The Gardens at Laguna Springs Memory Care

Allegation investigated: Facility staff do not ensure pull cords are accessible to residents in care Facility staff are not properly addressing pest infestation in facility Facility staff prevent residents from accessing food Facility staff mismanage residents medication Facility staff are not properly supervising residents who are a fall risk Facility staff speak inappropriately to residents in care Facility staff are not trained appropriately to provide care to residents Facility staff not safe guarding residents’ belongings

On 10/25/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced facility visit to complete and deliver findings for a complaint investigation received on 7/10/23. LPA met with Director of Resident Services Barbara Rose and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA toured the facility, conducted staff and resident interviews and reviewed records. Based on observations, records review, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegations mentioned above. Regarding the allegation that staff do not ensure pull cords are accessible to residents in care, it was learned that resident (R1) pulls her cord off the wall daily. Staff stated that they check and fix the cord on a daily basis. LPA observed that the pull cord in R1’s room is accessible and in good repair. Continued on 9099-C Unsubstantiated Regarding the allegation that staff are not safeguarding residents’ belongings, it was determined that there is not a preponderance of evidence to substantiate the allegation. Based on statement obtained, it was learned that facility has encouraged families to lock resident’s valuable upon move-in. Based on staff interviews, staff stated that they will help locate misplaced items and redirect residents if they try to enter a room that is not theirs. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided upon exit. Regarding the allegation that staff are not properly addressing pest infestation in facility, it was learned that pest control services were being done monthly and additional days were added to address the pest infestation that was happening in Elk Grove. According to resident interviews, residents stated that they observed some ants in their rooms, but it was treated. LPA conducted a review of the resident rooms and did not observe any pests. Regarding the allegation that staff prevent residents from accessing food, it was learned that all staff and residents have access to snacks and a variety of food on a daily basis. It was learned that residents do not have access to the kitchen for safety reasons. Based on resident interviews, residents stated that staff will provide snacks and food if they ask. Regarding the allegation that staff mismanage residents’ medication, there is not a preponderance of evidence to substantiate the allegation. Based on statements obtained, it was learned that medications were provided to residents according to doctor’s order. LPA conducted a medication review and did not observe any discrepancies. Regarding the allegation that staff are not properly supervising residents who are a fall risk, LPA finds insufficient evidence to substantiate the allegation. Based on statements obtained, it was learned that residents who are at fall risk were closely monitored. Regarding the allegation that staff speak inappropriately to residents in care, LPA finds insufficient evidence to substantiate the allegation. Based on statements obtained, there was no supporting information found. LPA interviewed staff S1, S1 denied making any inappropriate comments about residents. Regarding the allegation that staff are not trained appropriately to provide care to residents, LPA reviewed staff files and verified staff training. LPA interviewed staff S2. S2 denied providing any care to residents. S2 stated that they were only redirecting resident while waiting for available caregivers to come and assist. Continued on 9099-Cthe state’s words, verbatim · CDSS document, Oct 30, 2023 · control 27-AS-20230710111426

Type of visit: Office

A Non-Compliance Conference (NCC) was conducted on this day, 10/26/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 9/30/2022. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Analyst (LPA) Tung Truong, LPA Christina Valerio, facility Regional RCFE Stephen Sarine, VP of Operation Michelle Baker and facility staff Barb Rose and Kayleen August. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well. Since the last meeting on 9/30/2022, six new complaints have been filed against the facility and four Type A deficiencies have been cited. The facility was cited for the following issues: Personal Rights of Residents in All Facilities, Administrator Qualifications and Duties, Basic services care and supervision and Plan of Operation. The focus of the concerns at this time were as followed: - Designated Facility Administrator-Qualifications/Duties - Maintaining continued compliance - Oversight of facility staff for proper care and supervision - Facility staff roles, duties, and responsibilities - Plan of Operation regarding outside agency Continued on 809-C - Plan of Operation regarding resident with behaviors - Adhering to the Plan of Operation - Outside staff fingerprint clearance and facility association Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/3/23. - Provide updated Plan of Operation regarding admitting resident with behaviors - Provide updated policies and procedures regarding using outside agency staff - All staff including administrator shall receive training on Resident Intervention and Redirecting - All staff and administrator shall receive in-service training on Reporting Requirements Exit Interview Licensee/Administrator signature on file.the state’s words, verbatim · CDSS document, Oct 26, 2023

Allegation investigated: Staff do not ensure residents take medications as prescribed. Staff do not serve food of the quality necessary to met residents needs.

On 10/20/23, Licensing Program Analyst (LPA) Tung Truong conducted unannounced facility visit to complete and delivery findings for a complaint investigation received on 7/3/23. LPA met with Administrator Guadalupe Ramirez and discussed the conclusion for complaint and the findings. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on record reviews, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegations mentioned above. Based on statement obtained, it was revealed that facility staff do ensure residents were taking their medication as prescribed. Regarding the allegation that staff do not serve food of the quality necessary to met residents' needs, based on LPA observations and staff and resident interviews, it was determined that food was provided of quality to meet the residents’ need. Continued on 9099-C Unsubstantiated As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 27-AS-20230703082703

Allegation investigated: Staff physically assaulted resident in care resulting in injuries.

