Silverado Senior Living - Calabasas

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh conducted an unannounced required annual visit. Upon arrival, LPAs were greeted by the front desk staff and met with Administrator Patrice O'Grady shortly thereafter. Entrance interview conducted. Beginning at 10:25AM, the LPAs, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS/RESTROOMS: The LPAs observed a random selection of ten (10) resident rooms, all of which contain private restrooms. All bedrooms were furnished appropriately with clean linens, furnishings and sufficient lighting. Separate carbon monoxide detectors and smoke detectors were tested in various resident rooms and all functioned properly at the time of the visit. Restrooms were clean, sanitary and in operating condition with grab bars and non-slip surfaces. Water temperature was tested in various resident restrooms and temperatures ranged from 113.0 to 117.1 degrees Fahrenheit. COMMON SPACES: The facility contains multiple common areas throughout, including but not limited to: two (2) dining areas, three (3) activity/snack areas, common entry area, and a spa room. Walls and flooring were checked for cleanliness and good condition. Department required postings were found in the front lobby near the restrooms. Fire extinguishers were charged and serviced 09/11/2025. EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. Report Continued on LIC 809-C FOOD SERVICE: LPAs observed the facility's commercial kitchen, which was locked and inaccessible to residents in care. Kitchen appeared to be clean and appliances operable. Facility has sufficient supply of both perishable and non-perishable food, along with emergency food and water. The facility has a system for special diets, including a visual board and diet cards to ensure residents' special diets and dietary preferences are recognized. Storage for chemicals is separate from food storage, per regulation. FILES: Record review began at 11:19AM. The LPAs reviewed a selection of five (5) staff files for documents including, but not limited to: health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time. The LPAs reviewed five (5) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All five (5) resident files reviewed contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: LPAs reviewed both the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last disaster drill documented on 02/19/2026. Fire system 5-year inspection was completed on 05/16/2024 and the annual inspection was completed on 08/05/2025. No defects were noted during either inspection. MEDICATION REVIEW: Began at 01:47PM; LPA Huyhn, along with facility nurse, reviewed medications for five (5) residents. One resident (Resident #1-R1) did not have a centrally stored medication and destruction record (CSMDR), although R1's medications are being centrally stored by the facility. Nurse explained that the pharmacy sends the CSMDRs for the residents, however R1's prescriptions are filled at another pharmacy that does not provide a CSMDR. Administrator indicated that going forward, the facility will utilize Silverado's CSMDR, which meets the licensing requirements. All medications reviewed appeared to be administered as prescribed. INTERVIEWS: Throughout the visit, LPAs interviewed five (5) staff and five (5) residents. No concerns were noted. No deficiencies cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2026

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

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Administrator Patrice O'Grady and explained the reason for the visit. A suspected abuse report was emailed to the Woodland Hills Regional Office (RO) on Friday night 12/12/2025. Corresponding incident report related to Resident #1 (R1) and Resident #2 (R2) was emailed to the RO on Saturday 12/13/2025. Incident Report indicated R1 reported to facility staff that R2 had sexually assaulted R1. Immediately following R1's reporting of the incident, the facility placed R2 on 1:1 care, informed both residents' responsible parties, and reported to local police. Police responded to the facility and a police report was filed. During LPA's visit today, LPA discussed the incident report with Administrator at 11:34AM, toured the facility with Administrator at 11:52AM and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Administrator was informed that the incident was referred to Community Care Licensing Division's Investigations Branch (IB). If after reviewing all information further investigation is warranted, LPA and/or IB investigator may return at a later date. No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 16, 2025

Allegation investigated: Neglect/Lack of care led to Resident #1 sustaining multiple pressure injuries Facility did not seek timely medical care for Resident #1, resulting in retaining a resident with a prohibited health condition

