The Cottages of Lake Balboa 1

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 09:15am. Upon arrival LPA met with Administrator Justin Levi, and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The LPA began the inspection in the kitchen/food service area. LPA observed knives and sharp objects stored in a locked drawer to the right of the stove. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPAs inspected the common areas throughout the facility inside and out. All areas have been appropriately furnished. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Dining room and living room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced Jan, 01, 2023. At approximately 09:30am LPA inspected all six (6) resident bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Continued from 809 The laundry area and staff room were located to the right of the entry way door. LPA observed room to be inaccessible to residents in care. LPA observed a sitting area for staff in the staff room. In the laundry area LPA observed extra non-perishable foods and cleaning supplies all inaccessible to residents in care at this time. Surrounding Grounds (Outdoors): There was a shaded courtyard area with proper furniture for outdoor use to the left of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 2 and Cottages of Lake Balboa 3. Main Office is located in the rear of the facility. Records review began at 10:45 am, four (4) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. At 11am, four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Medications review began at approximately 12:00pm The medications are centrally stored in the main office located at the rear of the property, inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record. Infection Control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each resident bedroom as a single isolation rooms if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Between 10:15am - 10:45am the LPA interviewed two (2) staff members and two (2) residents. LPAs obtained the following documents - Census, Staff schedule, Emergency Disaster plan and updated Limited Liability insurance. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Sep 14, 2023

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management visit to the facility in order to continue the Annual/Required visit that was conducted on 9/1/2022. Upon arrival LPA met with Diana So and explained the reason for the visit. LPA spoke with Justin Levi who stated Diana can sign in his place. This annual had a specific emphasis on infection control practices and procedures. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): There was a shaded courtyard area with proper furniture for outdoor use to the left of the facility. There are no bodies of water on the premises. Facility shares a lot with Cottages of Lake Balboa 2 and Cottages of Lake Balboa 3. Main Office is located in the rear of the facility. The LPA spoke with Diana regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to isolate each resident in their private room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time. Exit interview conducted, report issued and sent via email.the state’s words, verbatim · CDSS document, Sep 13, 2022

Type of visit: Required - 1 Year

At 10:30 a.m., Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff Romulo Baterina Jr. LPA spoke with Administrator Justin Levi over the phone who stated that caregiver Romulo Baterina Jr. can sign for the report in his absence. This annual had a specific emphasis on infection control practices and procedures. At approximately 8:30am, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications and first aid kits were observed located in a locked kitchen cabinet. Restrooms were observed relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured at 115 degrees Fahrenheit. LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 9am, LPA observed residents resting in their bedrooms. Due to an urgent matter at the Regional office, LPA will need to return at a later date to continue the visit. Exit interview conducted. Report issued and sent to Administrator via email.the state’s words, verbatim · CDSS document, Sep 1, 2022

Allegation investigated: . Use of Improper Restraints Resulting in Injury 2. Failure to provide adequate Observation of Resident's Condition