On 9/7/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA met with facility representative Steve Sarine and explained the purpose of the visit. Throughout the course of the investigation, the Department conducted interviews and reviewed records. Regarding the allegation that staff physically assaulted resident in care resulting in injuries, it was determined that there is insufficient evidence to support the allegation. Based on interviews and records review, resident R1 has had several witnessed falls on 9/16/22 and 9/17/22 and was observed to have sustained bruising on face, chest and swelling in both arms. On 9/18/22, Garden’s staff (S2) witnessed R1 falling face down. Moreover, when the outside agency caregiver (S1) was interviewed, they denied causing any injuries to R1. Continued on 9099-C Unsubstantiated This Department has investigated the allegations noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 7, 2023 · control 27-AS-20220919221525

Allegation investigated: Resident was injured while in care.

On 9/7/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA met with facility representative Steve Sarine and explained the purpose of the visit. Throughout the course of the investigation, the Department conducted interviews and reviewed medical records. Regarding the allegation that resident (R1) was injured while in care due to staff’s neglect/lack of care, it was learned that R1 sustained a witnessed fall in the bathroom on 10/20/2022. Medical attention was sought for R1 on the same day. According to medication records, there is no evidence to show that R1’s blood glucose levels contributed to the fall. Per R1’s physician, R had several chronic health conditions that could have played a factor in his multiple falls. Continued on 9099-C Unsubstantiated This Department has investigated the allegations noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 7, 2023 · control 27-AS-20221122143318

Type of visit: Case Management - Deficiencies

On 9/7/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. LPA met with facility representative Steve Sarine and explained the purpose of the visit. The purpose of the case management visit is to follow up on deficiencies found during a complaint investigation conducted by the Department for complaint dated 9/19/2022, control number: 27-AS-20220919221525 The following deficiencies were identified during the complaint investigation: - Personal Rights - Staff blocked resident (R1’s) doorway with a couch to prevent resident from leaving. This incident was witnessed by facility staff. - Administrator Qualifications - The designated administrator (A1) did not act in their capacity as the Administrator. A1 told the Department that he was hired as a consultant and was working in the facility only until designated administrator (A2) could obtain their Administrator certificate. On 8/4/22, during a non-compliance meeting, A1 was designated as the facility administrator. - Basic Services - Facility did not provide adequate supervision which resulted in R1 sustaining multiple injuries from falls. During the investigation, (A1) stated that the private care agency will provide all the care and supervision to the resident, however per Department guidelines, private agencies are only allowed to provide companion services not care and supervision. Continued on 809-C - Plan of Operation - Observation of resident change in condition, bruises, prohibited condition. Per facility’s Plan of Operation which stated that a condition of combative, dangerous behavior or the inability to get along in a congregate setting is prohibited and would make the resident inappropriate for admission/move in. During the investigation, it was learned that R1 has displayed aggression towards staff on multiple occasions. Moreover, R1’s Physician’s Report also stated that R1 has behavioral disturbance and aggressive condition. As a result, deficiencies were cited on LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.the state’s words, verbatim · CDSS document, Sep 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 8, 2023

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: (3) To be free from punishment, humiliation, intimidation, abuse. This requirement is not met as evidenced by: Based on the department's findings, the licensee did not ensure R1 was free from punishment while in the care. Facility staff blocked R1's doorway with a couch to prevent R1 from leaving, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 7, 2023

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87468.1(a)(3) at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(b) · Plan of correction due date: Sep 8, 2023

87405. Administrator Qualifications and Duties (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement is not met as evidence by: Based on interviews and records review, facility representative A1 denied the fact that he was the responsible administrator. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 7, 2023

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87405(b) at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 8, 2023

87464 (f)(1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the department's findings, the facility did not provide adequate care and supervision which resulted in R1 sustaining multiple injuries from falls. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Sep 7, 2023

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87464(f)(1) at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87208(a)(3) · Plan of correction due date: Sep 8, 2023

87208 Plan of Operation - (a) Each facility shall have and maintain a current, written definitive plan of operation (3) Statement of admission policies and procedures regarding acceptance of persons for services. This requirement is not met as evidence by: Based on records review, although the facility has a plan of operation in place the facility failed to follow prohibited conditions outlined in the plan of operation regarding combative, dangerous behavior or the inability to get along in a congregate setting. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 7, 2023

Plan of correction: Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87208(a)(3) at all times.

Allegation investigated: Resident sustained a severe head injury due to staff neglect. Facility does not have enough staff to meet the needs of residents in care.

On 6/28/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA identified himself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Guadalupe Ramirez. Throughout the course of the investigation, the Department conducted interviews and reviewed medical records. Regarding the allegation that resident sustained a severe head injury due to staff neglect, it was learned that on 3/3/2023 resident (R1) fell out of her wheelchair and hit her head and sustained a large cut to her forehead. Based on staff interviews, staff stated R1 was in a reclined position prior to falling out of her wheelchair. Moreover, R1’s facility documents do not indicate that she is a fall risk or that she required certain care in her wheelchair. Continued on 9099-C Unsubstantiated Regarding the allegation of facility does not have enough staff to meet the needs of residents in care, LPA did not find sufficient evidence to support the allegation. Based on interviews conducted with residents, 2 out of 3 residents stated that their needs were met and do not feel the facility is short staff. Staff who were interviewed stated that the facility has adequate staffing to meet the needs of the residents. This Department has investigated the allegations noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and copy of report left at facility.the state’s words, verbatim · CDSS document, Jun 28, 2023 · control 27-AS-20230309133440

Allegation investigated: Resident sustained injuries while in care. Resident suffered falls while in care. Staff over medicate resident. Resident is left soiled for a long period of time. Staff are not administering medications to resident.