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation regarding the above noted allegations. LPA was greeted by front desk staff. LPA met with Administrator Patrice O’Grady at 02:05PM and explained the reason for the visit. Entrance interview conducted. During an initial complaint visit conducted on 04/18/2025, LPA Dulek along with Clinical Staff Manager conducted a health and safety check tour of the facility at 05:03PM. No immediate health and safety hazards were observed during facility tour. LPA informed Clinical Staff Manager that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB.) Investigator Dennis Seng conducted both telephonic and in person interviews with staff and other relevant parties on the following dates: 05/20/2025, 05/28/2025, 05/29/2025, 06/18/2025, 06/30/2025, 07/10/2025, 07/17/2025, and 07/25/2025. Investigator Seng also reviewed copies of R1’s medical records, including but not limited to facility medical Report Continued on LIC 9099-C Substantiated documents, physician’s documents and wound care records. LPA then reviewed all information obtained by Investigator Seng. The following was then determined: Allegation “Neglect/lack of care led to Resident #1 (R1) sustaining multiple pressure injuries:” The complaint alleges that R1, who is a former resident of Silverado Senior Living Calabasas, sustained at least three (3) stage three pressure injuries while in care at the facility. Record review revealed that R1 moved into the facility on 12/23/2020. R1’s diagnoses listed on the physician’s report dated 12/26/2022 included but were not limited to: dementia, type 1 diabetes and hypertension. R1 was noted to be non-ambulatory and required assistance with transfers. At that time, R1’s physician indicated R1 had no history of skin condition or breakdown. Facility care notes indicated that R1 had a “boil” on their right buttocks noted on 04/20/2023. Home health certification and plan of care with a certification period of 05/24/2023 – 07/22/2023 with provider listed as Sunset Healthcare, Inc. indicated a diagnosis of “pressure ulcer of right buttock.” Plan of care included “stage 3 pressure ulcer wound care and status until further orders from MD.” Review of documents provided revealed the facility reached out to R1’s family member requesting a change in Home Health provider on 07/24/2023. Initial consult with Wound Masters occurred on 08/07/2023 which indicates “per caregiver, [R1] previously had an abscess at that location that self-ruptured.” Site of the wound was listed as right posterior thigh/leg. It is unclear when R1 sustained this pressure injury, as facility charting is incomplete, with entry on 07/28/2023 indicating “home health eval for wound care to right medial buttocks wound,” however, no mention of the posterior thigh wound and no additional entries were made until 08/11/2023. It also appears that no home health was contracted or provided from 07/23/2023 to 08/07/2023. Interview with medical professional revealed that due to observed fat layer exposed, the thigh wound was categorized as a stage 3 wound. A third wound was assessed on 10/02/2023 on R1’s right gluteal fold, buttock. This wound was listed as a “pressure ulcer stage 3.” Wounds treated by Wound Masters were recorded as resolved on 01/22/2024. Interview with facility staff revealed the resident was repositioned every 2 hours, however, LPA did not observe any documentation of repositioning. Staff stated that they were unaware of any pressure injuries on R1 and staff referred to R1’s documented pressure injuries as “boils.” Even when IB investigator showed staff home health notes indicating R1’s wounds were labeled “pressure ulcer” or “pressure injury,” staff stated they had “no idea” why they had documented these wounds as boils or blisters. Although R1 had no history of skin breakdown prior, R1 sustained 3 (three) documented stage three wounds while in care at the facility. Based on information Report Continued on LIC 9099-C gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore the allegation “neglect/lack of care led to Resident #1 sustaining multiple stage three pressure injuries,” is deemed SUBSTANTIATED at this time. Allegation “Facility did not seek timely medical care for R1 resulting in the facility retaining a resident with a prohibited health condition:” The complaint alleges that facility staff did not seek timely medical treatment for R1’s wounds. As outlined above, the facility staff noted a “boil” on R1’s right buttock on 04/20/2023, however, home health services were not contracted to provide service for the stage 3 wound until 05/24/2023, over a month after the skin abnormality was identified. According to R1’s family member, they were not notified of the pressure injury until 05/31/2023. The Regional Office received no written notification of any of R1’s 3 (three) pressure injuries. Also, as outlined above, R1 did not have home health services to care for R1’s wound(s) from 07/23/2023 until 08/07/2023. During the intake assessment, Wound Masters identified a second wound. It is unclear when the second wound occurred, as the facility’s care notes were incomplete. Although the facility did assist in contracting home health services for R1’s wounds, there was a delay in beginning services and a lapse in coverage between providers. Additionally, stage 3 and stage 4 wounds are considered prohibited health conditions under Title 22 regulations and residents with prohibited health conditions cannot be retained at the level of care Silverado is licensed to provide as a Residential Care Facility for the Elderly (RCFE.) Under the facility’s approved hospice waiver, residents that are contracted for third-party hospice services can be retained with prohibited health conditions. However, record review and interview revealed that R1 was not admitted to hospice care until 10/01/2024, well beyond the time R1 had the 3 (three) identified wounds. Additionally, record review revealed R1’s physician’s report dated 12/26/2022 indicated R1 lacked the capacity to bathe, dress/groom or feed themselves, nor could R1 care for their own toileting needs or manage their own cash resources. Therefore, according to R1’s physician, R1 required full ADL (activities of daily living) care, which is also a prohibited health condition under Title 22 regulations. LPA reviewed documents sent to the Woodland Hills Regional Office and did not find an exception request to retain R1 with either prohibited health condition. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore the allegation “facility did not seek timely medical care for R1 resulting in the facility retaining a resident with a prohibited health condition,” is deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 29-AS-20250418092743

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 4, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes...appropriate assistance is provided when such observation reveals unmet needs... physician and the resident's responsible person, if any This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as staff noted R1 had changes in their skin beginning on 04/20, but did not have home health until 05/24, R1's family member was not made aware until 05/31/23, which posed an immediate health risk to R1the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator agreed to submit to CCL current policies and procedures related to observation of the resident, reporting, and prohibited health conditions. Administrator will document current process for reporting change of condition and communication. Documentation will be sent to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 4, 2025

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had documented stage 3 pressure injuries as well as total ADL care and R1 was not admitted to hospice care at that time, which posed an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Administrator agreed to submit to CCL current policies and procedures related to observation of the resident, reporting, and prohibited health conditions. Administrator will document current process for reporting change of condition and communication. Documentation will be sent to CCL by POC due date.

Allegation investigated: Neglect/Lack of Care led to Questionable Death

Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh conducted a subsequent complaint investigation regarding the above noted allegation. LPAs were greeted by front desk staff. LPAs met with Administrator Patrice O’Grady at 10:18AM and explained the reason for the visit. Entrance interview conducted. During an initial complaint visit conducted on 10/16/2024, LPA Dulek interviewed Interim Administrator Laken Lacy at 10:06AM related to recent incident reports and death reports submitted to the Department, reviewed and obtained copies of relevant documents. LPA, along with Interim Administrator and pending Administrator Patrice O'Grady, conducted a health and safety check tour of the facility at 11:05AM. No immediate health and safety hazards were observed during facility tour. LPA informed Interim Administrator that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB) and assigned to IB Investigator Laura Garcia. Investigator Garcia conducted both telephonic and in person interviews with staff Report Continued on LIC 9099-C Substantiated and other relevant parties on the following dates: 10/16/2024,10/18/2024, 10/19/2024, 11/07/2024, 11/11/2024, 02/26/2025, 02/27/2025, and 03/04/2025. Investigator Garcia also reviewed medical records for Resident #1 (R1). LPA Dulek reviewed information obtained from all sources. The following was then determined: The complaint alleges that while being transferred using a Hoyer lift, R1 fell, causing a brain hemorrhage, resulting in R1’s death. An incident report was submitted to the Woodland Hills Regional Office on 09/03/2024 indicating R1 fell while Staff #1 (S1) was attempting to transfer R1 while using a Hoyer Lift. Staff interviews and documents reviewed indicate that R1 was a high fall risk and R1 required a 2-person transfer assist. Care Plan and Silverado policy states “Transfers – 2-person assist. Provide resident with 2-person physical assist to increase independence and ensure safety in transfers.” However, S1 admitted that although they were aware of Silverado policy and R1’s care plan, S1 did not call for assistance transferring R1 on the morning of 08/30/2024. As S1 pulled the lift back with the sling attached and R1 in the sling, S1 lost control of the lift and the lift tilted to one side. S1 admitted that due to S1’s stature and R1’s weight, S1 could not regain control of the lift, resulting in the lift falling, R1 hitting their head on the floor and causing a head injury. S1 called for assistance from the facility LVN on duty. R1 was assessed for injury and noted to be awake, but had a blank stare, was unresponsive to light and not blinking. 9-1-1 was called and R1 was taken to the hospital for further medical treatment. R1 was admitted to the hospital in critical care due to the head injury sustained at the facility. R1 was diagnosed with a subdural hematoma measuring 6 mm in maximal depth with a 2 mm midline shift to the left. R1 was discharged from the hospital to a Skilled Nursing Facility before returning to Silverado Senior Living Calabasas on 10/01/2024. R1 was admitted to hospice on the date of their return. R1 passed away under hospice care on 10/03/2024. Immediate cause of death listed on Certificate of Death was Traumatic Subdural Hematoma. Manner of death was listed as accidental as a result of injury sustained due to “fall in hospice facility” on 08/30/2024. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation “neglect/lack of care leading to questionable death” is deemed SUBSTANTIATED at this time. A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and/or 1569.49(f). Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report was provided. and other relevant parties on the following dates: 10/16/2024,10/18/2024, 10/19/2024, 11/07/2024, 11/11/2024, 02/26/2025, 02/27/2025, and 03/04/2025. Investigator Garcia also reviewed medical records for Resident #1 (R1). LPA Dulek reviewed information obtained from all sources. The following was then determined: The complaint alleges that inadequate staffing led to R1 falling during transfer, resulting in injury. An incident report was submitted to the Woodland Hills Regional Office on 09/03/2024 indicating R1 fell while Staff #1 (S1) was attempting to transfer R1 while using a Hoyer Lift. Staff interviews and documents reviewed indicate that R1 was a high fall risk and R1 required a 2-person transfer assist. Although S1 was aware of both Silverado policy and R1’s care plan, on the morning of 08/30/2024, S1 chose to transfer R1 alone. S1 stated they believed other staff to be busy assisting other residents at that time and S1 did not wish to “bother them.” S1 admitted they made a mistake and should have called for a second staff to assist with the transfer. Interviews and staff schedule review indicate at the time of the incident, there were 6 total care staff, 1 (one) LVN, and 1 (one) medication technician present at the facility on the date of the incident. The census on 08/30/2024 was 52 residents. At the time of the incident, 5 (five) caregivers were each assigned to care for their own specific group of residents and the additional caregiver was working as a floater, to assist with 2-person transfers and assist as needed with residents. S1 admitted they do have the ability to call for assistance, but on the date of the incident S1 did not request assistance. Management staff did “write up” S1 as a result of the policy violation. Based on the information obtained during the investigation there is insufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation “neglect/lack of supervision – inadequate staffing to transfer resident in care, resulting in resident falling” is deemed UNSUBSTANTIATED at this time. No citations issued related to the above allegation. Exit interview conducted. A copy of today’s report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 29-AS-20241015100719

