Savant of Norwalk

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Executive Director David Hernandez and explained the purpose for today’s visit. The Facility is a 2 story building located in Norwalk, CA. There are a total of 40 resident rooms. That is licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and cleaning/disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Dementia Plan and training, Care of Bedridden Residents Plan and training, and facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, a total of 8 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There is shaded patio/garden area for resident. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. (Continued on LIC809-C) Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Staffing: There appears to be sufficient staffing at all times in the facility. Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 6 staff files with no issues observed. Administrator (Executive Director) David Hernandez certificate expires on 4/15/2027. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 9 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman. Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers. 8 residents medications were reviewed during todays visit without any issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 10/16/2025. Residents with Special Health Needs: Facility admits residents that are bedridden and residents that require hospice service. Currently there are 0 Bedridden Residents and 3 Residents Using Hospice Services at the facility. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held, a copy of the report was provided to David Hernandez.the state’s words, verbatim · CDSS document, Nov 14, 2025

Allegation investigated: Financial abuse of deceased resident. Staff did not notify resident's authorized representative of death. Staff did not safeguard client's personal belongings. Facility is not properly managing resident's medication.

Licensing Program Analyst (LPA) Nicol Wesley conducted a 10 day complaint visit at the facility and met with Business Office Manager Janice Anguiano and shortly afterwards Executive Director David Hernandez arrived and joined the visit. Investigation consisted of: staff roster, resident roster, reviewed medication log, interviewed staff, and retrieved specific items from residents1 and residents 2 file. Investigation revealed: Regarding allegation: Financial abuse of deceased resident. LPA Wesley reviewed resident file and it indicated that they were self responsible and LPA observed in the file a RFMS(Resident Fund Management Service) sheet that showed payments to the facility with the last payment made on 12/06/24. It also showed that the account was closed and the resident expired on 12/28//24. The facility did not abuse any of the residents funds because he was self responsible and handled his own funds. Unsubstantiated Regarding allegations: Staff did not notify residents authorized representative of death and Staff did not safeguard client's personal belongings. Resident was away from the facility since 12/11/24 and passed away on 12/28/24 at the hospital. They notified the responsible parties on file. They called the first person on file and they were not answering the phone and the voice mail box was full, and they called the second person on file and spoke to them and they came to the facility to pick up the belongings and advised the facility to donate or give away the things they did not want. Regarding allegations: Facility is not properly managing resident's medication. LPA Wesley received a copy of resident 1 and resident 2 medications list and spoke to the Lead Medical Technician and Wellness Coordinator who said that both of the residents were taking their medication on time and they were in compliance. LPA Wesley was unable to speak to resident 2 because they are in the hospital. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation(s). 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. A copy of this report was given to the Executive Director David Hernandez and Business Office Manager, Janice Anguiano.the state’s words, verbatim · CDSS document, May 6, 2025 · control 28-AS-20250429100520

Allegation investigated: Facility staff are not dispensing medication as prescribed. Facility staff are not providing adequate activities to residents.

Licensing Program Analyst (LPA) Nicol Wesley conducted a 10 day complaint visit at the facility and met with Monica Beltran to discuss the purpose of the visit. Shortly afterward Business Office Manager Janice Anguiano arrived and joined the visit. Investigation consisted of: staff roster, resident roster, a copy of the activities schedule, reviewed medication log, interviewed staff, interviewed residents. Investigation revealed: Regarding allegation: Facility staff are not dispensing medication as prescribed. LPA Wesley interviewed residents, and they said that they are getting their medication as prescribed, interviewed staff #1 and they indicated that they have never made a mistake on the medication the log, the dosage, and the resident's name is right there, and their medications are separate. LPA Wesley interviewed staff 2 and they said they Continued on LIC 9099C. Unsubstantiated have never given resident the wrong dosage of medication and tried to cover it up. LPA Wesley interviewed staff #3 and they indicated that they have never given a resident the wrong medication, they have a picture of the resident, list of medications, and they follow the instruction that the doctor orders. LPA Wesley interviewed 8 out of 8 residents and they said the staff have never issued them the wrong medication, and they are giving the medication as prescribed. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff are not providing adequate activities to residents. LPA Wesley interviewed Activities Director who gave me a copy of the activities schedule and she indicated they have several activities for the residents and although the residents may not like to come out of their room, they encourage the residents to come out and join them. LPA interviewed 8 residents, 5 of the residents said they have activities and they like to participate in bingo, 2 of the residents indicated that they have bingo sometimes and not all of the time and they have movie night the other resident 1 said she has been at the facility for less than a week. Based on interviews conducted, and information that was gathered, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of this report was given to Business Office Manager, Janice Anguiano.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 28-AS-20250321133648

Allegation investigated: Staff did not prevent an inappropriate sexual interaction between residents

Licensing Program Analyst (LPA) Alberto Lopez made initial visit to investigate the above allegation. LPA was greeted by Office Manager Janice Anguiano and Executive Director David Hernandez. LPA reviewed and obtained staff and residents rosters, R1 face sheet and emergency contact information. The investigation consisted of LPA taking a tour of facility common areas, interviewed three (4) staff (S#1-S#4) and eight (8) residents (R#2- R#9) The investigation revealed: Regarding allegation Staff did not prevent an inappropriate sexual interaction between residents. It is alleged that a resident (identity unknown) tried to touch R1 (no longer at facility) inappropriately and staff did not prevent it from happening. (continued on 9099C) Unsubstantiated (continued from 9099) LPA interviewed four (4) staff and four (4) of four (4) staff denied the allegation. All four (4) staff stated that they would intervene if they ever witnessed any resident being inappropriate to another resident. LPA interviewed eight (8) residents and seven (7) of eight residents could not corroborate the allegation. R9 stated R1 was roommate and told R9 about the incident. R9 stated R9 did not witness the incident or any other similar incident since being at facility. All residents interviewed stated they like being at the facility and staff are kind and assist them with their needs. LPA was not able to interview R1 since R1 is no longer at facility and R1 contact information was not useful in contacting R1. There is insufficient evidence to support this allegation. Based on interviews conducted, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to David Hernandez.the state’s words, verbatim · CDSS document, Feb 7, 2025 · control 28-AS-20250130155839

Allegation investigated: Staff does not ensure residents personal belongings are properly secured Staff altered residents medication Staff do not ensure residents health care needs are being addressed Staff does not ensure resident is accorded a safe living environment

