The Courtyard

Allegation investigated: Staff forced resident to take medication.

LPA Hiratsuka, conducted this unannounced complaint visit to deliver the findings of the allegation above. LPA interviewed staff and the resident in question. LPA also reviewed the facility medication administration records. One of the medications is an as needed medication and the resident displayed symptoms of requiring it and the resident is capable of determining the need for it. Staff stated they offered the medication and the resident accepted it for several days. Staff interview stated the resident requested to have two medications mixed together on the last day and the resident stated they did not. The resident stated they didn't know they were taking the medication and felt the staff person mixed it with another one. Staff documented the resident requested both medications and the resident denied it. Unsubstantiated LPA cannot prove or disprove the allegation because each side has their own version of events. Due to the information gathered, LPA cannot determine the Staff forced resident to take medication. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated.the state’s words, verbatim · CDSS document, Sep 27, 2023 · control 59-AS-20230814173328

Allegation investigated: Staff spoke inappropriately to resident

LPA Hiratsuka, conducted this unannounced complaint visit to deliver the findings of the allegation above. LPA interviewed staff and the resident in question. The staff in question denied there was any ill intent when they approached the resident. The resident stated they were started by the way the staff person approached them and felt humiliated. The staff person has a naturally loud voice and can be boisterous at times and there was a discussion between LPA and the staff person about the voice volume. LPA was unable to contact any witnesses to the event. LPA cannot prove or disprove the allegation because each side has their own version of events. Due to the information gathered, LPA cannot determine the Staff spoke inappropriately to resident. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 27, 2023 · control 59-AS-20230825101845

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff caused a resident to fall while in care

LPA Hiratsuka, conducted this unnanounced complaint visit to deliver the findings of the allegation above. LPA interviewed staff and the resident in question. LPA also reviewed the incident report and resident's file. Resident stated the facility staff put an onxygen tank in the middle of the floor and the resident tripped on it. The staff stated they found the resident in the bathroom on floor with no oxygen tank around. LPA cannot prove or disprove the allegation because each side has their own version of events. Due to the information gathered, LPA cannot determine the Staff caused a resident to fall while in care. LPA finds allegation to be unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 23, 2023 · control 25-AS-20230109160715

Type of visit: Required - 1 Year

LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing surgical masks. This facility is on a campus surrounded by a wrought iron fence that has a gate for cars and an unlocked pedestrian gate. This campus also has a skilled nursing on it and behind this building is The Gardens 515001365. The buildings share common pedestrian areas and this building and the skilled nursing share the parking lot. This facility 54 resident rooms and all have full private bathrooms. There are two restrooms for staff and residents. There is a laundry room that is used mainly by staff but residents may use it if they wish. There are several small common areas, one large dining/activity room, and the front area has offices on the left and a small activity room on the right. Several topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Dec 20, 2022

Allegation investigated: . Staff are not properly trained to provide care and supervision 2. Staff leave the residents unattended while in care 3. Staff did not respond timely to the residents alerts 4. Staff are retaining residents who require a higher level of care 5. Resident was not provided comfortable accommodations 6. Staff are forcing the residents to sleep earlier while in care

LPA Hiratsuka, conducted this unannounced complaint visit. LPA wore a surgical mask and observed wearing surgical masks. LPA conducted the investigation into the allegations above. LPA interviewed staff and residents. LPA reviewed training records and reviewed records for two residents no longer at this community. 1. LPA reviewed staff training records. The facility provides the training required by Community Care Licensing Division. LPA also observed the facility staff going over topics during all staff meetings and if someone needs extra training the facility provides it. Based on the records, the allegation is unfounded. Unfounded 2. Resident interviews stated they have no issues with staff not assisting them or not having any staff around. They stated there is always staff around. Staff interviews stated there is always staff around. Allegation is unfounded. 3. Residents have all stated there are no issues with staff not responding to call lights. LPA was informed there was an issue with resident call pendant batteries dying and not noticed for a very short period of time. LPA reviewed the call button log and observed some residents pushing a button within minutes of someone responding to the initial call button. Based on the above the allegation is unfounded. 4. Interviews indicate there are a couple of residents who are being monitored closely for changes in condition but otherwise no residents are beyond what the facility can provide. Allegation is unfounded. 5. Resident interviews state no living condition issues. Allegation is unfounded. 6. Resident interviews stated there are no issues with staff and are treated very well. Allegation is unfounded. “This agency has investigated the complaint alleging; 1. Staff are not properly trained to provide care and supervision; 2. Staff leave the residents unattended while in care; 3. Staff did not respond timely to the residents alerts; 4. Staff are retaining residents who require a higher level of care; 5. Resident was not provided comfortable accommodations; 6. Staff are forcing the residents to sleep earlier while in care We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.the state’s words, verbatim · CDSS document, Dec 16, 2022 · control 25-AS-20220922101057

Type of visit: Case Management - Incident

LPA Hiratsuka, conducted this unannounced case management visit. This visit is in response to an incident reported to LPA while LPA was conducting an annual at the sister facility. When LPA arrived at the other facility, LPA was told by the administrator and nurse manager of both buildings that this facility was evacuated this morning about 6:30am due to smoke in the building. The residents were outside for roughly fifteen minutes. Fire department cleared the building for occupation and all residents are back inside. Everything is clean. The licensee's engineering department staff showed up to check and cleared the building. The staff conducted their emergency evacuation procedures. No residents or staff were injured during the evacuation. No deficiencies cited.the state’s words, verbatim · CDSS document, Nov 2, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Case Management Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by Front Desk. LPA conducted this visit in response to an incident reported last week by Director of Assisted Living Services Carol Pickard. A resident died unexpectedly on 07/06/2022. LPA discussed the incident and at this time no extra documentation is required. Further investigation is required. Several other topics were discussed. No deficiencies cited.the state’s words, verbatim · CDSS document, Jul 13, 2022

Type of visit: Case Management - Annual Continuation

1/04/2022 2:00 PM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Carol Pickard, Administrator (AD) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA Keane was screened by AD/staff person. LPA Keane and AD toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, four (4) bedrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the AD completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was given to AD.the state’s words, verbatim · CDSS document, Jan 4, 2022

Type of visit: Required - 1 Year

12/22/2021 11:00 AM Licensing Program Analyst (LPA) Dawn Keane arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Carol Pickard, Administrator (AD) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted AD and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. Additionally, LPA Keane was screened by AD/staff person. LPA Keane and AD toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, two (2) bathrooms, four (4) bedrooms, kitchen, storage areas. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA Keane and the AD completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited as a result of today’s inspection. Exit interview conducted and copy of report was given to AD.the state’s words, verbatim · CDSS document, Dec 22, 2021