Savant of Burbank East

Allegation investigated: Facility staff did not provide adequate care and supervision to a resident while in care. Facility staff made inappropriate comments to resident while in care. Facility staff did not treat resident with dignity and respect. Facility staff did not ensure that an Ombudsman poster is displayed at the facility.

**** This amended report supersedes report dated 11/18/2022. It was created to add additional resident information and new staff responses to questions to support the first 3 allegation findings and to correct resident # from R1 to R2 on allgation #1 The additional revision did not change any other aspects of the report and all aspects including the findings remain the same.*** Licensing Program Analyst(s) (LPA) Alberto Lopez conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Administrator NIrjara Acyarya and explained the reason for the visit. On Subsequent visit on 03/06/2023 LPA met with Office Manager Marili Barajas and expalined pupose of visit. The investigation consisted of the following: LPA requested the following documents: physician's report, for #1(R1) and #2(R2) and personnel and staff rosters. LPA interviewed resident #1(R1), #2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9) Administrator and staff #1(S1),#2(S2)#3(S3),#4(S4),#5(S5). (CONTINUED ON 9009C) Unsubstantiated The investigation revealed the following: Regarding allegation: Facility staff did not provide adequate care and supervision to a resident while in care. It is alleged that residents are not assisted while in care. Administrator and 7/7 staff all stated they provide best care to all residents. 6/9 residents did not collaborate the allegations. Administrator and 7/7 staff denied the allegations. LPA pulled call cord and staff arrived promptly. R2 asked and was taken to hospital due to health issues she was experiencing during the visit. R1 states that she advocates for R2 and that staff do not like it and talk behind her back. R1 stated that when staff come to room and if resident is on floor, staff just leave her there for about 5 minutes. S4 stated that they do leave resident on the floor for a while as precaution until it is determined safe to pick resident up. S6 stated that every fall in facility is recorded on incident report and sent to CCLD. S7 stated that protocol for falls at the facility requires Med-Tech to check resident for injuries and assess if it is safe to assist resident off the floor. Staff 7 stated that as far as she knows, R2 did not have any recorded falls and no record of falls could be found for R2. R3 stated R3 does not need care and supervision. R5 stated care is provided to R5. R6 stated that facility provides care and supervision and not aware of any problems. R8 stated that R8 has no problems with care at facility. R9 stated that good care is provided. Regarding allegation: Facility staff made inappropriate comments to resident while in care. It Is alleged that staff berate R1 and talk behind her back. Administrator and 7/7 staff denied the allegations. 7/9 residents could not collaborate the allegations. R2 stated that staff is very nice to R2. R3 Stated staff do not talk inappropriately to R3. R4 stated R4 has never witnessed that. R5 stated staff are not inappropriate. R6 stated staff are very kind. R8 has never heard of staff making inappropriate comments to residents. R9 stated that staff never make inappropriate comments. Regarding allegation: Facility staff did not treat resident with dignity and respect. It is alleged that staff yell and point fingers at R1 when addressing R1. Administrator and 7/7 staff denied the allegations and 7/9 residents could not collaborate the allegations. R2 stated that staff treat R2 with dignity and respect. R4 Stated R4 has not experienced this. R5 stated R5 is treated with dignity and respect. R6 stated that staff are very respectful. R7 stated that allegation is not true. Regarding allegation: Facility staff did not ensure that an Ombudsman poster is displayed at the facility. It is alleged that ombudsman poster was taken down at facility. Administrator and 5/5 staff stated that poster has always been at facility. 8/9 residents could not collaborate the allegations. 1/9 residents stated number was wrong. LPA observed the poster when walking into the facility on the left wall and tested the phone number and number was correct. Although the allegations 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 allegations are Unsubstantiated. Exit interview conducted with Office Manager Marili Barjas. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Nov 18, 2022 · control 28-AS-20221117125637

Allegation investigated: Resident contracted infections while in care resulting in hospitalization.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Marili Barajas, Office Manager). LPA/RA Ceniceros spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. An initial 10-Day virtual visit was conducted by LPA Nicol Wesley on 01/13/21 (via telephone) with S1 due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 8:15 a.m. - 9:00 a.m.) facility staff member and residents in care (R2-R3). Resident #1 was not interviewed; as the resident moved out of the facility on 12/29/20. LPA/RA Ceniceros reviewed pertinent documents (between 9:00 a.m. – 9:45 a.m.): Admissions Agreement, Emergency I.D. & Info, Physician’s Report, Pre-placement Appraisal Information, Power of Attorney Advance Health Care Directive, Resident Departure form for Resident #1; and facility staff roster and residents' roster. Unsubstantiated Regarding Allegation #1: this investigation revealed based on interviews conducted of facility staff and residents in care (R2-R6) corroborated that the facility conducted proper COVID testing to keep their residents safe from contracting COVID during the first year; however, Resident #1 was never diagnosed with COVID. Residents and Staff are tested twice a week for COVID to date. LPA/RA Ceniceros reviewed Resident #1's "Physician Report" (dated 09/25/20). A review of Resident #1's "Pre-placement Appraisal Information" form (dated 11/21/20) was completed and signed by Resident #1's Power of Attorney for Advance Health Care Directive documented under "Health History" (dated 11/21/20) documented: "UTI Infections" prior to Resident #1 being admitted to the facility on 12/01/20. Resident #1 moved out of the facility on 12/29/20 due to hospitalization for a diagnosis that the resident had once transferred from a skilled-nursing facility to the assisted-living facility on 12/01/20. Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident contracted infections while in care resulting in hospitalization is found to be UNSUBSTANTIATED. An exit interview was conducted and a copy of the Complaint Report provided to Staff #1: Marili Barrajas, Office Manager.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 28-AS-20210104085209