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Justin Levi to deliver to final findings of the allegations mentioned above. This investigation was conducted by Investigator Jose Santana from Community Care Licensing Division’s (CCLD’s) Investigations Branch (IB). The following was determined: Allegation # 1: Use of Improper Restraints Resulted in injury to Resident: On January 09, 2020, the Woodland Hills Regional Office (RO) received a complaint regarding an allegation of the use of improper restraints resulted in Resident #1 (R1) sustaining multiple bruises and head injury. On January 13, 2020, former LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On February 04, 2020 and February 07, 2020 IB Investigator Santana visited the facility and obtained further documents pertaining to the complaint. Interviews were also conducted by IB Investigator Santana with the resident/victim, family Substantiated of resident, staff, other residents and Administrators on January 18, 2020; January 21, 2020; January 24, 2020; January 30, 2020; and February 04, 2020. Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed. On January 15, 2019, it was documented that R1 was agitated and attempted to get out of bed and was assisted by staff. Somehow an unwitnessed fall occurred and R1 got out of bed alone, fell backward, and hit R1’s head on the wall. R1 sustained “several bumps.” On December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported during the investigation by IB Investigator Santana that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. Further, staff left R1 unattended even though R1 was at risk of attempting to get out of bed. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. The facility accepted and retained the resident, knowing R1 was a “high fall risk.” Due to the lack of care and supervision by staff, R1 sustained multiple bruises and a head injury. Also, during the incidents of the falls, facility staff failed to seek medical attention and notify R1’s responsible party in a timely manner. This is an immediate health and safety risk to residents in care. Therefore, there is evidence to corroborate the investigation conducted by IB, and the allegation “Use of Improper Restraints Resulting in Injury to Resident”, is Substantiated. Allegation # 2: Failure to provide adequate Observation of Resident's Condition. On January 13, 2020, LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed. Based on interviews, R1 was admitted to the facility on August 08, 2018, with several physical and mental disabilities and labeled as a “high fall risk”. Based on a physician’s report dated September 10, 2019, R1 was non-ambulatory and should not ambulate, transfer, or toilet without assistance; and needed assistance with activities of daily living (ADL’s). Incident reports and facility documents revealed that R1 had prior unwitnessed falls. As a result of the falls, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). On January 15, 2019 and December 28, 2019, R1 continued to have falls, as well as behavioral issues in the night in which R1 sustained injuries and staff had difficulty keeping R1 in the bed. It was also reported that on December 28, 2019, at 4:50am, R1 attempted to get out of bed and climbed over the bed rails. It was reported, that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. The improper use of bed rails caused the impact of the fall to be more severe. R1’s history of attempting to get out of bed is evidenced by R1 being on anxiety medication to control R1’s behaviors, and staff installing a motion sensor in order to prevent resident from getting out of bed. Through all the information obtained, interviews and documentation, the facility updated R1’s needs and service/appraisal plan on February 05, 2020, a year later, to address the issues and problems the facility was experiencing with R1. And because the facility accepted and retained R1, knowing R1 was a “high fall risk” and diagnosed with a mental health condition. This is an immediate health and safety risk to resident in care. There is sufficient evidence, the facility, This is an immediate health and safety risk to resident in care. There is sufficient evidence, the facility, “Failed to provide adequate observation of resident’s condition”, therefore the allegation is deemed SUBSTANTIATED. A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. Appeal rights given. A copy of the report was issued. Based on the information obtained, LPA determined that the facility provided musical activities monthly for the residents at the facility. LPA was able to observe videos of residents singing and dancing. And interviews revealed that staff assisted resident #1 (R1) to participate in the activities, but due to R1’s physical and mental disabilities, there were times R1 was not able to participate, based on R1’s tolerance. LPA was unable to interview any residents, due to the residents no longer living at the facility, at the time R1 was admitted. There is no evidence to support the allegation the facility failed to provide sufficient activities; therefore, the finding is UNSUBSTANTIATED at this time. Allegation # 4: Failure to provide meals of adequate quality: Concerns were expressed, the facility failed to provide meals of adequate quality. On January 13, 2020, former LPA Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed. Based on the information obtained, it was revealed, resident #1 (R1)’s appetite was sporadic, and had difficulty eating, due to missing teeth. Staff was instructed to cut R1’s food into small pieces or puree. R1’s appetite fluctuated and would go days without eating and would spit out food. It was also reported that there were never any complaints or concerns expressed to the Administrator or staff in regard to the types of meals that were being provided to R1 or other residents. Based on interviews, there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation # 5: Failure to Provide Sufficient Staff: Concerns were expressed, the facility failed to provide sufficient staff. On January 13, 2020, former LPA A. Arambulo conducted the initial visit, and obtained facility and resident documents. On January 18, 2020, January 21, 2020, January 24, 2020, January 30, 2020, February 04, 2020, and February 07, 2020, from various times, interviews with resident/victim, family of resident, staff, witnesses, and Administrators were conducted, and documents pertaining to the complaint was obtained were reviewed. Information, and documentation obtained, including interviews, revealed there are (3) regular staff, including (2) Administrators that work in mornings. Administrator also reported to LPA that, they use other caregivers from other owned facilities (Cottages of Lake Balboa 2 and Cottage of Lake Balboa 3), which are adjacent to each other to cover staffing as needed. LPA observed the facility and requested the staff schedule and resident list. In the evening, there (2) PM staff, depending on the census. During the graveyard, it was reported that there could be at least (2) overnight staff that cover. Although, during the incidents with resident #1 (R1), who had (2) un-witnessed falls, it was revealed that there were (2) staff working the graveyard shift, which according to the census at the time R1 was residing, there was sufficient staff. Also, during facility visits during the investigation, LPA witnessed sufficient staff. Therefore, at this time, based on the information, observation, and interviews, the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 4, 2022 · control 31-AS-20200109083157

