Silverado Senior Living-Sierra Vista

Allegation investigated: Staff are not ensuring residents are receiving their phone calls. Facility is not ensuring adequate staffing.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met Rangel-Gutierrez Selene DHS who assisted with the visit. The reason for the visit was explained. The investigation consisted of the following: LPA Margaryan toured the facility, obtained a copies of the staff roster, residents roster. LPA Margaryan also obtained copies of documents pertaining to Resident#1 (R1) including notes from staff in regards to R1's phone calls. LPA interviewed Staff#1 - Staff #5 (S #1 - S #5) and Resident #1 - Resident #6 (R #1 - R #6). Cont. 9099C Unsubstantiated Allegation: Staff are not ensuring residents are receiving their phone calls. It was alleged that unknown staff told caller that R #1 either busy, napping or only has one caregiver and is unable to go get him the phone. Staff interviews were conducted. Per staff interviews, staff are ensuring that residents are receiving phone calls. Per staff interviews, most residents residing at this facility do not use the telephone often due to their dementia and/or family involvement. Interviewed staff reported its residents personal right to use the facility phones any time, receiving or making calls. Staff stated when residents are receiving a phone calls, staff is locating the residents and they can speak on the phone to the caller. In case of residents are taking naps, resting or at the time of meals, they will ask caller, call residents back and taking massages, asking call back number. But most of the time residents are taking calls after staff transferring calls to them. Interviewed staff stated that facility has a total 13 phones available for residents to use: 7 land lines and 6 cell phones. During the facility tour LPA observed Telephones / land lines are located in Reception area, Wellness CT-CV, Wellness CT-TP, Middle Canyon View, Upstairs TP Tuscany, TP Dinning Room, Back- Social Worker Office and Cell phones in Reception area, CV Nurse office (2) , TP nurse office (2) and Unit Secretary phone. Interviewed staff stated when R1 received phone calls from the family members staff always transfer calls to R1. When R1 is napping , participating in activities or eating meals staff will ask callers call back. LPA obtained and reviewed staff notes regarding R1 calls received past few days: 10/19/23, 10/22/23, 10/23/23. Staff stated sometimes callers waiting on the line a few minutes until staff locating the residents, and they don't like it. During today’s visit, LPA interviewed R#1 - R #6. Resident interviews revealed that residents are receiving phone calls. Interviews conducted do not corroborate this allegation. Cont. 9099C Allegation: Facility is not ensuring adequate staffing. It was alleged that there is one caregiver and is unable to get Resident #1 the phone. Interviewed staff denied the allegation. They stated that Facility has enough staff. Staff stated that there is a paging system / walkie - talkie to page the staff to locate the residents. S3 or other staff never told the caller there is a only one caregiver and is unable to get R #1. When R1 or other residents are receiving calls from the family members, staff always transfer calls to R1 or other residents. Staff stated that not only caregivers are locating residents to get a calls. All staff at the facility have walkie- talkies and can hear the page. Staff who is available/has a cell phones will assist residents with the calls. Based on documents reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Rangel-Gutierrez Selene Director of Health Care Services.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 28-AS-20231019092218