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Mar 26, 2025

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking...Postural Supports This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as S1 did not transfer R1 per R1's care plan, which resulted in R1 falling, sustaining injury, and R1 passed away as a result, which posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Administrator stated Hoyer lift training was completed immediately following the incident, and additional vendored training was also provided. Disciplinary action involving S1 has been completed. Administrator provided documentation of trainings and disciplinary action completed, POC cleared.

Allegation investigated: Resident is being held at the facility against their will

Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh conducted an unannounced initial complaint visit for the above allegation. Upon arrival, LPAs were greeted by the front desk staff. LPAs were informed Administrator would be at the facility shortly. LPAs informed facility management of the reason for today's visit. Administrator Patrice O'Grady arrived at the facility at 10:05AM. Entrance interview conducted. During today's visit, LPAs interviewed Administrator at 10:05AM, Resident #1 (R1) at 11:02AM,interviewed facility staff at 12:51PM and 01:05PM. LPAs also spoke with other relevant parties telephonically throughout the visit and reviewed and obtained copies of pertinent documents. The following was then determined: The complaint alleges that R1 is being held at the facility against their will. Interview with R1 revealed that R1 does not wish to remain at the facility. R1 does not recall how they arrived at the facility, but suspects a family member moved R1 to the facility. Review of R1's physician's report and other relevant documents REPORT CONTINUED ON LIC 9099-C Unsubstantiated indicate R1 has a diagnosis of dementia and R1 moved into the facility on 02/21/2025. Interview with R1's family member revealed that R1 previously resided at home, however, there were safety concerns with that living situation. After a hospitalization, R1's family member moved R1 into the facility. Interview with staff revealed that R1 frequently verbalizes that they do not wish to remain at the facility and would like to return to their private home, however, R1 has not attempted to seek exit from the facility. All parties interviewed confirmed that R1 has not been held at the facility. Staff stated that the front door does have delayed egress and while R1 does sit in the front lobby and look out the windows, R1 has not attempted to open the door or exit the facility. LPAs also observed R1 in the front lobby but not attempting to exit the facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "resident is being held at the facility against their will" is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 29-AS-20250305110857

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kelly Dulek and Quoc Huynh conducted an unannounced required annual visit. Upon arrival, LPAs were greeted by the front desk staff. LPAs were informed Administrator would be at the facility shortly. LPAs informed facility management of the reason for today's visit. Administrator Patrice O'Grady arrived at the facility at 10:05AM. Entrance interview conducted. Beginning at 11:34AM, the LPAs, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS/RESTROOMS: The LPAs observed a random selection of 10 (ten) resident rooms, all of which contain private restrooms. All bedrooms were furnished appropriately with clean linens, furnishings and sufficient lighting. Smoke detectors and separate carbon monoxide detectors were tested in various resident rooms and all functioned properly at the time of the visit. Restrooms were clean, sanitary and in operating condition with grab bars and non-slip surfaces. Water temperature was tested in various resident restrooms and temperatures ranged from 113.5 to 115.3 degrees Fahrenheit. COMMON SPACES: The facility contains multiple common areas throughout, including but not limited to: 3 (three) dining/activity areas, common entry area, and a day room. Walls and flooring were checked for cleanliness and good condition. Department required postings were found in the front lobby near the restrooms. Fire extinguishers were charged and serviced 09/19/2024. EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. FOOD SERVICE: LPAs observed the facility's commercial kitchen, which was locked and inaccessible to residents in care. Kitchen appeared to be clean and appliances operable. Facility has sufficient supply of Report Continued on LIC 809-C both perishable and non-perishable food, along with emergency food and water. The facility has a system for special diets, including a visual board and diet cards to ensure residents' special diets and dietary preferences are recognized. Storage for chemicals is separate from food storage, per regulation. FILES: The LPAs reviewed a selection of 5 (five) staff files for documents including, but not limited to: health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time. The LPAs reviewed 5 (five) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All 5 (five) resident files reviewed contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: LPAs reviewed both the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last disaster drill documented on 02/19/2025. Fire system 5-year inspection was completed on 05/16/2024 and the annual inspection was completed on 09/18/2024. Both inspections were conducted by Absolute Fire Protection and all systems passed inspection. MEDICATION REVIEW: Began at 02:41PM, LPAs, Regional Director of Health Services, along with facility nurse, reviewed medications for 3 (three) residents. 1 (one) resident (Resident #1 - R1) was prescribed Vitamin B complex. The medication was filled on 02/27/2025, but did not have a start date indicated. 5 pills remain in the bubble pack. Administrator and LPA attempted to count the days back, however it appears there is at least 1 (one) pill remaining in the pack that should have been administered. R1's acetaminophen is prescribed three times a day and originally contained 27 pills. The start date is listed as 03/04/2025 and 6 (six) pills are remaining as of the medication review. While it is possible the house supply of acetaminophen was utilized, there is no documentation reflecting this. INTERVIEWS: Throughout the visit, LPAs interviewed 3 (three) staff and 5 (five) residents. No concerns were noted. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were providedthe state’s words, verbatim · CDSS document, Mar 13, 2025