On 5/10/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to conclude the investigation of the above allegation and to deliver the findings. LPA met with Regional Director of Operations Steve Sarine and explained the purpose of today’s visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on interviews and records review, LPA Truong has determined that the allegations are unfounded. No supporting information to the allegations was discovered. Complaint is deemed to be unfounded at this time. As a result of this investigation, LPA finds the allegations above to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. An exit interview was conducted, and a copy of this report was left at the facility. Unfoundedthe state’s words, verbatim · CDSS document, May 10, 2023 · control 27-AS-20230223142712

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.

Type of visit: Case Management - Other

On 5/3/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met with Administrator Guadalupe Ramirez and explained the purpose of the visit. LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. The lounge area, lobby, resident rooms, common areas, dining area, and activity room was toured. LPA observed the facility is clean and in sanitary condition. The hot water measured at 116.4 degrees Fahrenheit which is within the required range of 105-120*F. The temperature inside was observed at 70 degrees Fahrenheit which is within the required range of 68-85*F. Fire extinguishers were up to date. LPA reviewed 3 staff files to ensure staff training and first-aid certification is up to date. Based on a review of this facility during today’s visit, it was determined that this facility was found to be in compliance at this time. No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 3, 2023

Allegation investigated: Staff are not dispensing medication as prescribed Staff are not keeping accurate medication logs

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to deliver complaint findings on 2/7/23. LPA met with Administrator Guadalupe Ramirez and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed documents including, but not limited to resident R1’s file; Incident Reports, Medical Records, Physician Reports, Medication Administration Records (MARS), and Centrally Stored Medication Logs. Regarding the allegation of staff are not dispensing medication as prescribed, it was learned that this allegation was Substantiated on previous complaint, control number 27-AS-20220516090722 and has been resolved. Continued on 9099-C Substantiated Regarding the allegation of staff are not keeping accurate medication logs, it was determined that facility staff did not accurately log R1’s MARs when medication is dispensed. Based on review of R1’s MARs for the month of September 2022, there were multiple dates with missing staff signature. According to staff S4 and S5 who corroborated that the medication was provided to R1, but staff did not complete the MARs as required. As a result of this investigation, the Department finds the allegations above to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided. Regarding the allegation of facility staff is not performing resident's glucose testing as ordered, it was determined that there was insufficient evidence to substantiate this allegation. According to staff who were interviewed, R1’s glucose testing is being followed as ordered by R1’s physician. Staff S5 stated that R1 receives insulin within 30 minutes of glucose testing before meal. S5 stated that normally medication can be dispensed within 1 hour window before or after meal. S5 stated that staff will not administer Insulin without glucose testing. As a result of this investigation, the Department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 7, 2023 · control 27-AS-20220923100433

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(14) · Plan of correction due date: Feb 14, 2023

87506(a)(14) Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement is not met as evidenced by: Based on LPA's documentation of resident medical records, the licensee did not ensure residents medication logs are accurate. R1's Medication Administration Records (MARs) is not logged accurately. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 7, 2023

Plan of correction: Licensee/Administrator shall submit a plan by 2/14/23 stating how staff will receive additional training in medication logging and ensure the Health and Welfare of the residents at the facility. Send via email to LPA Tung Truong by plan of correction date: 2/14/23.

Type of visit: Case Management - Other

On 2/7/23 at 9:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met with Administrator Guadalupe Ramirez and explained the purpose of the visit. LPA toured and inspected the physical plant inside and outside to ensure compliance with Title 22 regulations. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPA observed the facility is clean and in sanitary condition. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The hot water measured at 118.8 degrees Fahrenheit which is within the required range of 105-120*F. The temperature inside was observed at 70 degrees Fahrenheit which is within the required range of 68-85*F. Fire extinguisher and first aid kit was up to date. Based on a review of this facility during today’s visit, it was determined that this facility was found to be in compliance at this time. No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 7, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Tung Truong and Pang Lee conducted an unannounced 1 Year Annual Inspection Visit on 12/15/22. LPAs met with Administrator Guadalupe Ramirez and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator Certificate # 6035691740, expiration date:7/12/2023. The facility had COVID -19 posters and signs throughout the facility. The facility had a mitigation plan completed and approved on 6/17/2021. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. LPAs toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPAs observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. A review was conducted of the apartment sizes and different layouts. Each unit has mini-split air and heating unit. The medication room was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPAs observed required furniture and lighting throughout the facility. The hot water temperature was measured at 117*F in resident apartment during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 69*F which was within the required range of 68-85*F. Continued on 809-C LPAs observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPAs observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPAs observed the fire extinguisher(s) and first aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair. LPAs requested resident and staff files for review. LPAs reviewed (5) resident files and (5) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPAs verified staff training for staff file reviews. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Dec 15, 2022