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Business Office Manager Janice Anguiano and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 12/05/2024, LPA interviewed Staff #1- Staff #8, Residents #1 -Residents #8, and checked R1’s medication for any errors or discrepancies. LPA obtained copies of the following documents: Staff roster, Resident roster, R1’s preplacement appraisal information, Physicians reports, orders for medication and facility notes. SEE LIC 9099C Unsubstantiated In regard to the allegation” Staff does not ensure residents personal belongings are properly secured”, it is alleged that staff are taking personal possessions from room. During interviews with residents six (6) out of eight (8) stated they never had any personal items missing from there rooms. R1 stated that staff keeps taking socks R8 stated fifty dollars was missing and once reported staff gave him/her a lock for a drawer. During interviews with staff seven (7) out of eight (8) staff stated they have never heard items were missing from residents’ rooms. S6 stated “They get a key for a nightstand in their room if they ask for one. I am in charge of giving them one. They sometimes say there belong are gone. Like they lose the key, but they find it later”. In regard to the allegation “Staff altered residents’ medication”, it is alleged that staff are putting water in prescription eye drops. During interviews with residents six (6) out of eight (8) stated that they have no problems with medications given to them by staff. R1 stated “they used to give me eye drops. First one was good now these are water and salt. They threw them away”. LPA Gutierrez checked medication for R1 and eyedrops were in original bottle from pharmacy. R8 stated medication were sometimes late. During interviews with staff eight (8) out of eight (8) stated that facility does not alter medication. S8 stated that R1 sometimes refuses medication and that they have had psychiatric doctor to evaluate resident. In regard to the allegation “Staff do not ensure residents health care needs are being addressed”, it is alleged that facility staff are not addressing residents’ health concerns or assisting with making appointments with physician. During interviews with residents seven (7) out of eight (8) residents stated that facility will assist them with any medical needs that may arise. R1 stated “I see the doctor every week this doctor doesn’t know what he is doing”. During interviews with staff eight (8) out of eight (8) staff state facility always addresses the residents needs and assists with making doctor appointments. S3 states” We sometimes ask them if they want to go to hospital and they refuse. They say pills.” In regard to the allegation “Staff does not ensure resident is accorded a safe living environment” it is alleged that residents don’t feel safe. During interviews with residents seven (7) out of eight (8) residents stated they feel safe at the facility. R1 does not feel safe because his/her socks are being taken by staff. During interviews with staff eight (8) out of eight (8) state the facility is safe for residents and staff. S8 stated “If it wasn’t safe I wouldn’t be becoming back’. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Janice Anguiano.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 28-AS-20241127131439

Allegation investigated: Staff did not provide a statement of monthly cost upon resident's request

Licensing Program Analyst (LPA) Alberto Lopez made unannounced visit to investigate the above allegation. LPA was greeted by Business Office Manager Janice Anguiano and Executive Director Rochalle Reyes who assisted with the visit. The investigation consisted of interviews with three (3) staff (S#1-S#3) and seven (7) residents (R#1-R#7). LPA reviewed staff and resident rosters, R1 and R4 admission agreement, R1 updated Admission Agreement dated 11/19/2024, R1 record of Resident's Safeguarded Cash Resources, R1 Resident Statement Landscape, R1 physician's orders, R1 billing statement from 05/29/2024 to 11/05/2024. Signed copy of Resident Fund Management Service dated 12/28/2022. (continued on 9099C) Unsubstantiated (Continued from 9099) The investigation revealed: Allegation, Staff did not provide a statement of monthly cost upon resident's request. It is alleged that facility staff were asked by R1 to provide R1 with R1 monthly cost for staying at facility and staff was not providing R1 with the information. LPA interviewed three (3) staff and all three (3) denied the allegation. S2 stated she went over the cost to with R1 just yesterday and even provided R1 with $200 for personal expense. S2 stated S2 always provides any financial information that any resident request including R1. S1 also stated that R1 has been told many times about R1 cost. R1 stated R1 had asked a few times and staff have ignored R1. Documents reviewed indicated that R1 is being provided explanation of R1 cost and expenses. LPA interviewed seven (7) residents and six (6) of seven (7) stated that they are fully aware of their financial situation and how much they pay and have full confidence in the facility and how they handle their financial affairs with them. During today's visit, R1 stated R1 is satisfied with facility. S2 created a new Admission Agreement for R1 and LPA observed R1 sign many pages and stated R1 understood what R1 was signing. LPA discussed allegation that R1 daughter took $400 without R1 consent and R1 stated that is wrong. R1 stated R1 allows R1 daughter access to R1 bank account in order to pay R1 storage fee. There is insufficient evidence to substantiate these allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted with Administrator Rachelle Reyes and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 28-AS-20241115140906

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to the Executive Director, Rachelle Reyes and was granted entrance into the facility. The Administrator assisted with the tour of the facility. There are seventy-seven (77) residents who currently reside within the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a current Infection Control Plan on file in place. Physical Plant/Environment Safety: The facility property is a two-story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has six (6) fully charged fire extinguisher located in the front entrance and hallways and inspected on 03/29/2024. Cleaning supplies were observed in a secured area away from food in the kitchen. Carbon monoxide detector is tested and in working condition. There is an emergency sprinkler system throughout the facility. Water temperature readings measure between the required 105 - 120 degrees Fahrenheit in compliance with Tile 22 Regulations. Operational Requirements: The Program Design was reviewed. Care and supervision to meet the clients’ needs was observed. Liability Insurance is confirmed and currently on file. Staffing: A total of twenty-six (26) full-time staff members provide care and supervision to the clients. Personnel Records / Staff Training: Administrator certificate expired on 08/15/2024 and currently pending renewal. Staff have the proper criminal and background clearance. Seven (7) staff files for First Aid and CPR training, Personnel Record, Health Screening, TB Clearance, and Employee Rights. All other ongoing training was documented. Resident Rights/Information Physician orders were reviewed in resident files. Personal Rights is posted. Facility provides phone and internet access to residents. Resident Records/Incident Reports: Eight (8) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, and medication records were reviewed. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Planned Activities: LPA observed facility has sufficient activities, activity director, and sufficient indoor and outdoor space for planned activities. Incident Medical and Dental: Resident medical and dental records in resident files. Facility provides transportation for residents to medical and dental appointments if needed. All medications are centrally stored in Medication Room and are properly labelled and in their original containers. LPA reviewed 8 residents medications with no issues. Disaster Preparedness: Emergency and Disaster Plan was publicly posted and found within the facility. An emergency/disaster drill was last conducted on 08/13/2024. Residents with Special Health Needs LPA observed from record review and interview that the facility has no residents with special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview held and a copy of the report was provided to the Executive Director, Rachelle Reyes.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Staff mismanaged residents' medication Staff did not provide a safe and comfortable environment for residents

***The licensing report dated 08/27/24 is being superseded by this report dated 10/17/24. The purpose of the report is to include additional information not included in the previous report and to include all required information on the deficient practice statement and plan of correction. In addition, the finding of the allegation of “staff mismanaged residents’ medication” is being changed from unsubstantiated to substantiated. The findings regarding the allegation of “staff failed to provide safe and comfortable environment for residents” will remain substantiated***. Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced Subsequent Complaint Visit to deliver the new findings for (1) of (2) allegations. LPA met with Administrator Rachelle Reyes and explained the reason for the visit. **Continued-LIC9099-C** Substantiated On 02/16/2024 LPA Wesley conducted an unannounced complaint visit and met with Assistant Elizabeth Martinez. LPA requested a copy of resident roster, staff roster, interviewed staff and residents. Additional 05/03/24 LPA Wesley conducted an unannounced subsequent visit and met with Administrator Rachelle Reves. LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, and reviewed the medication. On 08/27/24 LPA Reyes superseded the licensing reported created on 05/03/24. The licensing report was redelivered due to additional interviews that were conducted and further information that was obtained. The investigation consisted of: On 08/27/24, LPA Reyes conducted interviews with Administrator Rachelle Reyes, Staff #1 (S1- S8), and Residents #1 (R1-R3 and R6-R12). Residents # 4, 5, and 13-15 were not available to be interviewed. LPA Reyes collected copies of Staff and Resident Rosters, Physician’s Order Routine Medication and Physician Report for R1- R11, Exit forms for R13-R15, and Training for S1, S6, and S8. Regarding the allegations Staff mismanaged residents' medication and Staff did not provide a safe and comfortable environment for residents. It is alleged residents are not receiving their medication. Residents’ medication is being left on dressers, on the dining room tables, or in the resident’s trash cans in their room. In addition, Med Techs are not ensuring the residents are taking their medication. (6) of (8) staff interviewed confirmed the allegation. Staff indicated that medication had been found in hallways, resident’s rooms, and dining room tables. Staff acknowledge that medication found unattended was reported. Staff members have also confirmed awareness of medication being reported and delivered by other staff. Therefore there is evidence that residents at the facility are not receiving their medications as prescribed. (9) of (12) residents could not corroborate the allegation. During a tour of the dining room on 8/27/24 at 12:09 PM LPA Reyes observed a dining room of residents having lunch near a unlocked, unattended, and accessible med cart **Continued-LIC 9099-C** LPA Reyes observed S8 with the med cart near the kitchen door of the dining room preparing to deliver medications to residents in the courtyard. S8 was then observed by LPA Reyes from exiting the dining room and on the other end of the courtyard with residents. During this time LPA Reyes did not view any other staff monitoring the med cart or present in the dining room. LPA Reyes positioned himself near the med cart while S8 was assisting residents outside in the courtyard. When S8 returned from the courtyard LPA Reyes opened the cart and confirmed with S8 that med cart was unlocked and accessible to residents. S8 apologized and acknowledged they failed to lock the medication cart. LPA Reyes explained to S8 the importance of locking the med cart. 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 interviewed conducted with Administrator Rachelle and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 28-AS-20240213092437