Allegation investigated: Resident is being financially abused while in care

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation regarding the above noted allegation. LPA was greeted by the front desk staff and was informed facility Administrator is not available today. LPA met with Regional Nurse Specialist Laken Lacy shortly after the visit began and explained the reason for the visit. During today's visit, LPA interviewed Resident #1 (R1) at 09:34AM, interviewed facility staff and management at 10:33AM, 10:37AM, 11:50AM, and 12:01PM. LPA also spoke with R1's conservator via telephone at 11:28AM, and reviewed and obtained copies of pertinent documents. The following was then determined: The complaint alleges that R1 is being financially abused while in care. Interview with R1 revealed that R1 has a public guardian conservator that manages R1's finances. R1 stated that they have a debit card REPORT CONTINUED ON LIC 9099-C Unsubstantiated which allows R1 access to R1's discretionary funds. R1 indicated their conservator has not given R1 their discretionary funds monthly as agreed upon. Facility staff have been trying to assist R1 with their concern related to discretionary funds, but because of the recent evacuation due to the wildfires, had yet to speak with R1's conservator and resolve this concern. R1 provided LPA with a copy of a receipt for the latest deposit into R1's account tied to their debit card, which showed a deposit in the amount of $350 on 12/20/2024, however funds were held "because the account had multiple overdrafts in the last six months." LPA spoke with R1's conservator who confirmed he deposited the check to R1's bank on 12/20/2024. Conservator also confirmed that he alone handles R1's finances and that the facility does not have access to R1's money. LPA observed that R1 does have their debit card in their possession and R1 stated that no facility employees have access to their debit card. Both facility staff interviewed and conservator indicated that R1 doesn't fully comprehend their finances and bills accumulated and that R1 spends their discretionary funds shortly after they are deposited on the debit card. R1 told LPA that on 12/27/2024, R1 went out of the facility, got their nails done, then purchased lunch at a local restaurant using their own debit card. LPA observed the 12/27/2024 receipt for lunch in R1's room. Facility staff informed LPA that fees for R1's room and board/care are sent via check by a third party insurance company and mailed monthly to the facility's corporate office, so at no time are any funds received at this facility for R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "resident is being financially abused while in care" is deemed Unsubstantiated at this time. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 29-AS-20250107000401

Allegation investigated: Facility employees failed to provide an appropriate level of supervision resulting in a resident assaulting another resident and the resident sustaining injury

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the above noted allegation. LPA met with Regional Nurse Specialist Laken Lacy and explained the reason for the visit. During an initial complaint visit conducted on 08/29/2024, LPA interviewed Interim Administrator Laken Lacy at 04:58PM and spoke with Regional Director of Operations Taylor Giunto telephonically during the interview. LPA reviewed documents and video footage related to resident eviction request. LPA, along with Interim Administrator, conducted a health and safety check tour of the facility at 05:24PM. No health and safety hazards were observed during facility tour. LPA informed Interim Administrator that the allegation was referred to Community Care Licensing Division (CCLD)'s Investigations Branch (IB). IB Investigator Douglas Real continued the investigation. Investigator Real reviewed a copy of the Los Angeles County Sheriff’s Report Continued on LIC 9099-C Unsubstantiated Department Incident Report related to the complaint allegation, reviewed medical records for Resident #1 (R1), documents related to R1 and Resident #2 (R2), and interviewed facility staff, residents, and other relevant parties on the following dates: 10/22/2024, 11/13/2024, 11/14/2024, 11/20/2024, and 12/07/2024. The following was then determined: It was alleged that facility staff did not provide an appropriate level of supervision, resulting in R2 attacking R1 and R1 sustaining a head injury. Review of R2’s facility records revealed that R2 had moved into the facility on 06/21/2024. Interviews with R2’s physician, Power of Attorney (POA) designee, and trustee all revealed that R2 did have a diagnosis of dementia, but R2 had no history of aggressive or assaultive behavior at the time R2 moved into the facility. Hospital records dated prior to facility admit did indicate R2 is “supposed to have 24/7 caregivers” but did not indicate the reason 24/7 care was requested. Trustee indicated they had informed the hospital staff of this request due to R2’s care needs becoming greater and resulting weight loss, but reiterated that R2 had displayed no prior aggressive behaviors. Hospital records did not indicate any aggressive behaviors were observed. When R2 moved into the facility, facility staff conducted 72-hour behavior mapping, as outlined in the facility’s protocol for all new residents. R2 did not display any aggressive behavior towards other residents during the 72-hour period. From the time R2 moved into the facility until the date of the incident, per their responsible party’s request, R2 had a private companion with them during normal business hours Monday through Friday. Incident reports reviewed revealed R2 had been involved in an incident with another resident on 06/30/2024, where R2 had pushed another resident. However, the incident did not result in injury to either resident and facility staff had reported the incident to R2’s physician, who adjusted R2’s medication. No additional incidents or aggressive acts were observed involving R2 and any other residents until 08/23/2024. R2’s private companion had been working with them during the daytime, but had gone home for the day prior to the incident. Incident report reviewed and staff interviews revealed that facility staff had assisted R2 with getting ready for bed prior to 09:00PM on 08/23/2024. R2 had appeared somewhat frustrated when care staff were providing R2 with assistance, but staff reported this behavior is typical of residents with dementia, including R2. Care staff had left R2 in their room in bed, but that R2 did not require 1:1 supervision and residents are free to leave their rooms whenever they choose. Around 09:00PM, facility staff heard a noise in the hallway near the patio and staff reported to the area to see what had occurred. When staff arrived, R2 was standing up and R1 was laying on the ground on their back. Facility staff assessed both residents and called 9-1-1 due to R1’s observed injuries. As both residents have a diagnosis of dementia, it wasn’t until Report Continued on LIC 9099-C video recordings were reviewed that staff found out what had occurred between the two residents. Video recording shows that R1 was in the hallway facing R2 when R2 approached R1. R2 grabbed either one or both of R1’s arms, appears to shake R1, and R1 takes several steps back before falling backward. As R1 falls backward, R2 falls forward onto R1’s right side. R2 gets up off the ground before staff report to the hallway. R1 was taken to the hospital where x-rays revealed a “subdural hematoma along the left cerebral hemisphere and left falx cerebri with tiny parenchymal hemorrhagic foci indicating contusion seen in the left nondisplaced subtle fracture of the right occipital bone.” All staff interviewed acknowledged that at times R2 had been resistant to care provided and R2 would occasionally hit at the care staff while they were providing care. However, staff interviewed indicated they had not witnessed any prior incidents where R2 had acted aggressively toward another resident. All third-party interviews conducted revealed that R2 had no history of aggressive behaviors and that when any new behaviors were identified by facility staff, that the facility acted swiftly to communicate with R2’s medical provider and responsible parties. Additionally, prior to the incident occurring, there was no documentation or indication R2 required 1:1 staff supervision. Following the incident, facility management required R2 to have a 1:1 companion at all times while in the facility as a preventative safety measure. After reviewing video footage of the incident, facility management chose to initiate an eviction for R2. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 29-AS-20240828141720