Allegation investigated: Resident is being overmedicated with Norco and Morphine

On 12/13/22, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA met with Administrator Guadalupe Ramirez and explained the purpose of today’s visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Based on the investigation, it was learned that resident (R1) is on hospice. It was observed that the facility was following Bristol Hospice's orders to provide R1 Norco 1 tablets orally 3 times a day for pain and morphine as needed. As a result of this investigation, LPA finds the allegation above to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. Exit interview was conducted with Administrator Guadalupe Ramirez and a copy of the report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Dec 13, 2022 · control 27-AS-20221109131622

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.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference was held via Microsoft Teams on September 30, 2022 at 10:00 AM. The Department explained the purpose of this office meeting to the Licensee/Administrator of Gardens at Laguna Springs Memory Care. The following were in attendance: Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analyst (LPA) Tung Truong, VP of Operation Michelle Baker, Executive Director Kirk Goodin, Administrator Steve Sarine, Regional Nurse Heather Ashby and facility representatives: Cyndie Bryant, Mary Keaton, and attorney, Joel Goldman. The purpose of today's conference is to discuss the facility non-compliance issues. The Non-Compliance Conference process was explained during this meeting to bring the facility back in compliance. Since licensure in 12/30/20, the facility has been cited 16 times in the last year. The facility was cited for the following issues: Basic services requirements, Incidental Medical and Dental Care, Criminal Record Clearance, Administrator - Qualifications and Duties, Personal Rights of Residents in All Facilities, Additional Personal Rights of Residents in Privately Operated Facilities, Storage Space, AWOL, appraisals and reappraisals. Issues discussed during the meeting were: - The amount of complaint's filed and substantiated against this facility since licensure. The facility was cited for 8 Type A citations and 8 Type B citations within the last 12 months. Continued on 809-C - Criminal record clearance - Staff training requirement - Administrator - Qualifications and Duties - Personal rights - Incidental Medical and Dental Care - Storage space - Basic services requirements. - Increase monitoring from Licensing - Resident AWOL'ed - Preplacement appraisals - Reappraisal assessment - Delay egress is not function correctly - New LIC 500 The facility has stated they will do the following to achieve continued and substantial compliance: - New office manager to manage staff association, ensuring staff are associated - Training on diabetic medication management - Audit of physical plant, egress doors - Ensure delay egress is function correctly - Ensure residents needs are met - Ensure staff have the tools to meet those needs - Ensuring disinfecting products are inaccessible to residents. - Review and update Plan of Operation The facility shall submit the following to LPA Truong by 10/14/22: Training on criminal record clearance, Guardian Training, Medication Training, LIC 500 and an updated Plan of Operation. Continued on 809-C It was agreed that the Department will conduct increased visits and will re-evaluate compliance with the facility in approximately 12 months. Technical Support Program was provided to the facility. Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Sep 30, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tung Truong arrived at the above facility to complete a Case Management visit. LPA met with Interim Administrator Stephen Sarine and explained the reason for the visit. The purpose of this visit is to follow up on an incident report submitted for R1, detailing an AWOL from the facility on 7/25/2022. R1, a dementia resident, AWOL'd from the facility on 7/25/2022 at approximately 11:45pm. R1 exit the delayed egress and through the front door of the building. R1 was outside of the building for roughly 9-10 minutes according to staff. R1 rang the bell for staff to unlock the door. According to Administrator, R1 did not leave the facility premises. The Administrator discovered that the delayed egress door was not latched properly. The Administrator acknowledge of the Absence without Leave (AWOL) of R1. Upon a review of the most recent Physician Report (LIC602) dated 3/19/21, it indicates that R1 is not able to leave the facility unassisted. LPA learned that there were three staff on duty but no staff was there to redirect R1 from exiting the building. During today's visit, LPA learned that the delayed egress door has been fixed and staff have completed in-service training on frequent checks, egress, alarm and door secure awareness. Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. Exit interview conducted, a copy of the report and appeal rights given.the state’s words, verbatim · CDSS document, Aug 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Aug 5, 2022

Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by: Based on incident report, the facility did not comply with section cited above in 1569.312(d). R1 AWOL'D from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Aug 4, 2022

Plan of correction: The facility shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Admninstrator/Executive Director shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended. The Adminnstrator shall email the date of the in-service training to LPA by 8/5/22 to meet the 24 hour POC requirement.

Allegation investigated: Staff handled resident in a rough manner Staff yelled at resident

