The Cottages of Lake Balboa 3

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced at 11:33 a.m. to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. The staff contacted the Administrator Justin Levi, and they arrived shortly thereafter. The LPA and the 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. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility’s temperature was maintained at 77 degrees. The smoke detector and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 01/09/2025. The LPA observed required postings throughout the common space. KITCHEN: Knives are locked in a kitchen drawer stored inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured 118.0 degrees Fahrenheit. BEDROOMS: There are (6) resident bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There was a linen closet in the hallway with extra towels and linens. Continues on LIC 809C ... BATHROOMS: The facility has three bathrooms. Two bathrooms are hallway shared bathrooms and one bathroom is a private bathroom located inside bedroom #1. All bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 115.0 degrees Fahrenheit. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. The washer and dryer are outside the facility. Detergent supplies are kept and locked in the laundry room. RECORDS: Records review began at 12: 36 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. One staff(S1) present at the facility did not have a file on site. Per the Administrator the staff was from an outside agency, and as a last-minute emergency/resort, due to a daily staff out for the day. MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area. Medications were audited and counted for accuracy of dispensing the medications. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate of Liability of Insurance The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Citations were issued. Exit interview conducted. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Sep 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Sandra Urena and Erica Mosley arrived at the facility unannounced at 11:53 a.m. to conduct a required annual inspection. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator arrived about 30 minutes later. The LPAs and the staff 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. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 71 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 01/09/2024. The LPAs observed required postings throughout the common space. The LPAs noticed that the Emergency Disaster Plan LIC 610E(Assignments) staff’s names need to be updated as some staff are no longer employed at the facility. KITCHEN: Knives are locked in a kitchen drawer stored inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 113.0 degrees Fahrenheit. During the inspection at 12:41 p.m., the LPAs observed the bottom sink cabinet which contained the chemicals to be unlocked and chemicals accessible to residents in care. The cabinet was secured during the visit. BEDROOMS: There are (6) resident bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At the time of the visit two bedrooms’ (Bedroom #2 and #3) exit door were obstructed by furniture. The furniture was removed during the visit. The LPAs observed and detected the smell of urine in bedroom #5, staff were instructed to change the bed linens. There was a linen closet in the hallway with extra towels and linens. Continues on LIC 809C ... BATHROOMS: The facility has three bathrooms. Two bathrooms (one shared and one private) were clean and sanitary and in operating condition with grab bars and non-skid surfaces. One shared bathroom’s toilet -between rooms #4 and #5 was observed to have dried feces- and a razor accessible to residents in care. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 113.0 degrees Fahrenheit. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. The washer and dryer are outside the facility. Detergent supplies are kept and locked in the laundry room. RECORDS: Records review began at 1: 36 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. Four out of four staff files are missing a current CPR/First Aid Certificate, and the annual 20-hour training. MEDICATIONS: Medications review began at 3:45 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area. Medications were audited and counted for accuracy of dispensing the medications. Two out of three medications audited were not properly documented on the centrally stored medications and destruction record. During the physical plant inspection, the LPAs observed that the staff had pill boxes for each of the six residents. The pill boxes had medications sorted out for each day of the week. INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. .Citations were issued. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 29, 2024

Allegation investigated: Staff mishandled a resident's medication while in care Staff did not address a resident's change in condition while in care

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit. On 01/28/2022, from 9:37 a.m. - 2 p.m., LPA initiated an unannounced complaint investigation for the allegations listed above. During the visit, LPA toured the physical plant, conducted Medication Audit, interviewed staff, residents and obtained pertinent documentation relevant to the investigation. On 06/09/2023, LPA interviewed residents and staff while on site for a separate investigation. On 10/27/2023 LPA interviewed Kaiser Home Health Nurse. Today LPA interviewed staff, residents and conducted a medication audit for residents in care. It was reported that staff mishandled a resident’s medication while in care, as it was alleged that R1 did not receive their medication Metorolol as it was not observed in R1's 7 day pill case. Interviews conducted and records reviewed revealed that facility was using a 7 day pill case for R1's medication. Unsubstantiated Continued from 9099 LPA's medication audits revealed R1 did have a 7 day pill case stored with their medication , but it was observed to be empty at that time. The Medication Administration Records (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Interviews revealed that staff did not recall specific occurrences where medication errors occurred. LPA's Interview with (4) four residents in care revealed they did not express any concerns as it related to receiving their medications. LPA's interview with seven (7) staff revealed they could not recall a time when a resident did not receive a medication due to error. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff mishandled a resident’s medication while in care has been deemed Unsubstantiated at this time. It was reported that Staff did not address a resident’s change in condition while in care, as it was alleged that facility staff did not report to R1’s home health nurse that R1 has not had a bowel movement for several days. Interviews conducted and records review revealed that R1’s home health nurse would visit R1 approximately twice a week and each time the home health nurse visited they were regularly notified about changes of condition in R1 by Staff #1 (S1) and Staff #2 (S2). Updates were also provided to the home health nurse via phone calls, emails and resident records kept at the facility. LPA records review of resident records from September 2021 to January 2022 revealed bowel movements were recorded and updated regularly during that time. Interviews conducted with seven (7) staff further revealed that if they observed a change of condition in any resident, they would notify the Administrator and notate their observations in the resident’s file. All (7) staff also indicated that when any home health nurse conducted visits, they would always update the nurse about their patient. Based on the information gathered during the investigation, the department does not have sufficient evidence to confirm this allegation occurred. Therefore, the allegation that Staff did not address a resident’s change in condition while in case has been deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 29-AS-20220121164812