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Regional Nurse Specialist Laken Lacy and explained the reason for the visit. A self-reported incident related to Resident #1 (R1) was received in the Woodland Hills Regional Office on 12/27/2024. Incident Report indicates "noted with an abrasion to R1's right knee. Injury obtained during transfer." LPA called the facility to inquire the circumstances surrounding the transfer and requested additional documents to be faxed to the Woodland Hills Regional Office, which were received on 12/31/2024. During LPA's visit today, LPA interviewed Regional Nurse Specialist beginning at 10:37AM, toured the facility with Regional Nurse Specialist at 01:19PM and LPA obtained copies of pertinent documents. No immediate health and safety hazards were identified during facility tour. Interview and document review revealed that R1 had previously undergone right knee replacement prior to R1 moving into the facility. Interview with Regional Nurse Specialist revealed that R1 does require transfer assistance and on 12/22/2024, an agency staff was assisting R1 with transferring between wheelchair and bed when R1's right knee bumped the wheelchair. R1 was observed with a small abrasion but did not report nor appear to be in any pain at that time. The following day, R1 appeared to be in pain, so R1 was sent to the hospital for additional medical attention. Hospital records reviewed indicate "apparent fracture of the distal femur above the site of the prosthesis." R1 returned to the facility with a knee immobilizer and pain medication. Follow up was scheduled with orthopedic specialist on 01/16/2025. Records reviewed do not indicate the injury is acute, nor do records indicate the fracture was sustained as a result of improper transfer or that the injury occurred due to lack of care and supervision. Based on the information obtained there is insufficient evidence to determine whether lack of care and/or supervision contributed to the injury R1 sustained. No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Staff did not address a change in the resident's condition. Staff do not ensure resident's hygiene needs are met. Staff locked resident in their room. Staff do not provide resident clean linens. The facility has no means for residents to call for assistance. Staff did not provide resident PRN medication as needed.