Allegation investigated: Staff inappropriately speak to residents in care. Residents are not being provided their medications as prescribed. Residents are being left in soiled diapers for long periods of time.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Marili Barajas, Office Manager). LPA/RA Ceniceros spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Glenn Trueman on 04/22/21 (via telephone) with S1 due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed two facility staff members (S1 & S5) and five residents in care (R2-R6). LPA/RA did not interview the following staff for the reasons noted: Staff #2 (Caregiver - resigned: 06/04/21), Staff #3 (Med Tech/Caregiver - resigned: 12/20/21)), Staff #4 (Med Tech - resigned: 05/11/21). Resident #1 was not interviewed; as the resident moved out of the facility on 04/01/21; however, attempts were made to reach the Unsubstantiated resident (via telephone), but to no avail. LPA/RA Ceniceros reviewed pertinent documents: Admissions Agreement (dated 03/05/20), Emergency I.D. & Information (03/05/20), Physician’s Report (dated 02/21/20), Pre-placement Appraisal Information (dated 03/05/20) for Resident #1; including facility staff roster and residents' roster; SIR (dated 02/19/21), Eight-Hour Medication Training (dated 02/16/22), Personal Rights training (dated 06/22/21), and Staff In-Service Training (dated 12/21/21). Regarding Allegation #1: this investigation revealed based on interviews conducted corroborated that residents in care have not been spoken to inappropriately by facility staff. Staff Members have not received complaints from residents in care and/or their responsible person(s) regarding same. A review of an SIR (dated 02/19/2) documented an incident (Aggressive Act/Self & Aggressive Act/Staff) that occurred involving Resident #1 towards Staff #4 (Med Tech); whereby, Resident #1 had become aggressive towards Staff #4. Resident #1 had been drinking alcohol at the facility which was found in Resident #1's room. Resident #1 became increasingly aggressive and began yelling obscenities (i.e., racial slurs at staff, EMTs, and police officers). Resident #1 was transported to the hospital for further evaluation. LPA/RA Ceniceros also reviewed facility's Personal Rights training which was conducted on 06/22/21. Based on the evidence gathered and interviews conducted and records reviewed, 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 of PERSONAL RIGHTS: Staff inappropriately speak to residents in care is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed based on interviews conducted corroborated that residents in care are being administered their medications by the med techs. LPA/RA Ceniceros toured the facility's medication room and observed the computerized "QUICK-MAR" system utilized for the residents' medication administration records and residents' medications stored in a secured cart. LPA/RA Ceniceros also reviewed the facility's last 8-Hour Medication Training that was conducted on 02/16/22 by a pharmacy's nurse consultant. Based on the evidence gathered and interviews conducted and records reviewed, 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 of MEDICATIONS: Residents are not being provided their medications as prescribed is found to be UNSUBSTANTIATED. Regarding Allegation #3: this investigation revealed based on interviews conducted corroborated that facility staff have not left incontinent residents in soiled diapers for long periods of time. Facility staff members had not received a complaint from residents in care and/or their responsible person(s) regarding same. A review of Resident #1's "Physician's Report" (dated 02/21/20) documented under "Physical Health Status" that the resident does not have bowel impairment or bladder impairment. A review of Resident #1's "Pre- placement Appraisal Information" (dated 03/05/20) documented that the resident is incontinent at times and wears pull-ups for precaution. A review of the facility's "Staff In-Service" training on the topic of "Checking all residents every two (2) hours as needed" was conducted on 12/21/21. Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Residents are being left in soiled diapers for long periods of time is found to be UNSUBSTANTIATED. An exit interview was conducted and a copy of the Complaint Report provided to Staff #1: Marili Barajas, Office Manager.the state’s words, verbatim · CDSS document, Oct 13, 2022 · control 28-AS-20210416113753

Allegation investigated: Resident sustained pressure injuries while in care Staff handled resident in a rough manner Staff failed to treat residents with dignity and respect Staff made inappropriate comments toward resident