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 18, 2024

87465(a) (4) 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: (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met evidence by. This pose an immediate health, safety, and risk to persons in care. Based on interviews conducted by LPA Reyes (6) of (8) staff confirmed they have observed medication in various areas of the facility on the floor and counters, including the hallways, resident rooms, and the dining room. The staff have stated they have either witnessed medication pills left unattended or had been informed by staff of such incidents.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Administrator will ensure staff assist residents with self- administered medication as needed by verifying medication is taken by resident before assisting another resident. The administrator will conduct in-service training, provide course materials, and attendance sheets with staff signatures to licensee by POC Due Date.

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

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met evidence by: Based on interviews conducted and observations by LPA Reyes, (6) of (8) staff confirmed they have observed medication in various areas of the facility on the floor and counters, including the hallways, resident rooms, and the dining room. Additionally, during the visit on (insert date) LPA Reyes observed medication cart being left unlocked, unattended, and accessible to all residents in the dining room. S8 admitted to LPA Reyes of leaving the med cart in dining room unlocked. This poses an immediate health, safety, and risk to persons in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Administrator will ensure centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. The administrator will conduct in-service training, provide course materials, and attendance sheets with staff signatures to licensee by POC Due Date.

Allegation investigated: Staff contaminated residents medication Staff do not ensure medications are dispensed as prescribed Staff do not ensure resident is provided with assistance for medical and dental appointments

Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Administrator Rachelle Reyes and explained the reason for the visit. The investigation consisted of the following: During the visit, LPA interviewed Resident #1 (R1 – R6) and Staff #1 (S1-S5). LPA requested copies of the resident roster, staff roster, and the Physician’s Reports LIC 602A, MARs, and Onsite Skilled Dental Care visits. The investigation revealed the following: regarding the allegation “Staff contaminated residents’ medication”, it is alleged that facility staff are altering the prescription medication which in return is causing irritation. --Continued LIC 9099-C-- Unsubstantiated (5) of (5) staff denied the allegation. Staff indicated that they have not witnessed any alterations to the prescribed medication nor heard of any other staff altering medications in a manner different from the way it was prescribed by the doctor. All medication have been administered according to the doctor's orders, and no unauthorized modifications have been made. (6) of (6) residents denied the allegation. Residents indicated they have not experienced any similar effects or issues with their prescribed medication. All residents confirmed that their medication have been administered as prescribed by their doctors without any changes. LPA Reyes contacted the pharmacist regarding (3) residents who are taking similar medication. The pharmacist confirmed that, despite different manufactures, the medication is the same brand and contains the same active ingredients. LPA Reyes observed and examined with S2 the alleged victims medication and found it to be sealed and with no signs of alteration. The investigation revealed the following: regarding the allegation "Staff do not ensure medications are dispensed as prescribed", it is alleged that facility staff are dumping medication out and replacing medication with another substance. (5) of (5) staff denied allegation. Staff have not witnessed nor heard of any staff not administering resident's medication as prescribed by a physician. All medication have been administered according to the doctor's orders, and no unauthorized modifications have been made. (6) of (6) residents denied the allegation. Residents have indicated they do receive their medication as prescribed and have not experienced any changes. LPA Reyes reviewed the alleged victims Mars and received confirmation from alleged victim that have stopped taking medication. The investigation revealed the following: regarding the allegation "Staff do not ensure resident is provided with assistance for medical and dental appointments" , it is alleged that medical documents are being taken from their room which in return is causing the resident to miss medical appointments. (5) of (5) staff denied the allegation. Staff indicated that after a visit is conducted by the dentist their paper work is then given to a staff for filing. If a resident does request a copy of recent visit a copy is provided. LPA Reyes spoke with (2) employees of Onsite Skilled Dental Care and confirmed that after a visit is completed paper work is provided only to a staff member. (6) of (6) residents have denied the allegation. Residents have indicated that they do not receive paper work from the dentist that it is provided to a staff member. The medical paper work they have obtained has not been taken from their room. It was reported to LPA Reyes that the alleged victim does have some memory issues. LPA Reyes reviewed alleged victim's LIC 602A and they do suffer from cognitive impairment. --Continued LIC 9099-C-- Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview was conducted with Administrator Rachelle Reyes and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 30, 2024 · control 28-AS-20240923120900

Allegation investigated: Staff speak to resident inappropriately. Staff cut resident's hair against his will.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegations listed above. LPA arrived unannounced and met with Administrator, Rachelle Reyes. The reason for the visit was explained. LPA obtained copies of the resident and staff roster. LPA interviewed the Administrator, Staff #1 - #4, and Residents #1 - #8. The investigation revealed the following: Allegation – Staff speak to the resident inappropriately. LPA interviewed the administrator, Staff, and residents regarding this allegation. The administrator stated she is not aware of any staff speaking inappropriately to residents. She stated she would immediately address it with the staff if this were to happen. She stated she had not disciplined any employees for this type of behavior since she became the administrator in February. Staff interviewed denied using any foul language toward residents. Unsubstantiated They stated they received training on how to interact with residents and would not disrespect them. LPA interviewed 8 residents who all stated staff are respectful and do not speak to them inappropriately. They are happy residing at this facility and think the staff are good. LPA obtained and reviewed in-service training provided by the facility and observed topics which included Workplace Violence policy, prohibited conduct policy, and customer service. Allegation – Staff cut the resident’s hair against his will. LPA interviewed Staff and Residents regarding this interview. The administrator stated that staff do not provide haircuts to residents. She stated she is in the process of hiring a hairdresser who will only be in charge of haircuts. In the meantime, the residents get their haircuts on their own or from a family member. LPA interviewed Staff who stated they do not cut residents’ hair against their will. Staff stated they do not provide haircuts but would help residents shave their beards or cut their nails with their consent. The residents interviewed stated that staff do not give haircuts. Some residents stated they go outside of the facility to get their haircut, a family member cuts it for them, or they do it themselves. One of the residents stated he/she asked the staff to help trim a little of the hair about a month ago but normally does it him/herself. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Administrator Reyes. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 27, 2024 · control 28-AS-20240920082021