Licensing Program Analyst (LPA) Jason Lund arrived to the facility unannounced to deliver findings on an complaint investigation. LPA Lund explained the reason for the visit to Director of Nursing Nekia Xavier. Census 30. The Department has determined the following as it relates to the allegations: Staff handled resident in a rough manner and staff yelled at resident According to an interview with staff 2 (S2), an incident occurred involving resident 1 (R1) and staff 4 (S4). S2 observed S4 handling R1 in a rough manner by lifting R1's arm above R1's head in a 90-degree angle while pulling the arm in a fast and harsh manner. S4 was getting R1 ready for a shower and had to bring R1 from the common area to R1's room. S2 reported that S4 talks really loud to everyone but does not yell. Unsubstantiated According to an interview with staff 1 (S1), S1 stated S4 was talked to about the incident. S1 reported that S4 was shocked that it was observed in that way and seemed remorseful. S1 stated the administrator was made aware of the incident, but they did not document the conversations or the incident. S1 stated S4 continued to work after the incident was reported. According to an interview with S3 (S3), S3 learned of the incident involving S4 a few weeks after it happened. S3 stated S4 is an employee contracted through a 3rd party contractor. S3 reported that S4 was immediately removed from the scheduled after S3 had learned of the situation. According to an interview with S5, S5 was unaware if any of the allegations were true or happened. According to records review, R1 is diagnosed with Alzheimer's Disease and receives memory care services from Gardens at Laguna Spring Memory Care. During an interview with R1, R1 was unable to provide information regarding any incidents or staff members. According to an interview with a family member, the facility staff was observed to be friendly to residents. During visits, staff were not observed to be handling residents in a rough manner or yelling at residents. It was said that the facility is short staff and there are many residents not happy about that. Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was given to Administrator.the state’s words, verbatim · CDSS document, Jul 29, 2022 · control 27-AS-20220429100622

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit on 07/26/2022 at 10:15 am. LPA met with Acting Executive Director, Kirk Goodin and Administrator Designee, Stephen Sarine and explained the purpose of the visit. The purpose of the visit today is to address the issues learned during a separate complaint investigation. It was learned that the facility doesn’t have a diabetic diet menu. Moreover, there was no Diabetic Care Plan available upon LPA request for review. During today’s visit, LPA observed the Diet and Nutrition Care Manual and reviewed care plan of five diabetic residents. It was learned that the facility doesn't have a specific menu for diabetic diet. Diabetic diet are followed by guideline from the Diet and Nutrition Care Manual and Diabetic protocols. Based upon documentation reviewed and received, no violations or deficiencies have been issued during today's visit. An exit interview was conducted with Designee, Stephen Sarine and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 26, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(b)(4) · Plan of correction due date: Jun 28, 2022

Diabetes. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following…Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidence by: Based on interviews and record reviews, the Licensee did not ensure a diabetic menu is in place. Facility has five diabetics residents. LPA s observed no Diet Menu regarding this matter. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2022

Plan of correction: Licensee/Administrator shall send Plan of Operation and Restrictive Health Care Plan for Diabetes. Administrator to send LPA Diabetic menu. POC due 6/28/22.

Allegation investigated: Resident missed medications Staff did not follow physician's orders

On 06/23/22 at 1:30 pm, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Mary Keaton and explained the purpose of the visit. Throughout the course of the investigation, LPA Truong conducted interviews and reviewed facility documents. Based on the interviews and reviewed of records, it was learned that on 4/18/2022, resident R1 had an unwitnessed fall. Staff (S2) who found R1 stated she can’t recall if EMS instructed not to give meds to R1. S2 stated R1 usually get his insulin around 8 am. S2 stated R1 left the facility at 8:05 and did not get his morning insulin. Continued on 9099-C Substantiated It was also learned that on 4/29/2022, resident (R1) was given insulin at approximately two hours late by staff (S3). LPA Truong was unable to contact S3 for a statement. According to staff (S1) and (S4), doctor’s order to give insulin at mealtime of 8am, 12pm, and 5pm. Staff (S1, S2 and S4) stated that R1 received his insulin two hours late on 4/29/22. Due to the above noted information, staff S3 did not provide insulin to R1 at the prescribed time by physician’s order. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided. As a result of this investigation, the Department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 23, 2022 · control 27-AS-20220503081127

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 24, 2022

87465(a)(1) A plan for incidental medical and dental care shall be developed by each facility...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not ensure meds were provided to resident. Resident R1 missed his morning insulin dose when leaving the facility. This posed an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 23, 2022

Plan of correction: Facility will obtain medication administration training from a certified trainer outside the facility. All staff who provide medication administration will be required to complete training and pass an evaluation. Licensee will submit documentation of training to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 24, 2022

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on LPA’s documentation review. The licensee did not ensure meds were given according to the physician's directions. Facility staff did not ensure insulin is provided timely to resident as prescribed by physician’s order. Resident R1 was given insulin two hours late. This posed an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jun 23, 2022

Plan of correction: Licensee/Administrator shall submit a plan stating how staff will receive additional training in medications, charting, and ensure the Health and Welfare of the residents at the facility. Send via email to LPA by plan of correction date: 6/24/22.

Allegation investigated: Facility is not providing resident's medication as prescribed.

On 06/23/22 at 1:30 pm, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Mary Keaton and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. The complaint alleged the facility is not providing resident's medication as prescribed. Based on the interviews and reviewed of records, it was learned that on 4/29/2022, resident (R1) was given insulin at approximately 10:00am, two hours late by staff (S3). LPA Truong was unable to contact S3 for a statement. According to staff (S1) and (S4), doctor’s order to give insulin at mealtime of 8am, 12pm, and 5pm. Staff (S1, S2 and S4) confirmed that R1 received his insulin two hours late on 4/29/22. Report continued on 9099-C Substantiated Due to the above noted information, staff S3 did not provide insulin to R1 at the prescribed time by physician’s order. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency was cited on the LIC 9099-D of Complaint Control Number 27-AS-20220503081127, per Title 22 Regulations. An exit interview was conducted, and a copy of the this report was provided. As a result of this investigation, the Department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the this report was provided.the state’s words, verbatim · CDSS document, Jun 23, 2022 · control 27-AS-20220516090722

Allegation investigated: Facility didn't follow resident's care plan. Insufficient staffing to meet the residents' needs.