This report supersedes the one dated 09/01/2022 to include additional information. Licensing Program Analyst (LPA) Glenn Trueman made a subsequent visit for the allegations listed above. LPA met with Office Manger Marili Barajas and Administrator Nirjara Acharya. At initial visit 08/19/2021 the following occurred: The investigation consisted of the following: Interviews with Administrator, and Staff S1-S 3 from 9:15 AM to 11:00 AM. LPA Trueman requested Physician's Report, Needs and Services Plan, Emergency ID page and Hospice Documentation from Resident 1's file. At today's visit 09/01/2022 from 1:15 PM to 3:00 PM Resident's 1-8 were interviewed. In regards to Resident sustained pressure injuries while in care, Documentation from Hospice Agency for Resident R1 specifies Physician's Order start date 08/10/2021 and stop date 09/08/2021 L ankle wound and to cleanse with NS pat dry and cover with gauze every 2 to 3 days as needed. Documentation titled Skin Impairment Assessment from Hospice Agency dated 09/09/2021 stated that R1 has existing treatment for left ankle wound. Staff interviewed stated that R 1 was on Hospice who were addressing wound care. Staff would try to soothe R 1 by putting pillow under feet. Unsubstantiated Interview with residents revealed that R3 had wound on leg and it is handled well. R 8 has had a wound on the back and it has been handled great 2x a week. R1 was diagnosed with Stage 2 pressure injury 06/07/2021 and required wound care which was provided by the hospice agency. Based on the documentation reviewed by the LPA, medical attention was sought to treat the wound once the resident was diagnosed and the facility met the requirements for retaining a resident with a restricted health condition as required in Title 22. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff handled resident in a rough manner, based on interviews conducted and information gathered interviews with R5, R6, R7 and R9 all have had diaper changes and stated that staff have never handled them roughly and always do a great job. R2, R3 R4 and R8 stated they had never been handled roughly when needing any kind of assistance. Interview with staff who stated that R1 is showered by Hospice who handles her gently and that when diaper is changed staff will never be rough. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff failed to treat residents with dignity and respect, based on interviews conducted and information gathered R2-R 9 stated that they have always been treated with dignity and respect and that staff have never acted inappropriately. Staff interviewed stated that they had never been disrespectful to R1 or to any residents. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff made inappropriate comments toward resident, this is a duplicate allegation that was previously addressed based on visit conducted on 06/02/2021 Complaint # 28-AS-20210525114334 Substantiated Findings and 9099 D page issued stating that S1 yells at residents and 9099 addressing allegation of inappropriate comments. Based on review of staff records and interview with Administrator 08/19/2021 who stated that S1 had been terminated 06/04/2021 therefore a deficiency was not issued at this time. A plan of correction was received by the Department on 6/23/21 and the deficiency was cleared. It should be noted that R1 had left on 9/11/2021 to St. Joseph Hospital and was discharged on 09/17/2021 from the facility. Attempts to contact R1 were unsuccessful.the state’s words, verbatim · CDSS document, Oct 12, 2022 · control 28-AS-20210818102537

Allegation investigated: Staff did not address an open sore on resident's buttock in a timely manner

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Marili Barajas Business Manager and explained the reason for the visit. The investigation consisted of the following: LPA requested staff/resident roster. LPA interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9) and staff #1(S1),#2(S2)#3(S3),#4(S4),#5(S5). LPA requested the following documents; physician's report, admission agreement, unusual incident report, face sheet, emergency and identification information, preplacement appraissal, and hospital discharge documents for resident #1(R1). The investigation revealed the following: Regarding allegation: Staff did not address an open sore on resident's buttock in a timely manner. It is alleged that caregiver changing R1 noticed an open sore on right buttocks, notify the Technician about the sore, and nobody followed up with R1. Interviews with residents revealed 5 out of 9 residents interview stated to not require assistance to schedule appoitnments to the doctor and do not have (CONTINUED ON LIC 9099C) Unsubstantiated any health needs that require assistance. 2 out of 9 residents interview stated facility staff assist with scheduling appointments or following up with needs.2 out of 9 residents interview stated facility does not assist them with scheduling medical appointments or health needs. Interviews with staff revealed 2 out of 5 staff interviewed stated R1's caregiver reported the open sore to the Med-Tech on 10/3/22 and R1 was send out to Kaiser Permanente Urgent Care on 10/3/22 and return to the facility with discharge documents on the same day. Documents review revealed R1 was seen at Kaiser Permanente on 10/3/22. Unusual incident report was submitted to the department on 10/3/22. Administrator stated that a follow up to obtain wound stage will be conducted and yearly in-service on identifying and care of wounds will be provided to staff. Based on interviews, observation, and document review conducted, there was insufficient evidence to prove the allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted with Marili Barajas - Business Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 11, 2022 · control 28-AS-20221005131717

Allegation investigated: Resident sustained pressure injuries while in care Staff handled resident in a rough manner Staff failed to treat residents with dignity and respect Staff made inappropriate comments toward resident