Allegation investigated: Staff did not seek timely medical care for resident

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with administrator Rachelle Reyes and the purpose of the visit was discussed. LPA conducted the following: Interviewed residents #2-#6 (R2-R6), resident #1 (R1) was unavailable for interview , interviewed staff #1-#6 (S1-S6) , interviewed R1's wound specialist (WS) and their agency (A1). LPA collected copies of the staff and resident roster, documents from R1's resident file which included medical reports, physicians reports, facesheet, admissions agreement, and care plan. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff did not seek timely medical care for resident" it was alleged that R1 developed an open wound which went unnoticed for several days without wound care or dressing changes resulting in it becoming infested with maggots. (6) of (6) Staff denied the allegation. (5) of (5) Residents interviewed denied the allegation. Staff interviews state that R1 receives wound care from a wound specialist weekly that is covered by their insurance. R1 has been receiving wound care for several months and it is not a new condition. The wounds are non pressure related. Staff interviewed added that they do not provide wound care for residents because they are not trained for it. Only a professional is able to do that but if any immediate issues arise, they will contact the nurse on shift or the wound care agencies to determine what assistance is needed. File review shows the last date that R1 received wound care by their specialist was on 9/10/24. Notes from that visit do not show signs or maggots or infections. On this same day during the night medication shift, S6 noticed that R1 had pulled their wound bandage back revealing possible maggots under the bandage. Facility was advised to transport R1 via non emergency ambulance transportation by their doctor. Ambulance arrived on the morning of 9/11/24 to transport resident. This shows the facility sought timely medical care for resident once they were aware of issues with their wound and was not an unnoticed wound left unattended for several days. Based on the interviews, files reviewed, and observations conducted there was not enough supportive evidence to concur with the reported 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 allegation is Unsubstantiated. Exit Interviewed conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 28-AS-20240912155054

Allegation investigated: Facility illegally evicted a resident in care. Facility is not following resident's contract.

Licensing Program Analyst (LPAs) Christian Gutierrez, Myra Cota, and Luis Deleon conducted an unannounced complaint investigation regarding the above allegations. LPA was met by Administrator Rachella Reyes and explained the purpose of the visit. The investigation consisted of the following: LPA Gutierrez requested and obtained copies of staff roster (LIC 500), client roster (LIC 9020), staff #1-3 interviews (S1-S3), resident #1-2 interview (R1-R2), identification and emergency information, physicians report dated 02/28/2024, admission agreement, house rules, police report numbers, warning letter, and MAR log. The investigation revealed the following. Regarding Allegation(s): Facility illegally evicted a resident in care: It is alleged R1 was illegally evicted from the facility. LPA interviewed S1-S3 who were able to corroborate all accusations. R1-R2 where interviewed and it was determined R1 did not adhere to house rules per his admission agreement. 30-day eviction was reviewed and contained all elements needed. 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, there for the allegation is UNSUBSTANTIATED. See LIC 9099C Unsubstantiated Facility is not following residents’ contract-It is alleged facility was not following resident’s contract LPA obtained R1s admission agreement along with house rules. LPAs interviews with S1-S3 corroborate R1 was not following house rules. Interview with R1 reveled that R1 was aware of house rules and admission agreement and given copy signed on 02/29/2024. 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, there for the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 28-AS-20240904114722

Allegation investigated: Staff mismanaged residents' medication

Licesning Program Anaylst (LPA) Tyler Reyes conducted an unannounced complaint investigation visit for the allegation listed above. LPA met Francine Reyes-Wellness Director and the purpose of the visit was discussed. On 02/16/2024 LPA Wesley conducted an unannounced complaint visit and met with Assistant Elizabeth Martinez. LPA requested a copy of resident roster, staff roster, interviewed staff and residents. Additional 05/03/24 LPA Wesley conducted an unannounced subsequent visit and met with Administrator Rachelle Reves. LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, and reviewed the medication. ***The licensing report created on 05/03/2024 is being superseded by this licensing report dated 08/27/2024. The licensing report is being redelivered due to additional interviews that were conducted and further information that was obtained. The investigation findings will remain the same.*** Continued on LIC 9099-C Unsubstantiated In regard to the allegation” Staff did not provide a safe and comfortable environment for residents” it is alleged medication is being left unattended within the facility and that med techs are providing residents with medications and not ensuring that the medications have been taken. The investigation consisted of tour of the facility dinning room and a random sample of resident rooms. LPA Reyes examined the dresser and trash cans of Resident #1 (R1) R1-R4, R6-R10, and R12's room. (5) of (8) staff confirmed the allegation. Staff indicated that they have witnessed pills inside the hallways, in resident's rooms, in the dinning room, and on the property outside the facility. (10) of (12) residents could not corroborate the allegation. LPA Reyes toured the dinning room and observed at 12:09 PM Staff #8 (S8) had left the med cart unattended and unlocked for few minutes while outside in the court yard administering resident's medication.When S8 returned from outside S8 apologized and stated they have forgot to lock the cart. LPA Reyes informed S8 it is important the cart remains locked when unattended. Therefore, 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 interviewed conducted with Francine Reyes Wellness Director and a copy of this report was provided with appeal rights. In regard to the allegation “Staff mismanaged residents' medication” it is alleged residents are not receiving their medication. It is alleged that some residents medications are being left on their dressers, in the dining room tables, or in their trash cans in their rooms. (8) of (8) staff interviewed denied the allegation. Staff indicated the following that they ensure all residents take their medication before assisting another resident with medication. Staff assist residents by providing water and notifying residents when it is time to take medication.(9) of (12) residents denied the allegation. Residents interviewed indicated that staff are efficient in administering medication. Residents state they receive their daily dose of medication. LPA Reyes conducted record review (6) or (6) residents' August 2024 "Physicians Current Orders of Routine Medication" and medication is being given as prescribed by a physician. LPA Reyes observed in dinning room at 12:09 PM staff #8 (S8) member assisting with administering medication to residents. Based on the interviews conducted, files reviewed, and observations conducted there was not enough supportive evidence to concur with the reported 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 Interviewed conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 28-AS-20240213092437

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 28, 2024

87465Incidental Medical Care(h) The following requirements shall apply to medications which are centrally stored(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible .... Based on observations LPA Reyes toured the dinning room and observed at 12:09 PM Staff #8 (S8) had left the med cart unattended and unlocked for few minutes while outside in the court yard administering resident's medication.This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 27, 2024

Plan of correction: Administrator will provide LPA Reyes with the following documents in-service training for all staff on medication. Administrator will provide within 24hrs the date for the planned traininig staff and the training materials.

Allegation investigated: Staff do not assist resident with obtaining and distributing medication as prescribed. Staff do not ensure facility is clean and sanitary.