/12/2024: Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to investigate the allegations listed above. The LPA met with the Administrator Patrice O’Grady and explained the reason for the visit. The LPA requested additional records at 12:25 p.m. On 08/15/2023, Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct an initial 10-day complaint visit. The LPA met with Administrator Terri Wheitzman and explained the reason for the visit. Continues on LIC 9099C... page 2. Unsubstantiated Staff did not address a change in the resident's condition. It is alleged that staff did not address a change in R1’s condition, and the concern of the Reporting Party (RP) is that the results of a swallow test given to R1, showed that R1can only eat pureed foods (pudding like). To investigate the allegation LPA Urena conducted record review and interviewed the RP. The LPA was unable to interview the facility Administrator employed at the time when the complaint was received by the Department, or the Director of Health Services (DHS), as they are no longer employed at the facility. Medical records obtained by the LPA indicates that on 05/24/2023, R1 had a Neurology Outpatient visit and the medical provider notes indicate that R1 was accompanied by R1’s POA, facility Administrator Terri Weitzman, and a facility caregiver. Furthermore, the case notes indicate that at the time of the visit; it was noted that R1 had developed dysphagia (difficulty swallowing) to solid foods in early 2023, and the recommendation was to provide R1 with soft moistened solids, purees, thin liquids, and with direct staff supervision. On 06/02/2023, the POA communicated via email with the DHS to inform them that during a visit with R1, the POA observed that R1 had a plate of breakfast in their room, and the POA asked that R1 eat in the dining room where R1 could be supervised during meals. On 09/08/2023, the POA communicated via email with the DHS and two other facility staff about the concern of R1 not having breakfast and lunch meal during a recent doctor’s appointment, in which day, R1 returned late to the facility from the appointment, and the dining room was closed, consequently the R1 had to wait for dinner time, and someone (staff) provided R1 with chips and crackers to hold R1 over till dinner time. On 12/04/2024 the LPA reviewed records provided by the facility. Record review indicates that the facility received Diet Recommendations from the Speech Therapist at Rancho Los Amigos Rehabilitation Center on 07/12/2023. The recommendations indicate that R1 needs to receive a diet of puree foods, and nectar thick liquids. The recommendations include three (3) pages with a detailed description of a ‘Puree diet purpose’, ‘Description of the diet’, ‘Guidelines’, and a ‘Food list’. The recommendations were received by the DHS on 07/12/2023 and given to the culinary staff via a Diet Request Form (DRF) on 07/12/2023. However, the DRF does not indicate in the instructions the specifics of the puree diet, direct supervision by staff during mealtimes, nor did the facility provide documentation as to how the directive was passed on to the direct staff (caregivers, etc.). Continues on LIC 9099C pg.3 Pg. 3 On 12/04/2024, the LPA requested R1’s file for review, and specifically asked for R1’s Resident Appraisal (s) (LIC 603 A), Appraisal Need and Service Plan (LIC 625), Physician’s Report (LIC 602A), but the current Administrator was unable to locate R1’s file at the time of the visit on 12/04/2024. The LPA requested that when the file was located to email the LPA the requested records. Furthermore, on 12/05/2024, the LPA emailed the Administrator reminding them of the requested documents, and as of 12/10/2024, the LPA had not received the requested records. On 12/12/2024, additional records were provided by the Administrator. The Administrator provided appraisal (Service Plan) done by staff on 06/01/2023. Per the Administrator the appraisal is a live document where designated and approved staff can make updates to the document. The Facility’s Service Plan (SA) is dated as Effective Date: 06/01/2023 and Date Scheduled: 09/20/2023. Per the Administrator, the SA can be modified as needed, and the SA indicates the updated Needs/Goals/Action. When the LPA asked the Administrator if the SA was shared with the POA, the Administrator could not say since the SA was created at a time when they were not employed at the facility. Although the allegation may have happened or is valid, based on record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Staff do not ensure resident's hygiene needs are met. On the allegation that staff do not ensure resident's hygiene needs are met; it is the concern of the RP that staff do not shower R1. The RP states that when they spoke to staff about R1’s hygiene, they were told that R1 does not like to take showers. The LPA was unable to interview staff/caregivers related to the allegation due to RP not recalling the name of R1’s caregiver. To investigate the allegation LPA Urena interviewed current staff and conducted record review. The staff’s interviews revealed that staff have a schedule they follow to give showers to residents. Per staff statements, when residents refuse to take showers, the staff/caregivers may delay the shower for the next day or try different approaches to getting the residents’ cooperation to take showers. The staff/caregivers stated that they keep records of the residents who did not get a shower and report during the “exchange” of the staff (AM, PM, NOC). The LVN keeps case notes of the residents who refused showers. The Administrator’s interviewed revealed that staff may attempt to give a shower to a resident but if the resident refuses, the residents cannot be forced, however the refusal of the shower is case noted and other methods to encourage the shower may be used, such as a different time of the day or a different face (caregiver). Continues on pg. 4 Pg. 4 The Regional Support Nurse (RSN) and staff stated that sometimes a PRN is needed (to relax the resident). The LPA interviewed the POA on 12/03/2024, and the RP stated that they were concerned about the hygiene of R1 as R1 had developed an odor, and the POA could tell R1 had not been showered. The POA stated that when they spoke to staff about R1’s hygiene, the POA was told by staff that R1 does not like to take showers, however the staff failed to notify the POA. The POA stated that they had to bring it up to the administrator’s attention for something to be done. The POA stated that after they expressed the concern to the administrator; R1’s shower was moved to a different time of the day, and that seemed to resolve the issue of R1 refusing showers. Record review of the shower schedule that is followed by staff revealed that currently each caregiver has about eight (8) to nine (9) residents per staff. The shower schedule revealed residents have a designated weekday or weekend day (2X per week) for showers. Although the allegation may have happened or is valid, based on record review, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Staff locked resident in their room. On the allegation that staff locks resident in their room, it is the concern of the RP that during visits, they have noticed staff locking R1’s door from the outside. R1 is extremely weak and would not be able to open the door from the inside if needed. R1 has fallen a few times because R1 tries to get up on their own when staff do not help. The RP is concerned that staff are locking the resident in their room and do not help with toileting. LPA was unable to interview the Administrator working at the facility during R1’s stay, as the Administrator is no longer employed at the facility. To investigate the allegation LPA Urena conducted a tour of the facility and interviewed the staff and the current Administrator. The Administrator stated that the bedrooms’ doors are kept unlocked from the outside and inside revealed, and they typically keep the rooms’ doors open. The staff, S1, S2, S3, S4, stated that the doors don’t lock from the outside, due to a mechanism in place to prevent door being locked. The LPA toured the facility and inspected six (6) randomly selected rooms’ doorknobs/locks. At the time of the visit, the LPA observed the bedrooms’ doorknobs to have a screw in-place inside and outside the doorknob that prevents the door from being locked from the outside and inside the room. Continues on Pg. 5 Pg. 5 Although the allegation may have happened or is valid, based on the interviews, and observation, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Staff do not provide resident clean linens. On the allegation that staff do not provide resident with clean linens; the concern of the RP is about R1 being dirty and malodorous, and the staff do not change R1’s bed linens. The LPA interviewed the POA on 12/03/2024, and the POA stated that staff informed the POA that the linens are changed when the residents get a shower, and at least once a week. To investigate the allegation, on 12/04/2024 LPA Urena interviewed the RSN and current staff. The LPA was unable to interview the staff and the DHS employed at the time of the allegation, due to the staff and the DHS no longer working at the facility at the time the LPA conducted interviews. The RSN stated that the linens are changed as needed and on shower days. The staff interviews revealed that they change linens two times a week and/or on shower days, or as needed. When staff (S1) was asked what happens when residents refuse showers, do they still change the linens? S1 stated that they do change the linens when the residents are out of their room. The LPA asked to see the linen closet for the facility, and