On 06/20/2022 at 9:15 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver findings. LPA Martinez met with Kirk Goodin and explained the purpose of the visit. Throughout the complaint investigation, LPA Martinez conducted interviews, toured the facility, and reviewed facility files. LPA Martinez reviewed resident 0's (R0) 2022 Resident Assistance Record. This document indicated care was not completed on some days in January, February, and March. Moreover, during a facility interview, it was reported it is unknown if care was provided on various days in January, February, and March of 2022. LPA Martinez also reviewed R0's 2021 Resident Assistance Record. This document showed that care was not provided on some days in October, November, and December. Continued... Substantiated LPA Martinez reviewed 01's January and February 2022 Medication Administration Record (MAR). It was determined medications were not being administered on some day in January and February. R0 Admission care plan includes providing and administering medication. As result, the facility did follow R0's care plan. During the investigation, LPA Martinez toured the facility. It was learned the facility does not have adequate staff to meet the needs of the residents in care. LPA Martinez observed a resident activity on June 6, 2022. LPA Martinez observed one activity caregiver and 14 residents. At times an additional caregiver entered the activities room, but the caregiver did not stay and assist with the activity. Throughout the duration of the activity, residents were eating each others snacks. Residents were also drinking each others water while the assigned activity caregiver was completing other tasks. The assigned activity caregiver had to stop her current task, and stop the residents from eating and drinking each others snacks and water. Resident 1 (R1) attempted to transfer onto a chair, and half his bottom was off the chair. The assigned activity caregiver stopped her current task to help R1. During this time, the other residents were not supervised. Resident 2 (R2) requires additional emotional support and attention. Throughout the activity, R2 continued to ask for help and asked for her hand to be held. R2's needs were not being met due to the assigned activity caregiver being busy with other tasks. LPA Pascua approached R2, and asked R2's if she needed any assistance. Additionally, resident 3 (R3) was sitting at the outside patio unsupervised. R3 was sitting on a wheelchair directly under the sun. LPA Martinez observed R3 from the activity room at 11:02 AM. LPA Martinez did not observer any care staff check on R3. At 11:13 AM, R3 woke up and pushed himself to the activity exterior room door. Residents tried to open the door for R3. Once the assigned activity caregiver became aware of this incident, the assigned activity caregiver stopped her current task to open the door for R3. The assigned activity caregiver did not offer R3 a snack or drink. In addition, the assigned activity caregiver did not encourage R3 to participate in the activity. Continued... R3 wandered off into the facility common area. During this time, resident 4 (R4) 02 nasal tubing was not on correctly, and LPA Martinez had to inform the assigned activity caregiver to assist R4. The assigned activity caregiver stopped her current task to help R4. The activity ended at 11:30AM and ambulatory residents were escorted to the dinning room. The following four non-ambulatory residents had to wait for other caregivers to assist them to the dinning room: Resident 5 (R5) was assisted at 11:35 AM. Resident 2 (R2) was assisted at 11:38 AM. Residents 6 and 7 (R6/R7) were assisted at 11:41 AM Moreover, LPA Martinez and LPA Pascua observed lunch in the facility dinning room. There were two kitchen staff working on this day, and caregivers were serving meals to residents. In addition, one kitchen staff 1 (K1) was assisting with serving meals to residents. It was also reported on June 6, 2022 there were two caregivers serving meals, and Kitchen staff (2) duties included, preparing meals, cooking meals, serving meals, washing dishes, cleaning kitchen. As a result, K2 was not able to complete some tasks. LPA Pascua was in the dinning room during lunch, and observed no caregivers from 12:04 PM to 12:12 PM. During this time, R2 did not have a drink. LPA Pascua assisted R2 by getting R2 a drink. As a result of LPA Martinez and LPA Pascua's observations, the facility does not have sufficient staff to meet the needs of the residents in care. The Department finds the allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Kirk Goodin. A copy of this report, LIC 9099-D, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Jun 20, 2022 · control 27-AS-20220323143616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jul 31, 2022

87705 (c) (4) Care of Persons with Dementia: Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety... This requirement was not met as evidence by: Based on observation the facility did not meet the needs of residents during an activity and lunch. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2022

Plan of correction: Administrator added 16 hours per day to The labor structure for caregiver. Follow Up with LPA Bi-weekly in regards to staffing numbers until 07/31/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Jul 31, 2022

87464 (d) Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement was not met as evidence by: Based on file review the facility did not meet R1's care needs. According to document "Resident Assistance Record" staff did not initial document stating care was provided to R1. It is unknown if care was being provided to R1. This posed a potential health & safety risk to R1.the state’s words, verbatim · CDSS document, Jun 20, 2022

Plan of correction: Staff training on care plans was conducted on 6/14-/6/15-6/16. conducting reassessments and writing new care plans. Assessments will be done by 07/31/2022. If facility staff needs additional time, Administrator shall contact LPA Martinez prior to 07/31/2022.

Allegation investigated: Resident is physically abusive to other residents.