Licensing Program Analyst (LPA) Vaid conducted an initial visit to investigate the above allegations. At 8:50 am, LPA met with Wellness Director Francine Reyes and explained the purpose of the visit. Administrator is on leave. The investigation consisted of the following: LPA obtained and reviewed staff and client roster, physician report, appraisal needs plan, face sheet, admissions agreement and medication administration records(MARS) for the month of July and August 2024 regarding R1. LPA conducted interviews with staff 1- 6 (S1-S6). LPA interviewed residents 1-5 (R1 -R5). LPA Vaid conducted tour of the physical plant and did not observe any deficiencies or health and safety concerns. Allegation: Staff do not assist resident with obtaining and administering medication. It is alleged that staff are not assisting residents with obtaining and administering their medications. Five (5) out of (5) staff interviewed deny the allegation. CONTINUED on 9099 C..... Unsubstantiated Seven (7) out of (7) residents interviewed, denied that the staff does not assist with obtaining and administering their medications. All residents interviewed state that the staff is proactive in ordering and obtaining the prescribed medications from the physician and pharmacy. By R1’s accounts medication has been given to them daily as prescribed. The facility contacted the pharmacy on 06/18/2024 to order refills for the following medications. 1. Lisinopril ½ tablet, once daily 2. Folic acid 1mg tablet once per day. The facility contacted the pharmacy on 06/21/24 and 06/25/24 for follow-up on the medications. The prescription 1 was filled and sent to facility on 06/28/24. The second prescription was not filled due to Insurance billing delays. LPA reviewed medication orders for R1, all medications have been prescribed as physicians orders as indicated in the Medication Administration Records (MARS) in the entire month of July 2024 and six (6) days in August 2024. Reviewed four (4) residents MARS, all medications have been administered as prescribed. Based on interview, resident #1's prescription medication were not refilled in a timely manner due to insurance billing delays causing resident #1's prescription medications not being administered from July 1, 2024, to July 6, 2024. The medication delay was acknowledged by the pharmacy who then contacted the physician on June 25,2024 to reinstate medication for R1 by 06/27/24. Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Allegation: Staff do not ensure facility is clean and sanitary. It is alleged that staff did not ensure that the resident was provided with housekeeping services and the facility is not kept in sanitary conditions. Five (5) out of (5) staff denies this allegation. Seven (7) out of (7) residents deny this allegation. Interviews with staff members revealed that housekeeping is done daily, and room checks (taking out trash, replacing paper products) are completed daily with the deep cleaning done once a week, bedsheets are changed twice per week. Walls and furniture are dusted twice per week. The bathroom sink and floors are cleaned daily. Housekeeping is performed daily. Staff members have not heard any residents complaining about this issue recently. Interviews with staff indicated that housekeeping staff provide housekeeping services like, cleaning and room checks daily. CONTINUED on 9099C... LPA reviewed the facility's housekeeping/maintenance schedule as well as housekeeping deep clean schedules and duties for July 2024. The documents revealed that they have staff assigned to clean the residents’ rooms daily and deep clean on a weekly basis. According to R1 recollection housekeeping comes every day to clean and tidy the room. Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held, and a copy of this report was provided to Francine Reyes.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 28-AS-20240730121748

Allegation investigated: Staff did not safeguard resident's personal items

Licensing Program Analyst (LPA) Jose Villalobos conducted an unnannounced complaint investigation visit for the allegation listed above. LPA met with Administrator Rachelle Reyes and the purpose of the visit was discussed. LPA conducted the following on todays visit: LPA interviewed Residents #1-#7 (R1-R7), Interviewed Staff #1-#5 (S1-S5), LPA toured the physical plant which included the common rooms and resident room #s 8, 13,16,18, and 25. LPA also reviewed and collected a copy of the staff and resident roster. LPA reviewed and collected documents from R1's file such as: the Facesheet, Physicians Report, Needs and Services Plan, Admissions Agreement, and List of Valuables documentation. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff did not safeguard resident's personal items" it is alleged that staff and residents of the facility are stealing information and documents from R1's drawers. (5) of (5) Staff interviewed denied the allegation. (6) of (7) Residents interviewed could not corroborate the allegation. R1 stated to believe that someone in the building was stealing documents from their locked drawer. R1 was unable to detail what and when the specific documents and information was being taken. R1 was not sure if anyone else had a key to their locked drawer. Staff interviewed denied taking any documents or information from R1. Staff also stated that they do not have access to any locked cabinets in residents rooms and only the residents whom the drawer belongs to will have a key. LPA observed R1 to have the key to their locked drawer on their person. File review does not show that there are any incident reports involving R1 having personal items missing. File review does not show that there are items belonging to R1 that R1 signed off on the facility being responsible for. Based on the interviews conducted, files reviewed, and observations conducted there was not enough supportive evidence to concur with the reported 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 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2024 · control 28-AS-20240627170558

Allegation investigated: Staff are not preventing resident from harrassing other resident while in care.

Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced visit at the facility to investigate the above allegation. LPA met with Janice Anguiano – Business Office Manager and explained the purpose for todays visit. Investigation consisted of the following: LPA obtained staff and resident rosters, copies of documents within R1's file, interviews with 3 staff and 7 residents. (continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are not preventing resident from harassing other resident while in care. It is alleged that roommates R1 and R2 are having verbal altercations, R1 is being harassed by their roommate R2 and staff have done nothing to diffuse the situation. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation and stated they have not been told about altercations between R1 and R1 prior to todays visit. Interview with S3 revealed that R1 was experiencing aggressive behaviors over incidents that are outside of the reported allegation, R1 is not in the facility as they have been sent for a psychiatric evaluation. LAP interviewed R2 and they denied the above allegation and stated they have never had any altercations with anyone at facility. LPA reviewed incident reports and there was nothing noted about R2 having aggressive behaviors or altercations with residents. LPA interviewed a total of 7 residents and 7 out of 7 residents denied the above allegation, stating that when there are verbal altercations staff will mediate the situation, try to solve the problem and separate those involved in the altercation. Based on statements and interviews conducted with staff and residents and review of resident files, 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 to Janice Anguiano.the state’s words, verbatim · CDSS document, May 31, 2024 · control 28-AS-20240528123331

Allegation investigated: Questionable death Resident fell while in care Staff are mismanaging resident medication Staff did not seek medical treatment in a timely manner Staff are not responding to residents calls Staff left resident's in soiled diapers for extended period of time

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced subsequent visit at the facility and met with Administrator Rachelle Reves to discuss the purpose for todays visit. Investigation consisted of: copy of resident and staff roster, interviews with clients, staff, and obainted copies of specific documents. Regarding allegation: Questionable death It appears that the resident was outside smoking and they asked him to come for lunch, 20 minutes passed and he appeared to be in the sleeping in the chair. Staff tried to wake him and he was not responding, there was no pulse and 911 was called. DNR was noted in the residents file. Regarding allegation: Resident fell while in care. it appears that resident #2 had an unwitnessed fall Continued on LIC 9099C Unsubstantiated in care. it appears that resident #2 was in bed and said his legs got very weak. Staff #2 noticed he was speaking differently, his speech was blurred. She tried to assist him but he was not able to bear weight on his legs, so she called 911 for a possible stroke. Regarding allegation: Staff are mismanaging resident medication LPA interviewed residents and there is no indication that staff are mismanaging the residents medications. Resident #3 left the facility and did not inform staff he was leaving for the weekend. When he came back on the following Monday, they gave him his medication. There is no way they are supposed to give him the missed medication for 2 days unless the doctor said it was okay to do so, and according to the complainant the resident takes 4 sets of medication in 1 day. Regarding allegation: Staff did not seek medical treatment in a timely manner. In regards to Resident #1,and #2 the facility sought medical treatment in a timely manner. Resident #1 had information in his file, and Resident #2 was under Hospice care. Regarding allegation: Staff are not responding to residents calls. LPA Wesley interviewed staff #1 and she indicated that the staff are responding to residents calls because she answers them. LPA interviewed resident #5 and she couldn't recall stating that the staff#1 didn't answer her calls and hangs up. She did say that they answer the phones now. LPA asked Resident #3, #5, and resident #9 and they all indicated that they calls are answered. Regarding allegation: Staff left resident's in soiled diapers for extended period of time. LPA Wesley interviewed resident #3, #4, and #5. Resident #3 and #5 informed the LPA that they couldn't remember. LPA interviewed resident #4 she said she doesn't even remember wearing diapers in 2022. Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported 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.the state’s words, verbatim · CDSS document, May 3, 2024 · control 28-AS-20220511142439

Allegation investigated: Staff mismanaged residents' medication. Staff did not provide a safe and comfortable environment for residents.