it appeared that the facility had an adequate quantity of linens for the residents at the facility. Although the allegation may have happened or is valid, based on the interviews, and observation, there is not sufficient evidence to prove the alleged violation did or did not occur. Although the allegation may have happened or is valid, based on the interviews, and observation, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. The facility has no means for residents to call for assistance. On the allegation that the facility has no means for residents to call for assistance The RP states that the facility does not have a call system or means for residents to ask for help. The RP stated ‘if R1 needs to go to the bathroom or needs assistance, R1 has to wait for staff to check in’. The RP states that when they inquired with staff about a call system, they were told that staff check on residents every two hours. Furthermore, the RP stated that they were told that if they wanted R1 to have a call pendant they could buy / order one from Amazon. The RP stated that staff told RP what device to buy, but when the pendant arrived at the facility the staff never gave it to R1. The RP stated that when they followed up with staff about the pendant, the RP was told that a doctor's order is required to use the pendant. Continues on Pg. 6... Pg.6 To investigate the allegation LPA Urena conducted a tour of the facility along with the Regional Support Nurse (RSN). The LPA interviewed staff, RSN, and the Administrator. The tour of the facility revealed that each room has an alert signal system plate located inside the room by the door frame leading to the bathroom. The plate has a ‘PUSH’ sign to activate the system that sends a signal to the front desk and the Wellness Center staff, requesting assistance by the resident in the room. The RSN interview revealed that they were not aware the rooms had a call system. The staff interviews revealed that the alert signal system plate has been in place for some time. The staff interviewed, have been employed at the facility between one (1.7), four (4) and 16 years. Furthermore, the staff interviews of S1, S2, S4, revealed that once the system is activated by the residents, the signal will go to the front desk and the wellness center. Based on who receives the alert (the front desk or the wellness staff) will send a message to the caregiver/s via the telephone/radio each caregiver carries with them, and the caregiver(s) go to the resident’s room to give assistance to the resident. The current Administrator’s interview revealed that the system has been in place to their knowledge since they became the Administrator this year. The LPA reviewed communication between the POA and the DHS dated 08/19/2023. The communication is via an email between the two parties: the DHS states, ‘The call button is next to R1’s bed, and the caregivers are aware of this, and to remind R1 use it to call for help/assistance. It is in R1’s room, and if it best to have R1 wear it around the neck, we can do so as well’. The LPA was unable to interview the ‘caregivers’ related to this communication as they could not be identified by name by the POA and the DHS is no longer working at the facility. The LPA interviewed the POA on 12/03/2024, per the POA they were not aware of the alert signal system plate, nor they were told about the system by staff, and consequently they purchased a call pendant for R1 based on the information provided by the DHS. On 12/11/2024, the LPA reviewed additional records, The records dated 07/17/2023, indicate that the facility’s Social Worker is communicating with the POA in regard to information about the call button to be purchased, which was being recommended by the DHS. Although the POA was not made aware of the alert system by the facility staff, and the POA purchased a call pendant for R1, the facility had a call system in place at the time of the allegation. There is insufficient evidence to prove that the alert system was not functional at the time of the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Continues on Pg. 7 Pg.7 Staff did not provide resident PRN medication as needed. It is alleged that R1 staff is not providing R1 with PRN medication when requested by R1. The concern of the RP is that R1 is bedbound due to illness complications, and the illnesses are progressing, consequently R1 experiencing more pain. RP states that R1 has more pain, and when R1 asks staff for prescription Tylenol (PRN) they do not provide the medication to R1. To investigate the allegation LPA Urena conducted record review and interviewed the Administrator and the POA. Record review of the facility’s eMAR (Electronic Medication Administration Record) dated 07/01/2023 to 07/31/2023, revealed that R1 did not receive the PRN medication for the full month of July. The eMAR dated 08/01/2023 to 08/15/2023, revealed that R1 did not receive the PRN medication from 08/01/2023 to 08/15/2023. The PRN instructions are to dispense the medication as requested by the resident for pain. The eMAR dated 08/16/2023 was reviewed and it indicates that the new PRN medication was started on 08/15/2023 at bedtime and continued as indicated 2 times a day, once in the morning with breakfast and second dose at bedtime. Although a PRN medication was prescribed prior to 08/15/2023, the prescription was that the medication was to be administered when requested by the resident. Per the POA the resident complained of pain, but resident did not know how to ask for the pain medication. Once this concern was brought up to R1’s physician, the prescription was changed to 2X per day. The facility provided the eMAR documenting the doses administered for the new prescription. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted, and a copy of the report was issued. The record review of the Physician’s Order Review form dated August 15, 2023, indicates that R1’s physician ordered the knee braces to be put on both knees during the day and to be removed at bedtime. The staff’s interviews revealed that the residents’ personal items such as clothing does sometimes go missing, it may happen during the wash period. When the LPA asked staff (S1 and S2) about the process for the laundry, the staff stated that the clothes are collected from the residents’ rooms in bags and the bags are then taken to a room where the staff in charge of laundry collect the bags to take to the laundry room. The interview of S3 revealed that, ‘all residents clothing items are labeled with their name’. The residents’ clothes are washed mixed with other residents’ clothes. Clothes must be sorted after the wash and dry. The laundry staff return the clothes to the residents’ rooms. The RSN interview revealed that the residents’ responsible parties fill out a log with the personal belongings.’ The Administrator stated that because the residents’ room doors are kept open, sometimes other residents (with dementia) may take items. But, if an item is reported missing and cannot be located, the facility provides credit for the cost of the personal item. Based on the information obtained through interviews and record review, the personal items of R1 were not safeguarded by staff. Therefore, the allegation is deemed Substantiated at this time. Staff do not supervise resident when eating. On the allegation that staff do not supervise resident when eating, it is the concern of the RP that R1 requires supervision when R1 eats, but the RP noticed during visits that R1 is sitting there (dining room) alone with their food. To investigate the allegation LPA Urena conducted record review. Medical records obtained by the LPA indicates that on 05/24/2023, R1 had a Neurology Outpatient visit and the medical provider notes indicate that R1 was accompanied by R1’s POA, facility Administrator Terri Weitzman, and a facility caregiver. Furthermore, the case notes indicate that at the time of the visit; it was noted that R1 had developed dysphagia (difficulty swallowing) to solid foods in early 2023, and the recommendation was to provide R1 with soft moistened solids, purees, thin liquids, and with direct staff supervision. On 06/02/2023, the POA communicated via email with the DHS to inform them that during a visit with R1, the POA observed that R1 had a plate of breakfast in their room, and the POA asked that R1 eat in the dining room where R1 could be supervised during meals. Additional record review of medical records dated 07/12/2023 revealed that the facility received Diet Recommendations from the Speech Therapist at Rancho Los Amigos Rehabilitation Center on 07/12/2023. The recommendations indicate that R1 needs to receive a diet of puree foods, and nectar thick liquids. In addition to the diet recommendations, the medical document clearly states that “Close supervision to ensure patient takes 5-6 swallows per bite”. On 09/08/2023, the POA communicated via email with the DHS and two other facility staff about the concern of R1 not having breakfast and lunch meal during a recent doctor’s appointment, in which day, R1 returned late to the facility from the appointment, and the dining room was closed, consequently the R1 had to wait for dinner time. Per the POA a staff (name unknown) gave R1 chips and crackers to hold R1 over till dinner time. Based on the information obtained trough record review and interviews, the facility the facility staff did not ensure R1 was supervised during mealtime, at all times. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D). Citations were issued Exit interview was conducted. A copy of the report and the Appeal Rights were provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 29-AS-20230807152205