Licensing Program Analyst (LPA) Glenn Trueman made a subsequent visit for the allegations listed above. LPA met with Office Manger Marili Barajas and Administrator Nirjara Acharya. At initial visit 08/19/2021 the following occurred: The investigation consisted of the following: Interviews with Administrator, and Staff S1-S 3 from 9:15 AM to 11:00 AM. LPA Trueman requested Physician's Report, Needs and Services Plan, Emergency ID page and Hospice Documentation from Resident 1's file. At today's visit 09/01/2022 from 1:15 PM to 3:00 PM Resident's 1-8 were interviewed. In regards to Resident sustained pressure injuries while in care, Documentation from Hospice Agency for Resident R1 specifies Physician's Order start date 08/10/2021 and stop date 09/08/2021 L ankle wound and to cleanse with NS pat dry and cover with gauze every 2 to 3 days as needed. Documentation titled Skin Impairment Assessment from Hospice Agency dated 09/09/2021 stated that R1 has existing treatment for left ankle wound. Staff interviewed stated that R 1 was on Hospice who were addressing wound care. Staff would try to Unsubstantiated soothe R 1 by putting pillow under feet. Interview with residents revealed that R3 had wound on leg and it is handled well. R 8 has had a wound on the back and it has been handled great 2x a week. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff handled resident in a rough manner, based on interviews conducted and information gathered interviews with R5, R6, R7 and R9 all have had diaper changes and stated that staff have never handled them roughly and always do a great job. R2, R3 R4 and R8 stated they had never been handled roughly when needing any kind of assistance. Interview with staff who stated that R1 is showered by Hospice who handles her gently and that when diaper is changed staff will never be rough. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff failed to treat residents with dignity and respect, based on interviews conducted and information gathered R2-R 9 stated that they have always been treated with dignity and respect and that staff have never acted inappropriately. Staff interviewed stated that they had never been disrespectful to R1 or to any residents. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation Staff made inappropriate comments toward resident, this allegation was previously addressed based on visit conducted on 06/02/2021 Complaint # 28-AS-20210525114334 Substantiated Findings and 9099 D page issued stating that S1 yells at residents and 9099 addressing allegation of inappropriate comments. Interview with Administrator 08/19/2021 who stated that S1 had been terminated. It should be noted that R1 had left on 9/11/2021 to St. Joseph Hospital and was discharged on 09/17/2021 from the facility. Attempts to contact R1 were unsuccessful.the state’s words, verbatim · CDSS document, Sep 1, 2022 · control 28-AS-20210818102537

Allegation investigated: Residents are being exposed to cigarette smoke while in care.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with the Administrator Nirjara Acharya and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA toured the facility including common areas and smoking area. LPA also interviewed the Administrator, Staff #1 - Staff # 3, and Resident #1 - Resident #9. The investigation consisted of the following: in regards to the allegation "residents are being exposed to cigarette smoke while in care", it is alleged that residents smoke too closely to the main entrance door which causes the smoke to enter the lobby where other residents are then exposed to the cigarette smoke. LPA toured the main entrance/smoking area of the facility and observed several residents smoking in the designated smoking area which is located near the main entrance of the building. Staff members interviewed indicated that staff will ensure the main entrance doors are closed and not propped open to ensure the cigarrette smoke does not enter the building. (CONTINUED ON 9099C) Unsubstantiated All staff members interviewed indicated that they have not had any residents complain to them regarding the cigarette smoke entering the facility. Staff members interviewed indicated they remind residents who are smoking outside to close the doors to ensure the cigarette smoke does not enter the facility. 9 out of 9 residents interviewed indicated that they are not bothered or affected by the cigarette smoke from the designated smoking area. LPA did not observe any residents smoking inside the facility during the visit. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2022 · control 28-AS-20220614102941

Allegation investigated: Resident was stuck in facility elevator Facility elevator is not operating appropriately

Licensing Program Analyst (LPA) Lopez conducted a complaint visit to investigate the allegation listed above. LPA met with Manager Marili Barajas and explained the reason for the visit. The investigation consisted of the following: Interviewed resident #1-9 (R1), Manager and five facility staff (S#1-S#5 were interviewed. LPA obtained resident and staff roster, SIR dated 5/08/22, 7 elevator repair invoices dated 09/17/21, 10/13/21, 12/03/21, 12/07/21, 03/02/22, 05/08/22, and 5/12/22, no elevator repair logs are kept by facilty and fax transmittal for 05/08/22 SIR Allegation: Resident was stuck in facility elevator Manager and 4/5 staff and 7/9 residents collaborated allegation that resident was stuck in elevator on 5/08/22 LPA tested elevator and it moved up and down properly, However, phone was not functioning and it was not known how long it has been in disrepair. Based on information and documentation received allegation is SUBSTANTIATED (continued on 9099C) Substantiated Allegation: Facility elevator is not operating appropriately Manager and LPA tested elevator and it functioned properly going up and down with no issues, however, phone inside elevator is not functioning and it is not known how long it has been in disrepair Based on information and documentation received allegation is SUBSTANTIATED Exit interview was conducted and copy of report provided to Manager Marili Barajasthe state’s words, verbatim · CDSS document, May 20, 2022 · control 28-AS-20220512163229

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87691(a) · Plan of correction due date: May 27, 2022

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 is not met as evidenced by On 05/20/22, at 9:33am upon LPA arriving at the facility, LPA tested the elevator by pressing the elevator button and observed the elevator to be in fuctioning and going up down, however the phone inside the elevator was not working and it is not known how long it has been in disrepair. R1 was trapped inside and phone did not function preventing R1 from calling for helpthe state’s words, verbatim · CDSS document, May 20, 2022

Plan of correction: Administrator will ensure the elevator phone is in good repair and submit proof of invoice showing the repair was made. The POC must be submitted to CCL by the due date 05/27/22

Allegation investigated: Staff unlawfully evicted resident.