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced subsequent visit at the facility and met with Administrator Rachelle Reves to discuss the purpose for todays visit. Investigation consisted of: LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, reviewed the medication, did not see any medication laying around. The investigation revealed: Regarding allegations: Staff mismanaged residents' medication, and Staff did not provide a safe and comfortable environment for residents. LPA Wesley conducted interviews with 8 of the 11 residents, and they all said that they received their medication from Staff #1 and all the Med Techs who issues medication. LPA Wesley interviewed the maintenance director, wellness coordinator, and the wellness coordinator. The maintenace director found pills on the floor but he said they appear to have continued on LIC 9099C Unsubstantiated been in the residents mouth(it has been spit out), all the other staff said its not just 1 person to blame, because the medication is found at random times and is not due to Staff not issuing them. Resident #1 was not admitted to the hospital due to lack of medication, he had health concerns, and the doctor did not put on his discharge papers that he was hospitalized due to missed medication. LPA Wesley also check the training for the Medical Technicians and they were up to date. Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported 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.the state’s words, verbatim · CDSS document, May 3, 2024 · control 28-AS-20240213092437

Allegation investigated: Staff did not prevent resident from using illegal narcotics in the facility. Staff do not ensure medication is dispensed in a timely manner. Staff dispensed medications incorrectly. Staff do not ensure residents medications are replenished timely. Residents left in soiled clothing for extended period of time. Facility did not maintain residents account ledgers. Staff do not address safety measures to prevent residents wandering away. Staff did not prevent unauthorized persons from sleeping in the facility.

Licensing Program Analyst(s) (LPA) Jose Villalobos and Tyler Reyes conducted a subsequent visit for the allegations above. LPA's met with Executive Director Rachelle Reyes and the purpose of the visit was discussed. Previous visits conducted by LPA Villalobos and Kruz Long between 4/19/23 and 8/25/23 consisted of the following: Tours of the physical plant. Observations of the facilities food supply.Copies of the staff and resident rosters were obtained. Documents from residents #1-#4 (R1-R4) files were collected. Copies of the food menu, emergency evacuation plan, fire drill log, and activity calendar were reviewed and collected. Staff #1 (S1) was interviewed, and residents #3-#9 (R3-R9) were interviewed. On todays visit LPA's interviewed Staff #2-#5 (S2-S5), R2 and Residents #10-12 (R10-R12). LPA reinterviewed R4, R8-R9. R1 and R13 are no longer in the facility and were unavailable for interview. LPA collected financial ledger for R4 between February2023-April 2023. LPA also collected physicians reports, medication records and any incident reports for R7 and R10-R11. The investigation revealed the following: CONTINUED ON LIC9099-C Unsubstantiated In regards to the allegation "Staff did not prevent resident from using illegal narcotics in the facility" it was alleged that staff did not prevent R13 from using illegal drugs in the facility. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. No staff or residents interviewed were able to say they observed R13 to be using illegal narcotics in the facility. Interviews state that R13 had a history of alcohol abuse and smoking in his room. Interviews state that staff addressed the issues with the resident multiple times. File review shows that R13 received warning notices for smoking cigarettes in the facility as well as for their behavior towards others between the months of October-December 2023. File review and interviews do not show that R13 was using illegal narcotics in 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 allegation is unsubstantiated. In regards to the allegation "Staff do not ensure medication is dispensed in a timely manner." it was alleged that medications were being provided to residents up to 2 hours late. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Interviews with staff stated that it is medications management protocol to have a 2 hour window for each medication, meaning if a medication is prescribed to be taken at 8am, it can be provided between 7am-9am. No residents interviewed had issues with the timely manner that they received their medications. LPA did not observe medication errors from staff for files reviewed. 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 allegation is unsubstantiated. In regards to the allegation "Staff dispensed medications incorrectly" it was alleged that staff provided residents the incorrect medications. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. LPA did not observe medication errors from staff for files reviewed. Interviews with residents did not state staff have provided any residents the wrong medications. 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 allegation is unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Staff do not ensure residents medications are replenished timely" it is alleged residents will be out of specific medications for a few days before their prescription refills are received. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Interviews did not state that has happened to residents in the facility. Residents interviews did not have that experience. LPA was not provided with information as to which residents were left without medications. 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 allegation is unsubstantiated. In regards to the allegation "Residents left in soiled clothing for extended period of time" it was alleged that staff were not changing resident diapers in a timely manner. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Staff interviews state that it is part of the caregivers duty to conduct check on all residents who need diaper changes every 2 hours. Residents are also able to communicate with staff and staff will assist residents with diaper changes. Interviews with residents confirmed the information. LPA was not informed of which residents were not being changed by staff as needed. 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 allegation is unsubstantiated. In regards to the allegation "Facility did not maintain residents account ledgers" it was alleged that the facility was not accurately handling resident finances. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Details provided state that R4 was not provided their monthly P&I funds in early 2023. Interviews with staff state that R4 had an overdue month of owed rent because they failed to pay for the month of January in 2023 and so R4 made an agreement with the facility to pay off the owed balance by paying $100 of their funds monthly until it was paid off. R4 confirmed the information. As of today, overdue bills has been paid and LPA observed R4's account ledger to reflect an accurate balance along with an accurate P&I provided to R4 monthly. 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 allegation is unsubstantiated. Continued on LIC 9099-C In regards to the allegation "Staff do not address safety measures to prevent residents wandering away" it was alleged that Staff fail to prevent R7,R10-R11 from wandering out of the facility. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Interviews state that the residents do not wander out of the facility and such incidents have not occurred. Review of the physicians report for R7 and R10-R11 show that the residents cannot leave the facility unassisted. There are no incident reports on file showing the residents have left the facility unassisted. Interviews with the residents conducted do not state they leave the facility unassisted. 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 allegation is unsubstantiated. In regards to the allegation "Staff did not prevent unauthorized persons from sleeping in the facility" it was alleged that homeless people have entered the facility and slept in the common room. (4) of (4) Staff interviewed today could not corroborate the allegation. (7) of (7) Residents interviewed today could not corroborate the allegation. Staff and residents interviewed stated to not have any knowledge of such an incident occurring. File review did not show any reports involving a homeless person sleeping inside 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 allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 28-AS-20230418144527

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility.