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Jan 10, 2025

1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff neglected to supervise R1 during meals, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Administartor will submit a plan how they will ensure appropriate care and supervision to meet the needs of residents. Submit to CCL by 1/10/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jan 10, 2025

87217 (b) Safeguards for …Personal Property, and Valuables. Every facility shall... safeguard residents'... personal property and valuables which have been entrusted...The licensee shall give the residents receipts for all... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as personal items of R1 went missing while in care, which posed a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: Administrator will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by POC date.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct an annual continuation visit, as well as a concurrent case management visit. Upon arrival, the LPA met with Interim Administrator Laken Lacy. Entrance interview conducted. This visit and related report serve as the annual continuation, legal non-compliance, and case management - incident visit. The purpose of today’s legal non-compliance visit is to ensure the facility is maintaining substantial compliance as outlined in the Stipulation and Waiver; and Order. The order is effective February 25, 2022 – February 24, 2025. The last legal non-compliance visit took place on 08/01/2023. Upon arrival, LPA met with Interim Administrator and further discussed an incident report that was sent to Community Care Licensing on 09/04/2024, although it was not received and discussed until an unrelated visit at the facility on 10/16/2024. The incident report relates to an allegation made by Resident #1 (R1)'s private companion on 09/03/2024. However, the report referred to an allegation of sexual abuse R1's private companion stated they first observed in March 2024. The facility provided LPA with additional documentation relating to R1, including but not limited to suspected abuse report and medical documentation. R1's family member, who is a medical professional, had R1 tested and no evidence of sexual abuse was found. At the time of the alleged observation/suspicion of abuse, R1 had been diagnosed with a UTI. R1 does have a diagnosis of dementia, so R1 is unable to coherently verbalize any concerns. Interim Administrator stated that following the allegation, both of R1's private companions were provided coaching on timely mandated reporting. After reviewing all information obtained, should a further visit be warranted, LPA will follow up with the facility. Report Continued on LIC 809-C PHYSICAL PLANT: Beginning at 10:51AM, the LPA and the Interim Administrator briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. During facility tour, staff were observed engaging with residents in activities. LPA spoke with various residents throughout the facility tour and no concerns were observed nor communicated. Fire extinguishers throughout the community were observed to be fully charged and last serviced 09/19/2024. FOOD SERVICE: LPA observed the facility's commercial kitchen, which was locked and inaccessible to residents in care. Kitchen appeared to be clean and appliances operable. Facility has sufficient supply of both perishable and non-perishable food, along with emergency food and water. The facility has a system for special diets, including a visual board and diet cards to ensure residents' special diets and dietary preferences are recognized. Storage for chemicals is separate from food storage, per regulation. MEDICATION REVIEW: Began at 11:20AM, LPA, Interim Administrator, along with facility nurse, reviewed medications for 3 (three) residents. All 3 (three) of 3 (three) residents' medications reviewed were stored and documented in compliance with regulation at the time of the visit. FILES: Beginning at 12:06PM, the LPA reviewed a selection of 5 (five) staff files for documents including, but not limited to: health screening, TB test results, background clearance, and training records. All staff records reviewed were observed to be complete and in compliance with regulation at this time. The LPA reviewed 5 (five) resident files for but not limited to: physician's report, needs and service appraisals, personal rights. All 5 (five) resident files reviewed contained all required documents. EMERGENCY DISASTER PLAN: LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The facility conducts emergency disaster drills on each shift quarterly, with the last disaster drill documented on 09/27/2024. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Resident was financially abused while in care.

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation regarding the above noted allegation. LPA met with Regional Director of Operations Taylor Giunto and Interim Administrator Laken Lacy and explained the reason for the visit. Entrance interview conducted. During today's visit, LPA interviewed both management staff at 10:45AM, conducted interviews with staff at 10:55AM and 11:40AM, a telephonic interview with Resident #1 (R1)'s conservator at 11:58AM, and interview with R1 at 12:12PM. LPA also reviewed and obtained copies of pertinent documents and toured the facility with Regional Director of Operations at 12:53PM. The following was then determined: The complaint alleges that there was fraudulent activity reported on R1's debit card. LPA reviewed documents for R1. R1's physician's report indicates that R1 is able to manage their own cash resources. An email dated 01/12/2023 and sent from R1's conservator to the facility's social worker authorizes facility Report Continued on LIC 9099-C Unsubstantiated staff to use R1's debit card to assist R1 in making online purchases. LPA spoke with R1's financial conservator, who confirmed that R1 does have a debit card in their room at the facility and staff are authorized to assist R1 with expenditures. Conservator indicated that each month R1's debit card is loaded with a specific amount of money that R1 is able to spent throughout the month at their own discretion. Interview with R1 revealed that R1 used their own debit card to purchase music on their phone, which accounts for the alleged "unauthorized charge" that was reported as fraudulent activity. R1 denied the allegation. Therefore, based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred; the allegation "resident was financially abused while in care" is deemed UNSUBSTANTIATED at this time. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 29-AS-20240821161633

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced required annual visit. Along with the required annual visit, the purpose of today’s visit was to address two self-reported Incident Reports. The LPA met with Administrator Kendall Mesa and explained the reason for the visit. The LPA, the Administrator and the Family Ambassador toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The dining rooms furniture appeared to be in good condition. BEDROOMS: The LPA observed a random selection of resident rooms, and rooms were furnished appropriately with clean linens, furnishings and sufficient lighting. RESTROOMS: The LPA observed a random selection of resident restrooms. Restrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms were stocked with soap and paper towels. Hand washing signs promoting good hand hygiene were observed in the common restrooms. COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. Department required postings were found lobby near the restrooms. Fire extinguishers were charged and serviced on 11/03/023. EXTERIOR: The facility has several enclosed courtyards with appropriate outdoor seating for resident use. The swimming pool on the premises was observed to be locked. Due to time constraints, the annual inspection will be completed on a follow-up visit. No deficiencies cited at this time. Exit interview conducted. Signatures obtained.the state’s words, verbatim · CDSS document, Mar 27, 2024