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608 · Plan of correction due date: Mar 4, 2022

Postural Supports: (a) Based on the individual's preadmission appraisal..for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports maybe... used to achieve proper body position and balance...but not limited to, preventing a resident from falling out of bed..This requirement was not met, evidenced by, based on incident reports, the facility installed full bed rails to secure R1 in the bed (although R1 was not on hospice). and R1 sustained serious injuries. This is a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator and LPA discussed during the visit, the plan of correction will be to continue to ensure that all residents who have bed rails, has proper documentation or a hospice care plan. Currently, there are (2) residents who are on hospice with proper documentation for bed rails. POC cleared during visit

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 4, 2022

Observation of Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...the licensee shall ensure that such changes are documented...This requirement was not met as evidenced by: during the investigation, the facility accepted and retained R1, when knowing R1 was a “high fall risk.” Because of the improper use of bed rails, the impact of the fall caused severe injuries to R1. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator and LPA discussed during the visit, the plan of correction will be to continue to ensure that all residents have current re-appraisals and needs and service plan, as well as current physician reports. Currently all residents documents are current and updated. POC cleared during visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a case management in conjunction with the complaint investigation to address issues related to the complaint (control #: 31-AS-20200109083157). During the investigation, conducted by the department’s Investigative Bureau (IB) and LPA it was reported through incident reports and facility documents, that R1 had two unwitnessed falls in which R1 sustained multiple bruises, a skin tear, and forehead contusion. From one of those falls, staff left R1 unattended on the floor for a period of time and did not seek medical attention nor notify R1’s responsible party in a timely manner. These are potential health and safety risks to residents in care. Under Title 22, Division 6, Chapter 8, following deficiencies were cited and recorded on LIC 809 D. Exit interview conducted. A copy of the report was issued. Appeal rights provided.the state’s words, verbatim · CDSS document, Mar 4, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: Mar 25, 2022

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: (8)To have their representatives regularly informed by by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met, evidenced by, based on information obtained R1 fell and staff did not notify R1's representative in timely a manner. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator and LPA discussed the plan of correction, that the facility will ensure that any incidents related to residents, all family or representatives will be notified in a timely manner, and will continue to submit SIRs to Licensing according to regulations. Training will be provided to all staff and documentation will be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(g) · Plan of correction due date: Mar 25, 2022

Incidental Medical and Dental Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis..This requirement was not met, evidenced by, based on R1 fell at the facility and staff did not provide medical attention to R1.the state’s words, verbatim · CDSS document, Mar 4, 2022

Plan of correction: Administrator will discuss with staff, the proper protocols when a resident is injured and when to contact emergency personnell, as wwhen needed. Training will be provided and documentation will be submitted to LPA by POC date.

Type of visit: Required - 1 Year

At 10:30 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff, DIANA SO. The Administrator JUSTIN LEVI arrived at the facility at 10:35 a.m. This annual had a specific emphasis on infection control practices and procedures. Between 10:50 a.m.- 11:30 a.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. OUTDOOR SPACE: At 10:55 a.m., LPA observed the back patio, which has a covered outdoor area for resident use. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction. KITCHEN: At 10:50 a.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:16 a.m., hot water measured at 113.9-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:18 a.m., hot water measured at 115.2-degree Fahrenheit. Continued on LIC 809-C. Continued from LIC 809. COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and last serviced on 12/29/2020. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate. Between 10:50 a.m. - 11:30 a.m., LPA conducted Infection Control mitigation module with Administrator. No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.the state’s words, verbatim · CDSS document, Sep 9, 2021