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint visit to investigate the above allegation. LPA met with Administrator Chanel Sanchez and discussed the purpose of today’s visit. At today's visit Resident and Staff Roster was submitted. Interview was conducted with Administrator at 12:30 PM. File was reviewed for Resident R 1 and the following forms were submitted: Physician's Report, Admission Agreement, and Emergency ID. Special Incident Report's (SIR's) were submitted. Documentation from Nowalk Police was submitted dated 12/15/2023 and 12/17/2023. Interviews were conducted with Staff S 1 and Staff S 2 from 12:45 PM to 130 PM. Interviews were conducted with Resident's R 2- R 7 from 1:35 PM to 2:15 PM. In regards to the allegation, Staff did not provide adequate supervision resulting in resident wandering away from facility, based on interviews conducted and information gathered it was revealed on Physician's Report dated 11/15/2023 for Resident R 1 that box is checked yes for able to leave the facility unassisted. Unsubstantiated Documentation from Norwalk Police dated 12/15/2023 Report # 023-14437-0453-400 and 12/17/2023 Report # 023-14508-0453-400 are reports that were done by the facility for a missing person's report. Resident's interviewed all stated that staff do a great job and perform their jobs professionally. All of the resident's stated that there is no lack of supervision or neglect by staff and they are always on their toes and always on point. Also stated that there is a sign in and out sheet and staff are at the front desk and can see everyone leaving. 2 of 6 resident's knew of R 1 not coming back, and doesn't think anything neglectful by staff and said there is no way to hold him here because he has the right to leave. Interviews with staff who stated that R 1 has personal rights to leave facility unassisted and that can't be taken away. Stated that R 1 has often gone out and returns. Said he is not a wanderer. Said the care staff is up front. 1 staff interviewed stated that R 1 said he had gone overnite to his old house and then to the VA to follow up on his meds. Said that the facility picked him up the following day and had filled out a missing person's report when R 1 did not return. It should be noted that R 1 was not at the facility at today's visit and is currently in the hospital. Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported 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. A copy of this report was given to Chanel Sanchez, during the exit interview.the state’s words, verbatim · CDSS document, Dec 21, 2023 · control 28-AS-20231215154209

Allegation investigated: Staff did not provide resident with a 60-day notice of rent increase. Staff demanded financial information from resident.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Administrator Chanel Sanchez and explained the reason for the visit. During this visit, LPA obtained a copy of the resident and staff rosters and reviewed Residents #1 (R1) to Resident #7 (R7) filles and obtained relevant documentation. LPA also interviewed Staff #1 (S1) through Staff #4 (S4) and Resident #1 (R1) through Resident #7 (R7). Continued on LIC 9099-C Unsubstantiated Allegation: Staff did not provide resident with a 60-day notice of rent increase. It was alleged that resident’s(R1) rent increased from $980 to $1300. Also Resident was advised that they owes $800.00 for back pay, and that they will be charged an additional $100/month to cover this outstanding balance. Record review confirm that R1 was admitted to the facility on 05/11/2023. Admission agreement was signed by R1 with the Monthly rate $1344.82. For May,June and July R1 paid $920.00 for each month (copy of the invoice obtained by LPA). R1 was agreed to pay amount they own the facility. Administrator and Staff #2 stated that the facility has developed a payment plan for R1, due to the fact that R1 has an outstanding balance, and is not current on their rent. There are 2 portions of Payment plan: one was developed on 07/24/23 and the second on 09/05/23. Both were singed by R1. R1 was agreed to pay the amount of $125.00 beginning 08/03/23, and $100.00 beginning 10/03/23 and ending when the balance is paid in full. Interviewed Administrator and S2 stated that residents and their responsible parties always were made aware of the rate increase. Per record review, it was confirmed that the annual increase letter was sent out for residents indicating the increase. Interviewed R1, R2, R3, R5 and R7 stated that they notified by administrator about rate increase. Responsible parties for R4 and R6 will be notify with the 60 day notice if their rent will increase. At this time there is no rent increases for R4 and R6. Based on information obtained, there was insufficient evidence to corroborate the allegation of facility not providing a 60 day notice of rental increase. Therefore, the allegation is unsubstantiated at this time. Allegation: Staff demanded financial information from resident It was alleged that on an unknown date, R1 observed a female staff (no name)who deals with financial matters at the facility, demand the debit card PIN from a resident (no name) to get money out of the account for something the resident owed. Interviewed administrator S2, S3, S4 denied the allegation. They stated that staff will never demand the debit card PIN from the residents. Interviewed S3 stated that sometimes residents asking for help to call to the bank to verify their account balance and S3 assisting them. In same cases S3 was provided personal information by residents. S3 stated that information provided voluntary. S2 confirmed that they had assisted residents with filling out financial forms and will assist with debit card PIN numbers if residents request assistance. All interviewed residents denied the allegation and indicated they have not heard other residents complaining about staff to demand their PIN. Interviewed R1 stated that staff not demand R1's card PIN and R1 didn't hear that staff demand PIN from other residents. Staff and resident interviews do not corroborate this allegation. Based on information obtained, there was insufficient evidence to corroborate the allegation. Therefore, the allegation is unsubstantiated at this time. Exit interview held and a copy of the report and appeal was provided to the Administrator. .the state’s words, verbatim · CDSS document, Dec 8, 2023 · control 28-AS-20231201155952

Type of visit: Case Management - Deficiencies

A case management visit was conducted during the course of the investigation of complaint 28-AS-20231201155952 by LPA Nune Margaryan. Staff and client interviews were conducted. The following deficiency was observed. Interviewed S3 stated that S3 help the residents to call the bank to check their account balance. In some cases S3 get personal information from the residents. At the time of visit Interviewed Administrator and S2 stated there is one staff at the facility in charge to handle any financial matters. No other staff is permitted to assist the residents obtaining financial information and get any personal information from the residents. The deficiency cited is documented on the LIC809D. Exit interview held and a copy of the report and appeal was provided to the Administrator.the state’s words, verbatim · CDSS document, Dec 8, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Dec 15, 2023

Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement is not met as evidenced by.There is one staff at the facility in charge to handle any financial matters (S2). No other staff is permitted to get any personal information from the residents. In same cases S3 was provided personal information by residents.the state’s words, verbatim · CDSS document, Dec 8, 2023

Plan of correction: Administrator shal review section 87208 and will send LPA a written letter stating that the section has been reviewed and is understood, by POC due date.

Allegation investigated: Staff failed to assist resident with diaper change. Facility did not allow visitors, violating residents personal rights. Facility failed to keep resident(s) furniture in good repair.

Licensing Program Analyst(LPA) Nicol Wesley Licensing Program Analyst (LPA) Nicol Wesley conducted the Subsequent complaint visit to investigate the above allegations. LPA met with Adminstrator Chanel Sanchez to discussed the purpose of today’s visit. LPA Wesley requested copies of: resident files, staff files, shower log, resident shift report, interviews with residents, interviews with staff, and interviews with resident #1. Regarding allegation: Staff failed to assist resident with diaper change. LPA interviewed 7 out of 8 residents who said the facilty staff assists them with diaper changes and facility showers on time. LPA interviewed 4 staff members who said they provide the residents baths and showers in a timely manner. LPA interviewed all 4 staff who indicated that resident #1 never wants to get changed when the staff is available to change them, and he doesnt' want to be bothered when he's sleeping, or is going outside to smoke. Staff said Continued on LIC 9099C. Unsubstantiated they try to work with the resident, but he yells at them and starts cursing them out. LPA interviewed resident #1 but was not successful because resident #1 was using foul language. Regarding allegation: Facility did not allow visitors, violating residents personal rights. LPA interviewed 7 out of 8 residents who said the facility have not denied any visitors from coming to the facility last month in November 2023 due to covid or any other reason. The 7 residents said when the pandemic first hit in 2020 they denied visitation because everyone in the facility had COVID and the hospitals were full and they could take the clients who were effective, so to stop the spread they denied visitor. This was supported by the CDPH and CCLD. LPA interviewed 8 staff who said they haven't denied any visitation last month November 2023, but when the COVID outbreak was high, they weren't allowing any visitation in the beginning. Regarding allegation: Facility failed to keep resident(s) furniture in good repair. LPA interviewed 7 out of 8 residents and they indicated that if anything breaks in their room, the facility is good about repairing or replacing it. LPA interviewed 4 staff who indicated that resident #1's bed is not broken, you need 2 people to assist with putting it up or down. LPA interviewed resident #1 but was not successful because resident #1 was using foul language. Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported 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. A copy of this report was given to Chanel Sanchez, during the exit interview.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 28-AS-20231109161630

