to the allegation of "Resident has severe case of scabies" LPA interviewed the facility regional nurse and reported that residents were not diagnosed with scabies and residents only had suspicious rashes. Everything was resolved already but they still treat residents prophylactically for prevention. LPA also reviewed the residents' physician communication report and indicated for rashes and itching. However, LPA contacted the medical professional and it was confirmed the facility did have scabies infection about two to three months ago. The medical professional reported he did not remember how many residents got infected but for sure its more than two residents. And the medical professional did treat the residents with a proper treatment but everything is cleared now. 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 Administrator Maya Mnoyan along with the Appeals Rights. The investigation revealed of the following: In regard to the allegation of "Staff are not meeting resident's hygiene needs" LPA interviewed 6 residents and families and all denied the allegation. They all reported facility take good care of the residents and residents are all clean and dress well. LPA interviewed staff and all denied the allegation and reported all residents have shower two to three times a week or as needed and staff also changed residents diaper every two hours or as needed. LPA also observed residents and they look clean with good hygiene. Based on LPA's observation, interviews conducted with staff and residents, 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 provided to Administrator Maya Mnoyanthe state’s words, verbatim · CDSS document, Nov 18, 2022 · control 28-AS-20220902163645

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Nov 28, 2022

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The requirement was not met as evidenced by LPA contacted the medical professional and confirmed the faciltiy had scabies infection two to three months ago. And faciltiy had about 7 residents infected which pose an potenial risk to residents in care.the state’s words, verbatim · CDSS document, Nov 18, 2022

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

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff is unlawfully evicting resident

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced 10 day complaint visit to this facility and met with Administrative Assistant, William Woods and discuss the purpose of the visit. The investigation consisted of: LPA Pena obtained copies of the staff/resident roster, Medical chart notes, incident reports, Resident #1 file, ID page, physician's report, IPP, Admissions agreement and resident appraisal. Regarding allegation: Facility staff is unlawfully evicting resident. It was alleged that Resident #1 was not being accepted back to the facility after her hospital stay. R1 was ready to be discharged and able to return to the facility effective immediately with hospice care but S1 refused to take R1 back. According to RP, R1's brother arranged for a private hospice nurse to take care of R1 but S1 still refused her back. ***Report continued on LIC 9099-C*** Substantiated The investigation revealed that the facility's Regional Nurse (S3) conducted the pre-appraisal and went to the hospital for re-assessment. S3 stated that R1 is now high risk and will need a higher level of care and that the facility will not be able to meet the residents' needs. S3 has reported this to S1 who in turn called W1 (R1's responsible party) to advise that the facility will not be able to take R1 back to the facility due to her medical condition. S1 spoke to W2 on the phone while W1 was on a speakerphone and explained the situation. S1 told W1 and W2 that R1's medical condition would need a higher level of care and the facility will not be able to meet her needs, hence they are not accepting her back to the facility. S1 stated that she did not provide an eviction notice to the family or CCLD. S2-S6 stated that they have not heard and unaware of any illegal evictions of residents in the facility. All staff interviewed stated that they do not know if anyone was evicted illegally. R2-R5 stated that they never had any issues or problems coming back to the facility after hospitalization. R2-R5 indicated that they have not heard and did not know if any resident was evicted illegally. R2-4 stated that they were hospitalized before and they came back to the facility. LPA reviewed R1's documents and observed that S3 has noted the medical charting of R1 stating her current medical condition and her level of care and needs will not be met by the facility. Although the facility conducted the pre-appraisal.re-assessment of R1 at the hospital to find out if R1 can come back to the facility, the eviction procedure was not followed. S1 should have issued an eviction notice and sent to CCLD within 5 days of finding out that R1's medical condition has changed to a higher level of care. 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 Administrative Assistant, William Woods along with the Appeals Rights.the state’s words, verbatim · CDSS document, Nov 14, 2022 · control 28-AS-20221109142252

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Nov 21, 2022

87224 Eviction Procedures...(a) The licensee may evict a resident.. Thirty (30) days written notice to the resident is required....(4)If, after admission, has a need and a reappraisal has been conducted ... the licensee and the person who performs the reappraisal....not appropriate for the resident. This requirement is not met as evidenced by: The Administrator did not issue/provide the required thirty (30) days eviction written notice to the family or the resident's responsible party and CCLD.the state’s words, verbatim · CDSS document, Nov 14, 2022

Plan of correction: The Administrator will submit a copy of the written eviction notice and a signed statement that she read, reviewed and understood Title 22 Regulations Division 6 Chapter 8 Article 04 Section 87224 Eviction Procedures to LPA on or before the POC due date.