On 04/29/2022 (11:00 AM), Licensing Program Analyst (LPA) Gail Johnson arrived at Burbank Senior Villa East, formerly named Le Bleu Chateau and conducted an unannounced subsequent complaint visit. LPA met with Manager Marili Barajas. LPA Johnson explained the purpose of today’s visit. Investigation consisted of the following: LPA reviewed and obtained the following documents: 30 day notice and fax receipt to CCL, rent payment invoices, R1 Resident Departure Form, Admission Agreement, County of Los Angeles Sheriff’s Department Receipt for Possession of Real Property (May 3, 2021), R1 Face Sheet, and R1 Physician’s report. LPA conducted interviews with House Manager Marili Barajas and R1. Conitnued on LIC-9099C Unsubstantiated Investigation revealed the following: based on the review of records, interviews with relevant staff and all documents regarding R1: Licensee provided a 30 day notice / fax cover sheet sent to CCLD, rent payment invoices, Resident Departure Form, Admission Agreement, Sheriff’s Department Receipt for Possession of Real Property, Face Sheet, and Physcian’s report. Regarding the allegation “Staff unlawfully evicted a resident.” 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. Investigation revealed the following: Allegation- Staff Unlawfully Evicted Resident Based on the review of records and interviews conducted, LPA found that R1 was provided a 30 day notice on 10/20/2020. LPA Johnson conducted and interviewed with House Manager Barajas, who stated that the 30 Day Notice was issued to R1 for failure to pay rent, as R1 stopped paying rent in October of 2020. House Manager Barajas stated that assistance to secure a placement at a new facility was offered; however, R1 declined assistance and remained residing at the facility until April 19, 2021. R1 moved from the facility independently on April 19, 2021. LPA Johnson conducted an interview with R1, who stated that he understands the purpose for the eviction was because rent was not being paid and he made a decision to move from the facility and now lives independently. Upon R1’s departure from the facility in April 2021, the Los Angeles Sherriff’s Department posted an order of Receipt of Real Property on R1’s room door. Based on evidence gathered, LPA did not find sufficient evidence to support the above mentioned 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 allegations are Unsubstantiated. An Exit interview was conducted with House Manager Marili Barajas.the state’s words, verbatim · CDSS document, Apr 29, 2022 · control 28-AS-20210416101629

Allegation investigated: Staff stole resident's money.

Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegation listed above. The initial complaint visit was conducted on 12/15/21. Licensee, Adam Zenou assisted with that visit. The investigation consisted of the following: During the initial visit, Resident #1's (R1) file was reviewed. Interviews were conducted with the Licensee and Business Office Manager. R1 is no longer a resident of the facility and therefore was not interviewed at the time. On 1/19/22, LPA discovered R1's whereabouts and R1 was interviewed. Also on 1/19/22, LPA contacted an investigator from the Social Security office to inquire about R1's social security funds. During today's subsequent visit, 7 residents were interviewed. The investigation revealed the following: It's alleged facility stole R1's social security money and stimulus checks. Facility was the payee for R1's social security funds. Facility records indicate R1 would receive money from facility staff when R1 requested it. R1's file contain signed withdrawal receipts signed by R1. Continued on 9099C. Unsubstantiated R1's money account statements indicate that the IRS deposited a $600 stimulus check to R1's account on 1/4/21. On 4/7/21, R1's account statement from the facility indicates a IRS check for $1,400 was rejected. The system rejected the check due to R1 being discharged from the facility on 4/1/21. Social security investigator reviewed R1's social security account and did not find any suspicious activity. Staff interviewed deny the allegation that any money was stolen. Residents interviewed indicated they have not had any issues with staff and their finances. 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. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 16, 2022 · control 28-AS-20211215131442

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with Office Manager Marili Barajas, Licensee Adam Zenou and Administrator Nirjara Acharya who assisted with the visit. The purpose of the visit was explained. Facility is licensed to serve 100 Non-Ambulatory residents; of which ten (10) may be bedridden. Facility is approved to retain/accept thirty (30) hospice residents. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is located in a residential area and consist of a two story structure that contains the following: Entrance / Lobby 1, an office for staff, and Lobby 2 /TV room areas for resident use, an interior courtyard, a dining room, a kitchen, a laundry room on first and second floors, storage space on first and second floors. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. LPA toured randomly selected residents rooms. All bedrooms were furnished with required furniture. The bathrooms were observed to be clean, operational and equipped with grab bars and non-skid mats. The hot water temperature was tested throughout the facility and measured within Title 22 Regulations guidelines. Continue 809C The kitchen was toured. All appliances were clean and operating properly. There was a sufficient amount of perishable and non-perishable food. Smoke alarms and carbon monoxide alarms were operational, fire extinguishers on first and second floor observed to be fully charged. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed 7 residents and 5 staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA randomly chose some residents' medications to review. Medications are documented properly and stored appropriately. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the Administrator.the state’s words, verbatim · CDSS document, Feb 23, 2022

Allegation investigated: Staff did not provide a refund to resident.

Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegation listed above. LPA met with Licensee, Adam Zenou and explained the reason for the visit. The investigation consisted of the following: Resident #1 (R1) and two facility staff were interviewed. R1's file was reviewed including R1's admission agreement. The investigation revealed the following: It's alleged R1 was not provided a refund after moving out of the facility on 10/17/21. Allegedly R1 was verbally told he/she would receive a refund since R1 paid the rent for October 2021. R1 was interviewed and indicated that he/she did not provide the facility with a 30-day notice, but insisted that Staff #1 (S1) verbally promised a pro-rated refund from 10/18/21 - 10/31/21. S1 was interviewed and indicated he/she did not promise a refund. R1's admission agreement dated 5/1/20 states residents are required to provide a 30 day advance notice of intent to move. Continued on 9099C. Unsubstantiated 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. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2021 · control 28-AS-20211203111612

Allegation investigated: Suspicious death

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Office Manager / Marili Barajas and was later joined by the Administrator / William "Bill" Boles who assisted with the visit. LPA Katrdzhyan explained the purpose of today’s visit is to discuss the above mentioned allegation of "Suspicious death". During today's visit, LPA conducted interviews of various persons to include the Office Manager, Administrator, CEO / Adam Zenou and Residents 1 - 4 (R1 - R4). The investigation revealed the following; The details of this allegation stated that there was a suspicious death / murder in the facility. Based on interviews conducted, LPA discovered that there has been no such incident of a suspicious death or a murder at Burbank Retirement Villa East. Statements obtained were consistent and stated that the incident Unfounded involving a suspicious death / murder occurred elsewhere and not at Burbank Retirement Villa East. Based on the information gathered, the allegation of "Suspicious death" is unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Therefore, the complaint allegation is being dismissed. An exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Oct 19, 2021 · control 28-AS-20211018141120

Allegation investigated: Resident does not attend scheduled appointments while in care. Resident's grooming needs have not been met while in care. Staff have not addressed a resident's change in medical condition while in care. Staff does not provide a comfortable environment for a resident while in care.

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day investigation visit. LPA met with S-1 and discussed the purpose of today's visit. Facility Administrator (S-3) arrived at approximately 10 A.M.. During today's visit, LPA obtained the staff roster, resident roster, interviewed Staff #1 through Staff #4 (S-1 through S-4), interviewed Resident #1 through Resident #6 (R-1 through R-6) and obtained relevant documentation. Refer to LIC 9099C for the contination of this report. Unsubstantiated Allegation: Resident does not attend scheduled appointments while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated that residents are provided with transportation to scheduled appointments, going to the bank and/or going to the store. S-4 schedules the transportation for Residents. Interviewed staff indicated they have not received any complaints and/or concerns regarding transportation to attend scheduled appointments nor any issues in regards to Residents not being able to come in and out of the transportation vehicle. Interviewed Residents indicated they are aware that this facility provides transportation to medical appointments, stores and to the bank. Interviewed Residents indicated they schedule their transportation needs with the Receptionist (S-4). (5) out of the (6) interviewed residents indicated that they do not have any issues coming in and out of the transportation vehicle nor have any issues with being taken to their appointments. Staff and Resident interviews do not corroborate this allegation. Allegation: Resident's grooming needs have not been met while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated they have not received any complaints nor concerns in regards to staff not meeting Residents grooming needs (getting hair done). Interviewed staff indicated that some Residents go out on their own to the nearby beauty salon to get haircuts. (1) out of the (6) interviewed Residents indicated they have not groomed their hair for “approximately 3 weeks”. (5) out of the 6 interviewed Residents indicated they either go out on their own to get their haircut/hair done or have someone come to the facility to have their hair grooming needs met. Staff and Resident interviews do not corroborate this allegation. Allegation: Staff have not addressed a resident's change in medical condition while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated they have not received any complaints nor concerns in regards to staff not addressing residents change in medical condition while in care. Interviewed Staff indicated they assist Residents with scheduling appointments with their Physicians when there has been a change in medical condition. (1) out of the (6) interviewed Residents indicated they do not inform staff when they are feeling ill. (5) out of the (6) interviewed Residents indicated that they will notify Staff if they are not feeling well so that staff can assist with scheduling their medical appointments. Staff and Resident interviews do not corroborate this allegation. Refer to LIC 9099C for the continuation of this report. Allegation: Staff does not provide a comfortable environment for a resident while in care. During this investigation, LPA interviewed Staff #1 through Staff #4 (S-1 through S-4) and interviewed Resident #1 through Resident #6 (R-1 through R-6). Interviewed staff indicated they have not received any complaints nor concerns in regards to staff not providing a comfortable environment for residents while in care. Interviewed staff indicated they have not received any complaints/concerns in regards to the facility being cold. (1) out of the (6) interviewed Residents indicated the facility is cold. (5) out of the (6) interviewed Residents indicated the facility provides a comfortable environment and have no concerns in . regards to the facility temperature. Staff and Resident interviews do not corroborate 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. Exit interview conducted, a copy of this report provided and appeal rights were provided to Facility Administrator (S-3).the state’s words, verbatim · CDSS document, Oct 18, 2021 · control 28-AS-20211012134559