Allegation investigated: Staff did not adequately supervise resident resulting in resident falling. Resident is dehydrated.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met Rangel-Gutierrez Selene DHS who assisted with the visit. Shortly after Administrator Almavida Gwinn arrived. The reason for the visit was explained. The investigation consisted of the following: LPA Margaryan toured the facility, obtained a copies of the staff roster, residents roster LPA Margaryan also obtained copies of documents pertaining to Resident#1 (R1) including: Residency Agreement, Admission Record, Identification and Emergency Information, Preplacement Appraisal Information, Resident Appraisal, Physician's Report, Physician Order Review, Neurological Observation Results, Vital Signs Trend, Unusual Incident/Injury Report (SIR) dated 10/05/23. Interviews were conducted with 5 staff (S1 - S5) , 6 residents (R1 - R6) and 1 Family member (F1) Cont. 9099C Unsubstantiated The investigation revealed the following: Allegation: Staff did not adequately supervise resident resulting in resident falling. During this investigation, LPA obtained relevant documentation and interviewed staff and residents. Interviewed staff members denied the allegation. Interviewed staff indicated , there is always enough staff at the facility and they provide supervision to all residents in care. R1 does not have a one-on-one caregiver. Based on interviews conducted the findings indicate that resident (R1) sustained a fall on October 05, 2023. The resident was noted by S5 sitting on the floor in the living room. Per S5 a few minutes prior R1 was engaging in activity. S5 immediately notified the LVN. A body check was perform and noted abrasion to the back of the R1's head. Staff help R1 to stand and sit on the coach. LVN clean the abrasion with the saline water and put antibiotic ointment. R1 didn't show any sign of discomfort or pain. R1 was able to walk and ask for the tea and Icecream. Primary doctor and responsible party were notified. Neurological checks conducted. After incident, staff closely monitor the R1 for 2 days and R1 didn't complain of any pains. Residents interviewed were unable to corroborate the allegation. Interviewed residents indicated staff conduct rounds often throughout the entire day. 5 out of 6 residents stated that staff provide adequate supervision. LPA interviewed R1 who just answer "Yes" to all questions .R1 was unable to provide details and/or dates of alleged falls. Interviewed F1 who was visiting R5's at the time of visit stated that there is always enough staff to supervise the residents. At the time of visit LPA observed sufficient staff at the facility. LPA also observed that students from the Nursing School are assisting the residents. Facility staff schedule was reviewed, and it confirm that facility has a sufficient staffing at all the time. There is insufficient evidence to prove the alleged allegation. Documentation reviewed and interviews conducted with staff and residents do not corroborate this allegation. Cont. 9099C Allegation: Resident is dehydrated. It was alleged that R1 is very dehydrated. Staff interviewed denied the allegation and stated they have not received any complaints nor concerns in regards the allegation. Staff also stated that sometimes residents refused to eat lunch or dinner, but was reminded to drink fluids. Juice and water are provided during all day. Residents often received water supplies from family as well. R1 is one of them. The facility has six (6) water stations that all residents can access throughout the day. Residents can request fluids at any time of the day, and staff take the fluids to the resident room when requested. Residents interviewed did not corroborate the allegation. Residents indicated staff ensure residents have adequate drinking water. All Interviewed residents stated the facility provided drinks/fluids. They stated never dehydrated. During the visit, LPA observed residents getting water from water stations with plenty of water. LPA observed staff encouraging residents to drink the water. Based on file reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Rangel-Gutierrez Selene Director of Health Care Services.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20231013083953

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Annual Inspection visit focused on domains within the Compliance and Regulatory Enforcement (Care) Tools. LPA met with Selene Rangel (Director Of Health Care Services) and explained the reason for the visit. The following were observed/inspected: . Physical Plant: The facility has a fire clearance approved for 87 non-ambulatory residents aged 60 and older. Hospice Waiver approved for 12 residents. Approved for delayed egress, secured perimeter, and secured locked perimeter. This is a 2 story building. Outdoor and indoor passageways are free of obstruction. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Rooms observed all furnished as required by title 22 regulations. Bathrooms were clean and operational, water temperature in compliance. Smoke/carbon monoxide detectors were tested and operational. Fire extinguishers observed. Required postings observed. Central Air and Heating with temperature comfortable. Emergency supplies observed. Toxins and sharps locked and inaccessible to residents. Appliances such as a microwaves, refrigerators, and stoves were observed to be clean and operating properly. Food utensils were clean and sufficient for the number of residents to be served. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. MEDICATION: Medications are stored, locked and inaccessible to residents. First Aid Kit Observed RECORD REVIEW: Eight (8) Staff Files reviewed. Eight (8) Resident files reviewed. ACTIVITIES: LPA observed activities for resident use as well as sufficient space and accommodations for residents to do activities. POSTINGS: All necessary postings were observed to be posted in appropriate places. A current Plan of Operations and Disaster plan is maintained at the facility. Operating telephone was observed and available for resident use. Care Tool was completed and based on Title 22 Regulations, no Deficiencies will be documented. An exit interview was conducted and a copy of today's report was provided and discussed.the state’s words, verbatim · CDSS document, May 22, 2023

Allegation investigated: Resident not accorded reasonable access to telephones, to both make and receive confidential calls. Resident not accorded dignity in relationships with staff. Staff are locking the resident on facility premises.

Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with Administrative Assistant Maria Torres and explained the reason of the visit. The investigation consisted of the following: On 6/29/21, LPA David Sicairos interviewed Administrator, Director of Health Care Services, Staff #1 (S1) and Resident #1 (R1). LPA obtained copies of R1's file. LPA also toured the facility which included the common areas. On today's visit, LPA Wong interviewed Administrator, Director of Health Care Services via telephone and Staff#1-#2 (S1-2) and Resident#2-#6 in the facility and obtained the documents included resident sign-out log from June 10th to 24th, 2021 and visitors sign in sheet from May 28th to June 26th, 2021. (Please See LIC 9099C for continuation) Unsubstantiated The investigation revealed of the following: In regard to the allegation of " Resident not accorded reasonable access to telephones, to both make and receive confidential calls." LPA interviewed residents and they all denied the allegation and stated that they were able to make phone calls any time they want. There's no restriction for them. LPA also interviewed staff and reported its residents personal right to use the facility phone any time they wanted. Staff also stated that the facility has a wireless phone for residents to use. There's also common phone in the middle of the area for residents to access. The staff reported that R1 also had her own cell phone at that time. R1 can make any phone calls or receive any phone calls that R1 wanted. In regard to the allegation of " Resident not accorded dignity in relationships with staff." LPA interviewed residents and they all denied the allegation. They all stated that all the staff in the facility are nice and respectful. They treat them very well. LPA interviewed staff and also denied the allegation and reported they never witnessed any staff was disrespectful to the residents in the facility. And all the staff have been trained to be respectful and kind to all residents and guests, basically everyone in the facility. In regard to the allegation of "Staff are locking the resident on facility premises." The administrator and staff stated that the facility is a secured community/facility for residents safety but the residents are not in person or locked in the facility or something. The administrator stated that as long as someone is able to sign the resident out, the resident is able to go out with their family, friends or whoever signed them out. Based on statements and interviews conducted with staff, residents and recorded review, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of the report and appeal right was provided to the Administrative Assistant Maria Torres. The investigation revealed of the following: In regard to the allegation of "Staff are not allowing resident to leave or depart the facility at any time." LPA reviewed the resident sign out log and LPA did not see any visitors sign R1 out from June 10th to July 11th, 2021 when R1 reported friends wanted to take R1 out to lunch before June 24, 2021 but got rejected from the facility to leave the building. In regard the allegation of "Staff are not allowing resident to have visitors during reasonable hours and without prior notice." LPA also reviewed the visitor sign in sheet. On June 18, 2021, R1's friend name was not on the visitor sign in log. R1's friend was unable to visit R1 on June 18, 2021. LPA reviewed R1's friend name but was able to visit R1 on either June 19th or June 20th, 2021. Therefore, it shown proof that R1 was not allowed visitor at one point. Administrator also mentioned that R1's son did not want one of R1's friend to come and visit R1 at one point. Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC9099D. An exit interview is being conducted with Administrative Assistant Maria Torres and a copy of this report is being provided and Appeal Rights were given.the state’s words, verbatim · CDSS document, Nov 10, 2022 · control 28-AS-20210624125839

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Nov 24, 2022

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on documents reviewed, R1 was not able to leave or depart from the facility while R1's friend wanted to go out with R1 which posed a potential risk to residents in carethe state’s words, verbatim · CDSS document, Nov 10, 2022

Plan of correction: The administrator will ensure the personal right of residents in all facilities The administrator will retrain staff regarding the personal right and send the staff training log to LPA by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Nov 24, 2022

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. The requirement is not met as evidenced by: Based on the documents reviewed, R1's friend was not able to visit on June 18, 21 which posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, Nov 10, 2022

Plan of correction: The administrator will ensure the personal right of residents in all facilities The administrator will retrain staff regarding the personal right and send the staff training log to LPA by POC due date

Allegation investigated: Facility was odoriferous. Facility staff are not meeting resident's hygiene needs. Facility staff did not ensure that resident was wearing clothing free of rips.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Vida Gwinn (Administrator) and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 4 (S1 - S4), Resident 1 - Resident 7 (R1 - R7), and conducted a facility tour. The investigation revealed the following: regarding the allegation "facility was odoriferous", it is alleged that in the main living area where all residents stay, there was a smell of poop in the air and a caregiver was seen just sitting in one of the chairs. Administrator and staff interviewed denied the allegation and stated that any odor identified is immediately addressed by the staff. Residents interviewed could not corroborate the allegation. During the tour of the facility, the LPA did not smell any odors and observed staff interacting with the residents in the main living area. (CONTINUED TO LIC 9099C) Unsubstantiated Regarding the allegation "facility staff are not meeting resident's hygiene needs.", it is alleged that residents are left sitting on their poop. Administrator and staff interviewed denied the allegation and stated that staff check and change diapers every 2 hours or as needed. Residents interviewed could not corroborate the allegation. Regarding the allegation "facility staff did not ensure that resident was wearing clothing free of rips", it is alleged that a resident was walking around with a ripped shirt. Administrator and staff interviewed denied the allegation and stated that if a resident is seen with ripped clothes they are taken back to their rooms and have them change into other clothes are not ripped. Residents interviewed could not corroborate the allegation. During the tour of the facility, the LPA did not observe any residents with ripped clothes. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 27, 2022 · control 28-AS-20221019142854

Allegation investigated: Staff have stolen resident's personal belongings. Staff stole the resident's dog. Staff do not treat the resident with dignity. Staff have hit the resident.

Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the findings. LPA met with RN Selene Rangel and explained the reason of the visit and also assisted LPA with the visit. The investigation consisted of the following: On 2/2/2022, LPA Sicairos conducted the initial 10 days complaint visit and obtained copies of Staff and Resident Rosters. LPA requested copies from Resident #1 (R1's) file. On today's date, LPA also interviewed the administrator, four staff (S1-S4) and five residents (R2-R6). (See LIC 9099C for continuation) Unsubstantiated The investigation revealed of the following: In regards to the allegation "Staff have stolen resident's personal belongings" LPA interviewed residents and all denied the allegation and reported no staff ever stole their personal belongings and they never missed or lost anything in the facility. LPA interviewed staff and reported when R1 first moved into the facility. R1 only came in with few clothes and a fanny pack. The facility and conservator had to buy her extra items that R1 needed. R1 also has a court appointed conservator for her finances and medical decision. In regards to the allegation "Staff stole the resident's dog." LPA interviewed administrator and staff and all reported R1 did not have a dog when R1 moved into the facility. The dog chewy is the facility dog and he's a therapy dog for the residents in the facility. All residents can play with the facility dog. Staff also stated that R1 would even claim chewy as her own dog. In regards to the allegation "Staff do not treat the resident with dignity." LPA interviewed residents and all denied the allegation and reported all staff are nice to them and respect them and they are happy living in the facility. LPA interviewed staff and all denied the allegation and reported no staff ever witness any staff being disrespectful to residents in the facility. Staff also reported only R1 was being disrespectful to the staff. R1 would yell and scream and curse at staff and other residents in the facility. In regards to the allegation "Staff have hit the resident." LPA interviewed residents and all denied the allegation and reported they never witnessed any staff hit residents and reported all staff are nice and its never happened in the facility. LPA interviewed staff and all denied the allegation. It had never happened in the facility. The facility would not allow staff doing it and they are all mandated reporter. Staff also stated that no staff even want to get near to R1 due to her behaviors. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of the report and appeal right was provided to the RN Selene Rangelthe state’s words, verbatim · CDSS document, Oct 27, 2022 · control 28-AS-20220201132645

Allegation investigated: Resident sustained unexplained bruising while in care.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Selene Gutierrez (Director Of Health Care Services) and explained the reason for the visit. The investigation consisted of the following: during the initial visit conducted on 09/30/21, LPA obtained copies of Resident & Staff Rosters. LPA also reviewed Resident #1 (R1) file and obtained copies of: Identification and Emergency Information Sheet, Physician's Report, Preplacement Appraisal Information, and Progress Notes. During today's visit, LPA interviewed R1, and Staff #1 - Staff #3. The investigation revealed the following: in regards to the allegation "resident sustained unexplained bruising while in care", it is alleged that R1 was admitted to the emergency room on 09/23/21 due to a possible clavicle fracture. R1 was examined at the hospital and no fracture was identified, however bruising was observed. Interviews conducted with staff members denied the allegation. Review of R1's Progress Notes dated 09/16/22 indicate R1 began complaining of right shoulder pain. (CONTINUED ON 9099C) Unsubstantiated R1's Primary Physician and Responsible Party were notified. R1 continued to be monitored for right shoulder pain for the next few days. On 09/22/21, facility ordered x-ray of right shoulder area which results indicated "mildly displaced medial right clavicle fracture". On 09/23/21, R1's Responsible Party took R1 to Urgent Care for follow up were more x-rays were completed and x-rays came back negative for clavicle fracture. Staff indicated R1 disclosed that she had suffered the right shoulder bruising as a result of swimming exercises. Interview with R1 indicated that she is happy at the facility and has no issues or concerns with staff. R1 indicated she could not recall how she suffered the bruising to her right shoulder area. Staff members interviewed denied causing the bruising. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Aug 26, 2022 · control 28-AS-20210924131831