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220121164812). LPA met with Justin Levi and explained the reason for the visit. The purpose of this visit is to issue a citation for deficiencies observed during the complaint investigation which were not related to the complaint. During today's visit, LPA conducted physical plant at approx 11:25am and observed medications for six (6) residents in care were pre-pored and out of their original containers for more than 24 hours. LPA observed the rest of resident medications to be securely stored in the Assistant Administrators office. LPA conducted medication audit. The Medication Administration Record (MAR) indicated that medications for the residents were administered as prescribed at this time. LPA also checked resident medications for expiration dates and instructions and the LPA uncovered minimal discrepancies. The LPA reviewed facility incident reports, and the LPA was unable to uncover incident reports as it related to known medication errors. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 30, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Nov 3, 2023

87465(h)(5) Incidental Medical and Dental Care - Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on observations and interview, LPA the licensee did not comply with the section cited above as (6) residents had medications pre-poured and out of their original containers for more than 24 hours which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2023

Plan of correction: Licensee agreed to review section cited and provide a statement of understanding to CCL via email by EOD 11/03/2023.

Allegation investigated: Staff is not assisting the resident with managed incontinence.

**This report supersedes report issued on 06/19/2023** Licensing Program Analyst (LPA) Brian Balisi, conducted an unannounced subsequent complaint visit to issue amended findings for the above listed complaint allegation. Upon arrival LPA met with Administrator Justin Levi and explained the reason for the visit. On 11/02/2021 between 9:52am - 5:05pm, LPA Kelly Dulek conducted the initial complaint investigation. During that visit, LPA conducted physical plant, interviewed two (2) residents and three (3) staff, as well as reviewed pertinent documents relevant to the investigation. On 06/09/2023 at approximately 12:30pm, LPA conducted physical plant, interviewed four (4) staff, three (3) residents and their responsible parties, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/19/2023 LPA conducted physical plant and interviewed two (2) staff. Unsubstantiated Continued from 9099 It was reported that staff is not assisting Resident # 1 (R1) with managed incontinence, as it was alleged that staff did not change R1 in a timely manner. Interviews and records review revealed that there were at least two (2) occasions when R1 was not changed in a timely manner. The facility administrator was notified by R1’s home health that R1 was observed to have wet sheets on 02/17/2020 and 02/18/2020. Interviews reflected that there was an evening where R1 in November 2021, where R1 was left in a soiled diaper for an extended period of time. Interviews also reflected that R1 preferred only certain caregivers assist and refused services until those caregivers were available. Moreover, it was revealed that R1 had an agreement that the caregiver’s of R1’s preference would assist with R1’s incontinent needs at 10:30am. R1 preferred staff to finish assisting other residents and complete their morning routine prior to assisting R1 due to liked staff to take their time assisting R1 which would last approximately 30 minutes to one (1) hour. Interviews conducted with other residents reflected that they had no concerns with incontinent care needs and staff routinely assisted residents every two (2) hours, or as needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued. Continued from 9099 It was reported that staff is not able to meet the needs of R1, as it was alleged that there was not enough staff scheduled to assist R1 during the NOC shift. Interviews conducted and records reviewed reflected that during the time the complaint was received facility staffing was as follows: two (2) staff during the morning shift, two (2) staff during the afternoon/evening shift and one (1) staff during the NOC shift. Records further reflected that during the time of the complaint, R1 required assistance by two (2) caregivers. Therefore, based on information gathered there is sufficient evidence to determine that the facility did not have sufficient staffing to meet resident care needs during the NOC shift. Therefore, the above allegation is deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 29-AS-20211101125640

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 20, 2023

87411(a) Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... of adequate services. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the regulation cited above in that staffing was not sufficient in numbers to provide needed services to R1 who required 2 person assist which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2023

Plan of correction: Licensee has agreed review section cited and to write a Statement of Understanding and send to CCL via email by 10/20/23.