Allegation investigated: Staff not providing residents medication in a timely manner. Staff failed to keep an accurate medication log. Staff failing to provide adequate food service. Staff failed to meet residents dietary needs. Staff failed to keep facility clean.

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to this facility. The purpose of the visit was to gather information regarding the allegations and to complete the investigation. LPA met with Marili Barajas (House Manager) and explained the reason for the visit. During the initial visit conducted on 01/03/20, LPA obtained/reviewed a copy of the Staff/Resident roster, medication logs for Resident #1 through #7, interviewed Staff #1 in the staff dining room at 9:46 am, toured the facility at 11:03 am with Staff #1 and interviewed Resident #1 through #4 in the staff dining room between 11:28 am to 1:54 pm. During today's visit, LPA obtained a copy of the Staff schedule, Resident roster and food menu. LPA interviewed Resident #5 to #9 between 10:20 am to 11:30 am in the conference room, interviewed Staff #2 in the conference room at 11: 35 am and took a tour of the facility with Staff #2 at 11:45 am and interviewed Staff #3, #4, #5 and #6 in the conference room between 11:50 am to 1:00 pm. Continue to LIC9099C...... Unsubstantiated In regards to the allegation: Staff not providing residents medication in a timely manner. Interviews with Residents and Staff indicate that medications are provided on a timely manner. Review of medication record also indicate medications are provided on a timely manner. In regards to the allegation: Staff failed to keep an accurate medication log. LPA reviewed medications logs for Residents #1 to #7 revealing medications are accurately documented. Interviews with Staff indicate medications are accurately documented each time assistance with medication administration is completed. In regards to the allegation: Staff failing to provide adequate food service. LPA's interviews with Resident indicate that food service is adequate. Facility provided breakfast, lunch and dinner to Resident with snacks in between. LPA toured the kitchen and reviewed the food menu which indicate there is sufficient food supplies and foods are of good quality. Interviews with Staff also indicate Residents with certain dietary needs are provided food based on their modified diets. In regards to the allegation: Staff failed to keep facility clean. During the initial visit, LPA toured the facility and observed parts of the facility was being renovated. During the today's visit, LPA toured the facility again and observed the facility to be clean and in good repair. Interviews with Staff and Resident indicate that facility is clean. Facility renovations occurred in late 2019. Interviews with Staff and Resident indicate that proper notices were provided to Resident and Staff prior to the start of renovations and Residents and Staff were aware the facility will inevitably experience dust and debris. Based on LPA's interviews, observations and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Marili Barajas and a copy of this report provided. In regards to the allegation: Staff not answering call buttons in a timely manner. Interviews with Residents and Staff indicate there were incidents which Staff did not response to Resident's call switch in a timely manner. Based on LPA's interviews, investigation revealed that 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. Exit interview conducted with Marili Barajas and a copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 1, 2021 · control 28-AS-20191226095848

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(2) · Plan of correction due date: Oct 2, 2021

87415(a)(2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement is not met as evidenced by: Interviews with Residents and Staff indicate there were incidents which Staff did not response to Resident call switch in a timely manner.the state’s words, verbatim · CDSS document, Oct 1, 2021

Plan of correction: Licensee shall provide a plan to meet sufficient staffing and provide proof of sufficient staffing to the department by the POC date. NOTE: LPA's review Staff schedule during visit and observed that facility now has sufficient day and night staffing.

Allegation investigated: Staff did not address a resident's hygiene needs while in care Resident has not been properly fed while in care