Allegation investigated: Resident sustained an unexplained fracture while in care. Staff did not seek medical attention for resident while in care. Resident inappropriately touched another resident in care.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Selene Gutierrez (Director Of Health Care Services) and explained the reason for the visit. The investigation consisted of the following: during initial visit conducted on 12/29/21 by LPA Tao, LPA toured the facility with the Administrator and obtained copies from Resident #1 (R1) file. During today's visit LPA obtained copies of Staff & Resident Rosters. LPA also obtained copies from Resident #1 (R1) such as Identification & Emergency Info Sheet, Physician's Report, Resident Appraisal, Progress Notes for December 2021, X-Ray Results, and Incident Reports. LPA also interviewed R1, R1's Family Member (FM), and Staff #1 - Staff #3. The investigation consisted of the following: in regards to the allegation "resident sustained an unexplained fracture while in care", it is alleged that R1 suffered an unexplained fracture to her arm. Interviews with staff and family member confirmed that R1 did suffer a fracture to her right wrist. (CONTINUED ON 9099C) Unsubstantiated Radiology Report dated 12/29/21 indicates "fracture involving the distal metaphysis of the radius with slight impaction and minimal displacement." There is no evidence however, indicating that this fracture happened while at the facility. R1 moved into the facility on 12/23/21 and Progress Notes on that day indicate that "swelling to the wrist" was observed on R1's wrist upon move in. Resident was admitted to Hospice on the same day of move-in, and both hospice and facility were aware of the bruising and continued to monitor the area. Family member interviewed also indicated R1 suffered a couple of falls a few days prior to moving into the facility. R1 also has a history of carpal tunnel syndrome. Therefore there was insufficient evidence to corroborate with the allegation. In regards to the allegation "staff did not seek medical attention for resident while in care", it is alleged that facility failed to seek timely medical attention for R1 in regards to the wrist fracture. Staff members interviewed denied the allegation. Staff members interviewed indicated wrist bruising was observed and documented upon resident moving in. Staff members interviewed indicated wrist area was monitored daily, and R1 was receiving treatment from hospice agency. This is confirmed via Progress Notes. X-Ray was also requested and completed when bruising did not improve. Family member interviewed also indicated facility staff kept him informed of R1's condition. Therefore there was insufficient evidence to corroborate with the allegation. In regards to the allegation "resident inappropriately touched another resident in care", it is alleged that another facility resident entered R1's room and tried to touch R1 "inappropriately". Interviews conducted with staff members denied the allegation. Facility staff indicated that on 12/28/21, Azusa Police arrived at the facility to interview R1 as they had received a call that R1 had been touched inappropriately. After interviewing R1, Police left without filing any charges. During today's visit, R1 denied being touched inappropriately by anyone at the facility. Interviews with staff revealed they will redirect residents if they attempt to go into other resident rooms. Additionally, Reporting Party indicated they were not sure if the other resident actually touched R1 inappropriately. Therefore there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2022 · control 28-AS-20211228122731

Allegation investigated: Resident sustained unexplained injury while in care Facility has insufficient staffing to meet the residents’ needs Due to lack of supervision, the residents sustained falls while in care Facility overcharged resident Staff failed to provide a comfortable environment for residents in care Facility staff failed to assist residents in a timely manner Facility is not allowing visitors inside the facility