On 06/13/2022 at 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez and LPA Arielle Pascua conducted an unannounced facility visit to deliver findings. LPA Martinez met with Kirk Goodin and explained the purpose of the visit. Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility documents. It was learned resident 1 (R1) had a few incidents of being aggressive towards other residents. On March 6, 2022, it was noted R1 was getting physical with female residents, such as, grabbing and pulling at them. March 18, 2022 it was noted R1 was grabbing female residents and getting in their faces causing the residents to become anxious and agitated. Futhermore, on April 3, 2022 R1 grabbed items from another residents, which led to a family member almost falling. Continued... Substantiated As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. A exit interview was conducted, and copy of this report and appeal rights given to the facility.the state’s words, verbatim · CDSS document, Jun 13, 2022 · control 27-AS-20220330112105

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 15, 2022

87468.1(a)(2)Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on facility record reviews, R1 was being aggressive towards other residents. This posed a immediate health and safety risk to residents in care,the state’s words, verbatim · CDSS document, Jun 13, 2022

Plan of correction: Facility staff agrees to conducting redirecting training and aggressive behavior training. By POC Date: 03/15/2022. Email LPA with training documents.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPA) Avelina Martinez and LPA Arielle Pascua arrived at facility unannounced to conduct a case management visit on 06/13/2022. LPA Martinez and LPA Arielle Pascua met with Kirk Goodin and explained the purpose of the visit. The purpose of the visit today, is in response to learned deficiencies during a complaint investigation. Resident 1 (R1) had various significant physical, medical, and mental changes while residing at this facility. The facility staff documented R1's condition changes on daily nurse's notes and via physician fax communication sheet. However, a reassessment after each significant health change was not being completed. LPA Martinez obtained two different forms of R1's health assessments. One assessment was dated January 19, 2022 and the other was date April 10, 2022. Beginning on February 9, 2022, it was noted R1 was having suicidal ideations and continued on February 12,2022. Moreover, monitoring of R1 occurred on the following dates: February 12, 2022; February 13, 2022; February 17, 2022; February 18, 2022; February 19, 2022; and the last monitoring entry was on February 20, 2022. Furthermore, facility staff informed R1's physician of the suicidal ideations via fax communication on February 22, 2022 and requested an order for Seroquel. There are no other notes that indicate R1's responsible party was informed of the suicidal ideations. There was no other documentation noting the facility staff continued to monitor R1's suicidal ideations. Additionally, the facility did not complete a new assessment after R1's suicidal ideations incidents. Continued... It was also, learned R1 had multiple falls, and one fall with a serious injury. R1's January 19, 2022 assessment service plan reported R1 had a history of falling and had a score of one point. R1's first recorded fall was on February 1, 2022. After the initial first fall, R1 fell 6 more times. On March 16, 2022, R1 went out the facility egress doors onto the gated patio and fell. At this fall, R1 broke his nose. R1 was sent to the emergency room for care. The facility did not conduct a reassessment service plan in regards to fall prevention and care needs after the March 16, 2022 fall. It was not until April 10, 2022 that facility conducted a reassessment service plan. The April 10, 2022 reassessment service plan reported two or more falls in the last 30 days (impulsive to shift wt/transfer or ambulate, unsteady gate).This assessment service plan was not signed by R1's responsible party. On this 809 Licensing Report (LIC 809), this facility was given notice of a violation for which a civil penalty is prescribed by California Health and Safety Code Section 1548(c), 1568.0822(c), 1569.49(c), 1596.99(c), or 1597.58(c). The facility did not conduct reassessments in a timely manner, and did not address R1' eloping tendencies. Due to not addressing R1's eloping/exiting tendencies and fall risk need, R1 engaged in eloping/exit seeking behaviors during mid-night hours and sustained a fall and broke his noes. As a result, an immediate $500.00 civil penalty shall be assessed on June 13, 2022 for bodily injury and severe pain, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. R1's January 19, 2022 assessment states Cognitive Ability: Mental and emotional," wandering into other residents rooms..." On this assessment R1 was scored a 4. R1 began exhibiting exit seeking and wandering behaviors on January 20, 2022 although R1 was not reassessed. LPA Martinez reviewed January 20, 2022 through March 29, 2022 facility notes, and R1 had exit/elopement seeking behaviors on twenty-six different days during this period. On March 23, 2022, it was noted R1 was exhibiting elopement behaviors and attempted to climb over the counter in the nurse's station. During this time period, it was also noted it was difficult to redirect R1. R1 was also having unusual behaviors, such as, moving furniture around. R1 also developed a stooped gated on March 26, 2022. However, R1 was not reassessed until April 10, 2022, and was scored a seven, which stated, "attempts to wander from community...exit seek throughout the day and night...unsteady gate" As a result of the gathered information, the facility did not keep R1's reappraisal/assessments updated after each significant health change and did not immediately bring changes to his primary physician and responsible party. During today's visit LPA Martinez and LPA Pascua observed cleaning cart compartments were left unlock. Cleaning cart compartments had cleaning supplies and made accessible to residents in care. As a result of this Case Management visit, the following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D Page. An exit interview was conducted and appeal rights given.the state’s words, verbatim · CDSS document, Jun 13, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jun 16, 2022