Allegation investigated: Staff are not properly supervising residents in care. Resident's bedroom waste basket is not being emptied as often as needed. Resident's bedroom is malodorous. Facility meals are not of the quality or quantity necessary to meet the needs of the residents.

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above mentioned allegations of "Staff are not properly supervising residents in care, Resident's bedroom waste basket is not being emptied as often as needed, Resident's bedroom is malodorous and Facility meals are not of the quality or quantity necessary to meet the needs of the residents." Upon arriving at the facility, LPA met with Administrator / Sabina Nayberg who assisted with the visit. LPA Katrdzhyan conducted a prior visit to this facility on 7/14/22, in reference to the allegations listed above. The investigation consisted of interviews of various persons to include the Administrator, Staff members 1 through 3 (S1 - S3) and Residents 1 through 5 (R1 - R5). LPA toured a random selection of resident rooms, toured the facility kitchen and dining room. Also, a copy of the facility food menu for the month was obtained. Please see LIC 9099C for additional information. Unsubstantiated The investigation revealed the following; Allegation: Staff are not properly supervising residents in care. The details of this allegation states that one night (date unknown) around 8 or 9pm, an unknown female resident needed assistance because she was found lying on the floor. At the time, there was no staff available to help. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation. Staff and residents interviewed denied facility having insufficient staff to meet the needs of residents. Interviews conducted of staff determined that during the morning shift (6am – 2pm), there are usually 3 caregivers and 1 med tech on duty. During the afternoon shift (2am – 10pm), there are 2 -3 caregivers and 1 med tech on duty. During the knock shift (10pm – 7am), there are usually 2 caregivers and 1 med tech on duty. According to the Administrator staffing has been a struggle with Covid and it may vary day to day but there is always sufficient number of staff to meet the needs of residents. Based on interviews conducted, there is insufficient evidence to support this allegation to be true. Allegation: Resident's bedroom waste basket is not being emptied as often as needed and Resident's bedroom is malodorous. The details of these allegations state that adult diapers are thrown away in the bedroom waste basket and facility staff does not empty the waste basket often enough which causes resident rooms to smell bad. Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegations. Staff and residents interviewed stated that the waste baskets are emptied in resident rooms daily. Staff denied throwing away adult diapers in resident rooms causing resident rooms to smell malodorous. Residents interviewed denied their rooms smelling bad as a result of staff not emptying their waste baskets. During the visit conducted on 7/14/22, LPA toured a random selection of resident rooms (106, 143, 164, 171, 175, 178, 180, 183, 187, 131, 133 and 124) and the waste baskets in residents rooms were observed to be empty. Some of the rooms toured happened to be of residents with incontinent issues and during the walk through, there was no malodorous smell present in resident rooms and resident rooms were observed to be clean and sanitary. Based on interviews conducted and LPA's observation, there is insufficient evidence to support this allegation to be true. Allegation: Facility meals are not of the quality or quantity necessary to meet the needs of the residents. The details of this allegation states that food served to the residents at this facility is really poor quality and not enough (only one chicken leg and one scoop of rice or a hot dog and juice being served for dinner). Based on interviews conducted, the statements obtained were inconsistent and did not corroborated with the allegation. Staff and residents interviewed denied the food not being of good quality or quantity to meet the needs of residents. Staff and residents stated that the meals served during breakfast, lunch and dinner are of variety and residents get additional or seconds upon request. LPA verified on the facility food menu that the meals served daily are not the same and there is a variety during each serving. According to the Administrator, everything listed on the menu is approved by a dietician. In the event, a resident refuses to eat what is listed on the daily menu, there is a substitute which consists of a "Ham & Cheese Sandwich, Peanut Butter Jelly Sandwich, Grilled Cheese, Tuna Sandwich and Egg Salad". During the visit conducted on 7/14/22, LPA toured the facility kitchen and observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed meats, fruits, vegetables, eggs, juice, milk and snacks at the facility. Based on interviews conducted, LPA's observation and record review, there is insufficient evidence to support this allegation to be true. 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 provided.the state’s words, verbatim · CDSS document, Jul 21, 2022 · control 28-AS-20220706082808