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced subsequent complaint visit regarding the above stated allegations. LPA met with Selene Rangel and explained the reason for the visit. The investigation consisted the following: During the initial visit conducted on 04/22/22 LPA Margaryan inspected the facility including residents’ rooms, tested the signal system, obtained a copies of the staff roster, residents roster, other relevant documents and interviewed Administrator, Staff ( S1) to Staff 6 (S6) and Resident 2 (R2) to Resident 6 (R6). LPA was not able to interview Resident 1 (R1) because R1 moved from the facility on 03/25/22. Continue 9099C Unsubstantiated The investigation revealed the following: Regarding the allegation that “ Resident sustained unexplained injury while in care” and “ Due to lack of supervision, the residents sustained falls while in care” It was alleged that Resident 1 (R1) sustained an unexplained injury on her left breast and several times some of the residents sustained falls. To investigate allegations LPA interviewed administrator, staff, residents. Administrator and staff denied the allegations. They stated that staff noticed that R1 had a bruise on their left breast, but not due to lack of supervision. Interviewed staff indicated that R1 was very active and always move, push items everywhere: furniture, flower’s pots, clothing from other residents room. R1 often move / push residents on wheelchair, thinking helping them. It possible that moving / pushing items around cause bruises on R1 breast. Administrator stated that staff have reported observing bruising on R1’s breast and this incident is properly documented and reported to CCL (SIR dated on 10/28/2021). On 10/27/2021 R1 was visiting with daughter and complained of discomfort to left breast. Upon further assessment noted discoloration purple and pink in color to R1’s breast. No swelling noted at that time and R1 had no pain. Per DHS Rangel Selene (S1) R1 didn’t know how it happened. Caregiver (S2) stated R1 noted to be touching and pulling on breast over last day but no discoloration noted when S2 assisted R1 to dress for bed. Upon noticing the bruise/discoloration on R1’s left breast S1 contacted to Dr. Bahsoura after assessment and doctor ordered bilateral breast ultrasound and lab work for further assessment for unusual discolored area to left breast. Doctors visit was scheduled on 10/28/21 at 3:30 pm. Resident’s daughter was present at the time of visit. Facility staff follow to doctors order and the next few days staff observed that discoloration of the R1’s left breast was resolved. Lab and ultrasound results came back within normal range. There were “no focal lesions or other abnormalities”. Staff also indicated that when they notice anything out of the ordinary such as bruising it is immediately documented and reported to Administrator. Administrator and all interviewed staff and residents denied that some of the residents sustained falls several times at the facility. DHS stated that residents have a full body check 2 - 3 times a week during shower. Also, caregivers will address if any injuries observed during their shift providing care to residents. Staff will be noticed if any bruises or injuries of the residents sustained falls. Continue 9099C Regarding the allegations that “Facility has insufficient staffing to meet the residents’ needs” and “Facility staff failed to assist residents in a timely manner” It was alleged that anyone tries to contact the facility after hours no one answers the phone, residents with dementia walk outside the facility and go back and forth from one building to another building and none of the staff members are present to supervise them and whenever the residents call the staff for assistance it takes them 20 minutes to get back to the residents. Administrator and staff denied the allegations. Administrator and staff stated that there is always sufficient staff at the facility to assist residents and always someone at the front to answer the phone. Administrator also indicated that family members have her phone number and in case of emergency they can contact her. LPA observed that facility is consist of 3 buildings: Terrace Park – Early stage of dementia, Canyon View – Middle, late stage of dementia and Office building. Administrator stated that usually residents stayed in their neighborhood but because some of them are friends, sometimes they are visiting to each other. Interviewed staff denied that residents are going back and forth without supervision. There is always enough staff at the facility to supervise the residents. At the time of visit LPA observed sufficient staff at the facility. LPA also observed that students from the Nursing School are assisting the residents. Facility staff schedule was reviewed, and it confirm that facility has a sufficient staffing at all the time. At the time of visit LPA randomly choose the residents room and check on the call / signal system. It took 3 to 5 min that staff respond the calls. Interviewed residents denied the allegation. They stated that staff assisting them on timely manner, and they don’t have any complains about this matter. Regarding the allegation that “Facility overcharged resident” it was alleged that on an unknown date the facility overcharged R1 in the amount of $600 and told the RP that they charged the resident for incontinence needs. Administrator stated that R1 was charged for incontinence care for the month of February 2022 by Corporate office while facility does bowel and bladder monitoring to see if R1 is really is incontinent. She also indicated that amount was $565.00 not $600.00. Administrator provide the copies of emails that was sent to the Senior accountant at the Corporate Office on 02/07/22 requesting to not charge the resident before administrator will let them know the end of the month if R1 is incontinent and would need to pay the incontinence fees. Statements of February 2022 and March 2022 for R1 was provided. LPA reviewed the statements and observed that $565.00 was removed from the February statement and refunded to R1 account. LPA spoke with R1's doughier on 4/22/2022, who confirm that facility refund the incontinence fees. Continue 9099C In regards the allegation that "Staff failed to provide a comfortable environment for residents in care" it was alleged that there are 5-8 dogs at the facility that belong to the residents, and they wander everywhere at the facility. The RP stated that on an unknown date she found a dog sitting under her mother’s bed. The RP stated that the facility’s dining room is extremely crowded. At the time of visit LPA observed 3 dogs at the facility, in the office building. Interviewed staff and residents denied the allegation. They stated that there are 3 dogs and dogs not wandering everywhere at the facility. Interviewed staff indicated that dogs are friendly, and all staff and residents like them and most of the time dogs are in the Administrator’s office. LPA didn’t observe any dogs in other buildings or in residents room. Interviewed staff and residents stated that 3 dogs not belong to residents. LPA reviewed the facility's “Resident and Family Handbook” which indicated that pets are welcome at the facility and administrator approves all pets for the community and may revoke approval at any time. Facility “Resident and Family Handbook” was provided to all residents and family members with Residency Agreement. LPA reviewed the facility's philosophy on pets and policies and procedures. A review of the facility's pet records documented that the animals are current with their license, immunization record, animal identification. Interviewed staff indicated that the dining room not extremely crowed. There is not only one dining room at the facility. LPA observed that facility has 2 main dining rooms, 2 private and 2 bistro areas that can be used as a dining area when needed. Interviewed residents indicated that dining rooms were not crowded. Staff and residents stated no one complains that dining rooms are crowded. Staff and residents interviews do not corroborate this allegation. Continue 9099C In regards the allegation that "Facility is not allowing visitors inside the facility" It was alleged that facility is still not allowing visitors inside the facility, and they tell everyone it’s because of the pandemic. The facility only allows visitors outside the facility for 2 hours in morning and 2 hours in the afternoon. LPA observed the facility visitation documents and observed that visitation hours could be changed, if facility has a Covid cases at the facility. Visitation hours can be limited to 2 hours at AM and 2 hours at PM. Facility provided the documentarians to LPA which include the dates, hours of visitations and the reason why the changes were made. Administrator stated that residents and family members / responsible parties were informed about changes. At the time of visit LPA observed at the front desk sign that shows visitation hours 9am - 5pm Monday - Sunday. Based on file reviews, observation and interviews, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED An exit interview was conducted, and a copy of this report was provided to Rangel-Gutierrez Selene Director of Health Care Servicesthe state’s words, verbatim · CDSS document, Jun 3, 2022 · control 28-AS-20220412094959