Allegation investigated: Illegal Eviction

Licensing Program Analyst(LPA) Nicol Wesley Licensing Program Analyst (LPA) Nicol Wesley conducted the initial complaint visit to investigate the above allegation. LPA met with Adminstrator Chanel Sanchez to discussed the purpose of today’s visit. LPA requested copies of: resident files, staff files, eviction notices, warning letters, interviews with residents, interviews with staff, and interviews with resident #1. Regarding allegation: Illegal eviction. LPA Wesley reviewed all documents, warning letters, and talks with the resident and found the eviction notice to be legal. The resident was given warning notices on the date of occurrence, and the eviction notice with the warning notices attached by Chanel Sanchez and Elizabeth Martinez. Also a copy of the eviction notice was given to the residents brother. Continued on LIC 9099C. Unsubstantiated Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported 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. A copy of this report was given to Chanel Sanchez, during the exit interview.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 28-AS-20231201113827

Allegation investigated: Staff do not prevent smoking in undesignated areas.

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint visit at the facility and met with Executive Director Chanel Sanchez to discuss the purpose for todays visit. During the visit, LPA requested a copy of the resident roster, staff roster, interviewed staff, interviewed residents, and received a copy of the Air Conditioning invoice. Investigation revealed the following: Staff do not prevent smoking in undesignated areas. LPA Wesley interviewed 10 out of 10 residents who indicated that staff does not make residents smoke in undesignated area's. The residents stand at the entrance to the facility and ignore the signs and the blue tape letting them know were the 20 foot rules begins. Although the signs are posted, the residents are not adhering to the smoking instructons and the staff are not always enforcing them. continued on LIC 9099C Substantiated Based on LPA observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations,Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Appeal rights were given. A copy of the LIC 9099/LIC 9099C/LIC 9099D was given during the exit interview.the state’s words, verbatim · CDSS document, Nov 21, 2023 · control 28-AS-20231116165916

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 5, 2023

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: The facility failed to keep the residents from smoking in the undesignated areas which is in front of the facility which poses a health and safety issues for clients in care.the state’s words, verbatim · CDSS document, Nov 21, 2023

Plan of correction: The administrator shall ensure that all residents are adhering to the non smoking signs. Complete an inservice training with you and your staff on ways to ensure the resident are adhering to non smoking signs. Send proof of service to LPA Nicol Wesley by POC date 12/05/23.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Nicol Wesley conducted a required 1 year (annual continuation) visit. LPA met with Administrator Chanel Sanchez and Assistant Administrator Elizabeth Martinez to discussed the purpose of today’s visit. The facility property is a two story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. LPA Wesley used the care tools to conduct the visit, and interview staff and residents. LPA toured the facility and visited medication room (health services office), hot water was tested measuring 112.4-113.3 degrees F. The Last fire drill was conducted on 10/19/23. LPA Wesley interviewed 9 residents and 5 staff. LPA conducted a complete tour of the facility, and observe the supply of food. Resident medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed 7 total fire extinguishers, 1 in the kitchen, 2 floor one(hallways), 2 floor two(hallways), 1 in the administrators office, and 1 underneath the front desk. There are no deficiencies according to the California Code of Regulations, Title 22. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 21, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nicol Wesley conducted a required 1 year visit. LPA met with Administrator Chanel Sanchez and Assistant Administrator Elizabeth Martinez to discussed the purpose of today’s visit. The facility property is a two story commercial building, licensed to serve 80 non-ambulatory residents ages 60 and above, of which 10 can be bedridden. The designated rooms for bedridden residents are rooms 1, 3, 5, 7, and 9, The facility has an approved hospice waiver for 30 residents. There are a total of 40 resident rooms. LPA toured the facility and visited medication room (health services office), hot water was tested measuring 112.4-113.3 degrees F. Administrator's certificate for Chanel Sanchez #6044357740 07/06/23. She is awaiting her new certificate, and has the canceled check all her paperwork in order. Due to time constraints, LPA Wesley will continue the required 1 year visit at a later date.the state’s words, verbatim · CDSS document, Nov 16, 2023

Allegation investigated: Staff did not provide resident with meals. Staff stole money from a resident.

Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial complaint visit to investigate the above allegations. LPA met with Elizabeth Martinez (Business Office Manager/Assistant Administrator) and discussed the purpose of today’s visit. During this visit, LPA obtained a copy of the resident and staff rosters and reviewed Resident #7’s (R-7) file and obtain relevant documentation. LPA also interviewed Staff #1 (S-1) through Staff #5 (S-5) and Resident #1 (R-1) through Resident #7 (R-7). Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff did not provide resident with meals. It has been alleged that when a resident misses a meal, the facility will not feed the resident. Staff interviews revealed that the facility provides (3) meals and (2) snacks per day. Staff interviews revealed that meal times are as follows: breakfast is from 7:45 A.M. to 9:30 A.M.,lunch is from 11:30 A.M. to 1:30 P.M. and dinner is from 4:30 P.M. to 5:45 P.M. Per staff interviews, when a resident shows up after the meal times, staff still provide a meal for them. Interviewed staff indicated they have not received any complaints/concerns in regards to residents not receiving their meals. Interviewed residents indicated meals are available (after the meal times) as well. Interviewed residents indicated they have not heard anyone complaining about staff not providing residents with meals. Staff and resident interviews do not corroborate this allegation. Allegation: Staff stole money from a resident. It has been alleged that a staff member stole money from a resident. Staff interviews revealed that staff do not steal money from residents. Interviewed staff indicated they have not received any complaints/concerns in regards to this matter. Interviewed staff indicated they are trained in resident rights and mandated reporting. Interviewed residents indicated staff do not steal their money. Interviewed residents indicated they have not heard other residents complaining about staff stealing their money. Interviewed residents indicated they do not any concerns in regards to this matter. Staff and resident interviews do not corroborate this allegation. Based on record review and interviews conducted the findings indicate, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview conducted, appeal rights and a copy of this report was provided to Elizabeth Martinez.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 28-AS-20231101121819

Allegation investigated: Resident sustained an unexplained fracture while in care of staff Staff did not transfer resident properly resulting in dropping the resident

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Administrator Chanel Sanchez who assisted with today's visit. Regarding the allegation that : Resident #1 sustained an unexplained fracture while in care of staff. The investigation was conducted by the department, and consisted of interviews with staff, residents, review of resident #1's file and review of medical records. The investigation revealed that resident #1 resided at the facility from 1/30/23 - 3/20/23. On 3/5/23, facility sent resident #1 to emergency room due to complaint of right knee pain. A CT scan was done, and was negative for any acute fracture. Resident #1 also mentioned shoulder pain, and medical records indicate that resident #1 did not have a fractured shoulder. Regarding the allegation that : Staff did not transfer resident properly resulting in dropping the resident. The investigation was conducted by the department, and consisted of interviews with staff, residents, review of resident #1's file and review of medical records. Unsubstantiated Staff interviewed denied that resident #1 was dropped. Staff stated that while transferring resident into wheelchair, resident #1 became still and was lowered onto the floor. Resident #1 was not consistent in statements made regarding being dropped. 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.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 28-AS-20230407114427