Liceising Program Analyst (LPA) Elizabeth Irra conducted an unannounced 10-day initial investigation for the above allegations. LPA met with Facility Administrator and discussed the purpose of today's visit. During today's visit, LPA obtained the Resident and Staff rosters,interviewed Staff #1 (S-1) through Staff #4 (S-4), interviewed Resident #1 (R-1) through Resident #6 (R-6) and obtained relevant documentation. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff did not address a resident's hygiene needs while in care During today’s visit, LPA interviewed Staff #1 (S-1) through Staff # (S-4) and interviewed Resident #1 (R-1) through Resident # 6 (R-6). Staff interviews revealed that Residents hygiene needs are being met while in care. Interviewed Staff indicated they perform Activities of Daily Living such as bathing/showering to Residents that require assistance. Interviewed staff indicated they have not received any complaints from anyone in regards to staff not meeting residents hygiene needs. Resident interviews revealed that staff meet their hygiene needs (including bathing and showering). (5) out of (6) interviewed Residents indicated their hygiene needs (with assistance from staff) are being met. (5) out of (6) interviewed Residents indicated they do not have any concerns with their hygiene needs not being met. (1) out of (6) interviewed Residents indicated they prefer to have (1) particular staff assist with hygiene needs (showers/bathing) and if that particular staff is not available, that Resident prefers to complete their own hygiene needs by using the sink to wash up. Staff and Resident interviews do not corroborate this allegation. Allegation: Resident has not been properly fed while in care During today’s visit, LPA interviewed Staff #1 (S-1) through Staff # (S-4) and interviewed Resident #1 (R-1) through Resident # 6 (R-6). Staff interviews revealed that Residents are properly fed while in care. Interviewed staff indicated they have not received any complaints from anyone in regards to Residents not being properly fed. Resident interviews revealed that staff properly feed Residents. (5) out of (6) interviewed Residents indicated they are properly fed, are fed all meals and are happy with the food selection. (5) out of (6) interviewed Residents indicated they do not have any concerns with being properly fed. Interviews revealed that Residents receive their meals in their rooms (tray service) and are given the options to select alternatives such as sandwiches, soup and salads. Staff and Resident interviews do not corroborate 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. Exit interview conducted, a copy of this report provided and appeal rights were provided to Facility Administrator.the state’s words, verbatim · CDSS document, Sep 20, 2021 · control 28-AS-20210914102641

Allegation investigated: A residents wheelchair was damaged while in care Staff did not provide necessary accommodations for a resident in care Staff are not providing resident with all medical records/incident reports Staff did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Administrator, William Boles who assisted with today's visit. Regarding the allegation that a former residents wheelchair was damaged while in care and staff did not provide necessary accomodations for resident in care, the investigation consisted of interviews with Administrator, Staff #1 and Resident #1 - Resident #6. Administrator and Staff #1 stated that they were not aware that former resident's wheelchair was damaged while in care. They stated that it was not brought to their attention. Administrator and Staff #1 stated that staff do provide necessary accomodations for residents in care. LPA interviewed 6 Residents who use wheelchair(s). 5 out of 6 residents stated that they have no trouble with the accomodations provided, and have no trouble maneuvering their wheelchair(s) at the facilty. 6 out of 6 residents stated that their wheelchair has not been damaged while in care. LPA toured the facility and observed that the facility hallways, resident rooms, and bathrooms are able to accommodate residents who use a wheelchair. Unsubstantiated Regarding the allegation that Staff are not providing former resident with all medical records/ incident reports. LPA interviewed Administrator and Staff #1. Administrator and Staff #1 stated that facility has not refused to provide medical records and incident reports to former resident. Staff #1 stated that she has spoken to former resident and is going to arrange for former resident to obtain copies of the records/ reports that are being requested. Regarding the allegation that Staff did not safeguard resident's personal belongings, the investigation consisted of interviews with Administrator, Staff #1 and Resident #1 - Resident #6. Administrator stated that he was not aware of any incident regarding former residents personal belongings not being safeguarded. Staff #1 stated that former resident asked a staff person to purchase items for her. Staff #1 stated that a staff person purchased items and returned the change to Former resident. Staff #1 denied that former residents belongings were not safeguarded. Residents interviewed were unable to corroborate the allegation. They stated that their personal belongings are safeguarded at the facility. Based on LPA's observations and interviews, investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. An exit Interview conducted and copy of report was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2021 · control 28-AS-20210730123119

Allegation investigated: Facility is financially abusing resident

An unannounced subsequent complaint visit was conducted on this day by Licensing Program Analyst (LPA)Wendell Smith . Upon arrival LPA met with administrator Bill Boles and explained the reason for this visit. Regarding the allegation listed above it is being alleged that the Licensee/Administrator stole resident 1 (R1's) identity, opened a bank account under his name and that his social security Income SSI is being deposited into this new account. Additionally, it is being alleged that administrator stole a money order from R1 in the amount of $500.00. Initial 10-day complaint visit was conducted on 5/13/2020 by LPA Yelena Avetisyan. During the visit LPA Avetisyan conducted interview with the administrator and requested document to be submitted related to the allegation listed above. Additionally, on 5/15/2020 LPA Avetisyan conducted interview with Resident 1 (R1). Unsubstantiated Interviews conducted and records revealed the following. upon admission to the facility resident 1 (R1) signed an "Authorization and Agreement for the licensee to Handle Resident Funds” The form indicates that the resident is authorizing Automatic transfer of Deposits to pay for care costs. The form was submitted to social security administration and R1's payments were automatically deposited into the account. When interviewed administrator stated that R1 was officially discharged from the facility 4/30/2020 at which time the agreement was terminated, and the account closed. Administrator also denied taking and cashing a $500.00 money order from R1's room. Additionally, administrator informed LPA that the resident spoke with him about the money order as well, however resident did not have receipt, money order #, the date it was purchased or any information that could be used to try and determine what happened to the money order. Based on the information obtained, the allegations of Facility is financially abusing resident is unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jul 16, 2021 · control 31-AS-20200508134915