Type of visit: Case Management - Other

A pre licensing visit was conducted on 4/21/22 by Licensing Program Analyst (LPA) Jewel Baptiste. The following deficiencies was observed during the visit: Broken Faucet in room #143 Cracks in tub and grab bars in room#136 ·Skids matt missing in room #104, #106, #114, #131, #136, #157 Broken call light in room # 135 Water temperature in room #106, #117, #118, #119, # 143, #135, #132 was not within the regulation of 105-125 degrees F. On 5/25/22 at 9:09 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an announced pre licensed visit to clear deficiencies from visit on 4/21/2022. Upon arrival LPA met with assistant administrator William Woods and explain the reason for the visit. Report Continued on 809c The following deficiencies was cleared during the visit: 1. Broken Faucet in room #143 2. Cracks in tub and grab bars in room#136 3. Skids matt missing in room #104, #106, #114, #131, #136, #157 4. Broken call light in room # 135 5. Water temperature in the following rooms was within the regulation of 105-125 degrees F · #106- 109.7 · #117 -107.4, · #118- 109.6, · #119- 105.1, · # 143- 109.2, · #135 -107.9, · #132 –106.2 Component III was reviewed during the visit due to the change of administration. All the above corrections was made and exit interview was conducted with administrator and assistant administrator and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 25, 2022

Type of visit: Prelicensing

On 4/21/22 at 10 :20 a.m., Licensing Program Analysts (LPAs) Jewel Baptiste and Valeria Maldonado conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPAs met with Gemma Deoso, administrator, who aided with the tour of the physical plant. An application was submitted to CCLD on 11/04/2021 for a Change of Ownership for a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 150 residents, which 130 may be non-ambulatory and 20 may be bedridden. Hospice waiver approved for 20. LPAs inspected and observed the following: Structure: Facility is a 1- story building with a front lobby/reception area, medication room, dining room, commercial kitchen, pantry, 89 bedrooms, shower room #1-#5, education and storage room,2 Activity room, Lounge, Theater room, Laundry storage room, Beauty shop, public restroom men/women, employee lounge, housekeeping closet, electrical utility closet, hygiene supply closet. Walls, floors, ceilings were observed to be clean and sanitary throughout the building. There are no obstructions to the walkways and/or driveways. There are no pools or bodies of water at the facility. Bedrooms for Residents: Bedrooms are equipped with a bed, bedframes, dresser, lamps, chairs and adequate closet space. There is adequate lighting throughout the room. LPA tested the signal system in the following rooms: #104, #114, #117, #118, #119, #132, #135, #136, #143, #158. Call signal in room #135 was not working. Bathrooms: Each residents room have private bathrooms. Some bathtubs have a grab bar and a non-skid mats. Bathrooms missing none skid matts: #104, #106, #114, #131, #136, #157. LPAs observed a broken faucet in room#143 and cracks in tub and grab bars in room #136. Residents that require assistance with transferring are taken to the community shower room for bathing. Common bathroom#1-5 contained shower, grab bars, non-skid matts or strips with shower chairs. Water temperature was taken in bedroom #106 at 91.5, #117 at 125.1, #118 at 122.5, #119 at 125.5, # 143 at 75.5, #135 at 124.9, #132 at 122.6. Report continued on LIC809 Kitchen: LPA observed a food supply that contained more than a 2-day supply of perishables and a 7 day supply of non-perishables from a variety of food groups that met title 22 guidelines. Kitchen counters and preparation areas were observed to be clean and sanitary. Appliances were in working order. Food items were appropriately sealed, labeled and dated. The refrigerator measured at 37.7 degrees and two freezers measured at -11 and -15 degrees that met title 22 guidelines. Outdoors: The outdoor grounds were toured and observed to be free of debris, obstructions, or hazards. There was a designated section for smoking and a shaded patio with table and chairs accessible for resident use. Staff and Residents files: Staff and Residents files are stored and maintained at the facility. LPAs randomly selected 6 residents and 5 staff files to ensure all required forms are in their files. The Administrator's certificate expires on 4/6/2023. Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are available in the hallways. The menu is posted in the kitchen. The fire extinguishers were last inspected on 12/5/21. Smoke Detectors: The facility has smoke/carbon monoxide combo detectors in the hall ways and each of the resident rooms, tested in working order. . Medications, First Aid Kit & Book: Medications are stored and locked in the Wellness office. LPAs randomly selected 3 residents' medication logs to review and all medications are being administered as prescribed. The first aid kit contains all the required supplies along with the current first aid manual. The facility to submit proof of corrections to correct, the hot water temperature, Broken faucet in room # 143, Cracks in tub and grab bars in room # 136, Skid matts in all rooms and broken call light in room #135. Component III: LPA Baptiste and Maldonado conducted the component III during today's visit to provide information on how to operate the facility within substantial compliance. LPA will return at a later date to follow up on the correction. An exit interview was conducted, and this report has been provided to the Executive Director.the state’s words, verbatim · CDSS document, Apr 21, 2022

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 150 Census (if any clients in care): 55 Method: Telephone call with Administrator COMP II Participants: Gemma De Oso Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Administrator has been advised to transmit signed LIC 809 to CAB.the state’s words, verbatim · CDSS document, Mar 24, 2022