Allegation investigated: Resident is denied visitations. Resident is not allowed to receive confidential calls.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Selene Rangel and explained the reason for the visit. The investigaton consisted the following: during the initial visit conducted on 12/29/21, LPA Tao interviewed the Administrator and obtained copies of Resident & Staff Rosters. LPA Tao also obtained copies from Resident #1 (R1's) file such as Physician's Report, Progress Notes, Appraisal, and Visitor Policy. During today's visit, LPA interviewed Resident #1 (R1) - Resident #5 (R5) and Staff #1 (S1) - Staff #4 (S4). The investigation revealed the following: in regards to the allegation "resident is denied visitations", it is alleged that on 12/26/21 facility staff denied visitation for R1. Interviews conducted with staff members denied the allegation. Staff members interviewed indicated that they are aware of resident rights regarding visitation and residents have the right to have visits from whomever they chose. Interview with R1 revealed that she doesn't recall the alleged incident that occurred on 12/26/21. R1 indicated it is possible that she wasn't feeling well and did not want to see any visitors on that day. (CONTINUED ON 9099C) Unsubstantiated R1 indicated that she does want this individual to visit her and call her at the facility. LPA was provided a document signed by R1 indicating that she would like advanced notice prior to being visited by this certain individual. R1 confirmed that she is aware of this document and that she signed this document. LPA did not observe any documents or evidence in R1's file indicating that facility is restricting visitation from certain individuals. All residents interviewed indicated that they are allowed to have visitors of their choice during visiting hours and facility does not restrict their visitation rights. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation "resident is not allowed to receive confidential calls", it is alleged that facility staff deny phone calls from certain individuals for R1 unless a staff member is present to monitor the call. Interviews conducted with staff members denied this allegation. Staff members interviewed indicated that they do not monitor any resident calls. Staff members interviewed indicated that residents have the right to confidential calls and there are multiple phones available throughout the facility to make and/or receive confidential calls. LPA torued the facility and observed multiple working phones. All residents interviewed indicated that they are able to make and/or receive calls in private and without staff monitoring the calls. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or arevalid, 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.the state’s words, verbatim · CDSS document, May 11, 2022 · control 28-AS-20211227115456

Allegation investigated: Facility is unkempt Facility is malodorous Facility has infestation of bugs Facility failed to provide residents with clean linens

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. Upon arriving at the facility, LPA met with Administrator Almavida Gwinn and Rangel-Gutierrez Selene DHS who assisted with the visit. The reason for the visit was explained. The investigation consisted of the following: LPA Margaryan inspected the facility including residents’ rooms, tested the signal system, obtained a copies of the staff roster, residents roster, other relevant documents and interviewed Administrator, Staff ( S1) to Staff 6 (S6) and Resident 2 (R2) to Resident 6 (R6). LPA was not able to interview Resident 1 (R1) because R1 moved from the facility on 03/25/22. Continue 9099C Unsubstantiated Regarding the allegations that the "Facility is unkempt" and "Facility is malodorous". It was alleged that the facility is extremely filthy and has a strong odor. To investigate those allegations facility was toured including but not limited residents rooms, bathrooms, dining rooms and common areas, Interviewed Administrator, S1 - S6 and R2- R6. Staff interviewed denied the allegations. Staff stated that the facility is cleaned daily, and more frequently as needed. Administrator stated staff continuously clean the facility throughout the day. Housekeepers clean during their assigned shift and their duties include cleaning client rooms, emptying thrash from client rooms and bathrooms, cleaning and sanitizing restrooms and hallways. Residents interviewed were unable to corroborate the allegation. They stated that facility is clean. During the tour LPA observed the facility was well maintained (inside and outside) and there was no odor or malodorous smell coming from inside or outside of the facility. Based on LPA observations and interviews conducted with clients and staff there was not enough supportive evidence to concur with the reported allegations. Regarding the allegation that "Facility has infestation of bugs". It was alleged that the facility has an infestation of bugs, and it gets worse during the summertime. To investigate those allegations facility was toured including but not limited residents rooms, bathrooms, dining rooms and common areas, Interviewed Administrator, staff and residents. Administrator And staff denied the allegation. They stated that the facility is not infested with bugs. They stated that the facility is frequently serviced by a pest control company. Review of pest control invoices did not indicate that the facility has a bug infestation. Residents interviewed were unable to corroborate the allegation. Continue 9099C Regarding the allegation that "Facility failed to provide residents with clean linens" It was alleged that the staff don’t provide the residents with clean linens. To investigate this allegation LPA interviewed administrator, staff, residents. Administrator and staff denied the allegation. They stated that residents are provided with clean linens frequently, 3 times per week, sometimes daily if needed. Staff checks on residents every 2 hours. When the incontinent residents are checked and staff observes the bed linens are soiled, staff will change bed linens within 10 -15 minutes. LPA observed the facility linen storage, had a sufficient amount of clean linens. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the Director Health Services .the state’s words, verbatim · CDSS document, Apr 22, 2022 · control 28-AS-20220412094959

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: Required - 1 Year

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Director of Health Care Services Selene Rangel-Gutierrez and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected. The following was observed/inspected: LPA and Ms. Rangel toured the facility which included the following: common areas, kitchen, dining room, activity room, living room, and laundry room. A random sample of resident rooms where toured in each wing/floor. There are multiple shaded areas available for resident use. There is a pool on the premises that is surrounded by fencing and in compliance with state and local building codes. Passageways and exits are free of obstruction. The water temperature was tested in a random selection of resident bathrooms in each floor and measured between 113F - 117.2F which is within the required 105F - 120F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Emergency call buttons were observed in every resident room. A random sample were tested and operable. Showers were free of mold/ mildew and non-skid mats or strips were properly in place. Smoke detectors and carbon monoxide detectors were observed throughout the facility and in each resident room which were tested and operable during the visit. LPA observed multiple fire extinguishers throughout the facility which were fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked and are inaccessible to residents. Multiple First Aid kits were inspected and were fully stocked with current manuals. Staff were observed wearing masks and screening visitors at the time of entry. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. 7 resident medications were randomly selected for review. Medications are centrally stored in the medication rooms. Medications are documented properly and given as prescribed. Staff and Resident files were not reviewed during today's visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 15, 2022

Allegation investigated: Resident illegally evicted.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial 10-day complaint visit to investigate the above allegation. LPA met with S-1 and discussed the purpose of today's visit. S-2/Director of Health Services arrived at approximately 11AM. During this investigation, LPA obtained a copy of the Resident Roster, a copy of the Staff Roster, interviewed S-1, S-2/Director of Health Services, S-3 and R-1's Conservator and reviewed R-1's file and obtained relevant documentation. Refer to LIC 9099C for the contination of this report. Unsubstantiated Allegations: Resident illegally evicted. During this investigation, LPA interviewed S-1 through S-3 and R-1's Conservator. Interviews revealed that R-1 was hospitalized on 01/24/22 (initiated by R-1). Once R-1 was ready to be discharged, S-2 initially informed the hospital that R-1 was unable to return due to R-1's behavior and risk for hurting others at this facility. S-2 then reconsidered R-1's re-admission to this facility (upon consultation with other facility personnel and R-1's Conservator) for R-1 to return to this facility with one-to-one support in place. Interviews revealed that the need for one-to-one support for R-1 was reasonable due to on-going behaviors. R-1 remained at the hospital and did not return to this facility. Per R-1's Conservator, this facility did not evict R-1 and R-1 was voluntarily moved out due to the monthly costs of this facility and the cost of one-to-one support if put in place (as agreed upon). Interviews revealed that R-1's Conservator came to this facility on 01/30/22 and sent movers on 01/31/22 to remove R-1's belongings. Interviews also revealed that the 30 day move-out notice was waived. Interviews do not corroborate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted, a copy of this report and Appeal Rights were provided to S-2the state’s words, verbatim · CDSS document, Feb 2, 2022 · control 28-AS-20220124104257

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) David Sicairos and Luis Mora conducted an unannounced case management visit in regards to a Special Incident Report that was submitted to Licensing on 06/21/21. LPAs met with Selene Rangel and explained the reason for the visit. Per Incident Report on 06/17/21, Staff #1 (S1) - Staff #2 (S2) noted that the medication in the medication card did not match the stated medication on the label. Upon further assessment it was noted that various medication cards had been tampered with. Cards appeared to have been cut and taped, visible only when held against the light. Azusa Police Department was called and an investigation was opened. On 06/30/21, Detective informed Administrator and Director of Care Health Services that there are two persons of interest (Staff #3 - Staff #4). Both employees have been suspended from facility pending investigation. Door codes and locks on medication carts have been changed and police investigation is still ongoing. LPA advised Administrator and Director of Health Care Services to keep Licensing informed of the police investigation findings. LPA also requested copy of the Police Report when it becomes available. No deficiencies were cited during today's visit. Exit interview held and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 8, 2021