87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities: in addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is met as evidence by. Based on file reviews R1 did not receive care and supervision conducive to his exit/eloping seeking behaviors which lead to breaking nose, suicidal ideations, unusual behaviors. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jun 13, 2022

Plan of correction: Facility staff agrees to conduct personal rights training by POC date 06/16/2022. Email training documents to LPA by 06/16/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a)(3) · Plan of correction due date: Jun 8, 2022

87463(a)(3) Reappraisals Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidence by: Based on file reviews and interviews, reappraisals were not being conducted after R1's significant changes. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Jun 13, 2022

Plan of correction: Facility staff agrees to conduct reassessments training by POC date 06/16/2022. Email training documents to LPA by 06/16/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jun 14, 2022

Storage Space 87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: Based on observation, cleaning carts compartments were left unlocked, which made cleaning toxins accessible to residents in care. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2022

Plan of correction: Facility staff agrees to provide training on Storage space regulation by POC date 06/14/2022. Email LPA Martinez training documents by POC date 06/14/2022.

Allegation investigated: Resident's room has a water leak Staff did not safeguard residents personal belongings Staff are not providing adequate laundry service

Licensing Program Analysts (LPAs) Tung Truong and Avelina Martinez arrived at this facility unannounced on 04/07/2022 at 10:20 am to conclude the investigation of the above allegations and to deliver the findings. LPAs met with Administrator Mary Keaton and explained the purpose of the visit. Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility. Throughout the investigation, it was learned resident 1's (R1) AC unit was not in good repair. The AC unit was retaining rain water causing R1's room carpet floor to have excess water. It was also observed that towels were placed under the AC unit to soak up the excess water. As a result, the facility did not ensure R1's room was sanitary and ensure that R1's AC unit was in good repair at all times. Report continued on 9099-C Substantiated Moreover, 5 out of 7 interviewees reported residents' clothing have been lost or misplaced due to staff not returning clothes to the correct resident after being washed by facility staff. The facility did not safeguard residents' clothing, and did not provide adequate laundry service. As a result of this investigation, the Department finds the allegations above to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations. An exit interview was conducted with Mary Keaton, a copy of this report, LIC 9099-D, and appeal rights were provided. The complaint alleged that a resident sustained a rash while in care. Based on interviews and review of records, it was learned that resident R1 has a rash of unknown cause. It was learned that R1 also going out into the community. As a result, LPA was unable to determine if the rash happened while in care. The complaint alleged that staff did not notify resident's authorized representative of R1's injuries. Based on interviews and review of records, it was learned that facility staff did notify R1’s responsible party of R1’s rash on 10/21/21 and 11/16/21. Based on interviews and statement obtained, residents and residents’ authorized representatives stated that their communication with the facility have been good and that the facility have been good on notify them of any concerns. The complaint alleged that staff are not properly cleaning resident's room. Based on interviews and observations, LPA observed a total of 10 residents' rooms on three different visit from 10/06/22 through 3/24/22. All of the rooms observed are clean. Based on information obtained, the department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 7, 2022 · control 27-AS-20220103142529

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 20, 2022

Maintence and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by: Based on observation and interviews, the licensee did not maintain the facility in good repair at all times. R1's room had a water leak due to the PTAC unit was not in good repair. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee and LPA agree to: Submit letter stating knowledge of, understanding of regulation 87303(a). Correction due 4/14/22. The facility had fixed the PTAC unit in R1's room.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Apr 20, 2022

Personal Rights of Residents in All Facilities. To wear their own clothes; to keep and use their own personal possessions. This requirement is not met as evidence by: Based on observation and interviews, the licensee did not ensure that residents' cloths are properly returned to the right resident. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: Licensee and LPA agree to: Submit a plan on how the facility will ensure that residents' belongings won't get lost or misplaced.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: Apr 20, 2022

Personal Accommodations & Services. The licensee shall assure provision of basic laundry service… This requirement is not met as evidence by: Based on interviews, the licensee did not ensure that residents receive adequate laundry services. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 7, 2022

Plan of correction: The licensee shall provide LPA Truong with a copy of its laundry service plan of operation, staff sign-in sheet regarding general laundry services

Allegation investigated: Unlawful eviction. Staff do not have the required training.

Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/24/2022 at 1:30 pm to open a complaint, LPA Martinez met with Jennifer Valcazar and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed facility files. It was learned resident 1 (R1) received an eviction letter due to R1's responsible party's weekly menu request and demands. R1 has not violated any of the following: Non-payment of the monthly rate, failure to comply with state or local laws, failure to comply with the general policies of the community. Additionally, the eviction letter that was provided to LPA Martinez did not contain the following: A copy of the resident’s current service plan. The relocation evaluation. A list of referral agencies As a result, this eviction is unlawful. Deficiency can be found on the 9099-D. Continued... Substantiated Moreover, LPA Martinez reviewed four employee files. Employee one (E1) had supporting new hire training documentation. However, Employee 3 (E3) new hire required Dementia training was not done in a timely manner. Employee 2 (E2) and Employee 4 (E4) files did not contain supporting new hire training documentation. As a result, the facility is not in compliance with Dementia training requirements. As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Mar 24, 2022 · control 27-AS-20220323143616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87707(a)(1) · Plan of correction due date: Apr 14, 2022

87707(a)(1)Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments: residents with dementia or related disorders shall ensure that all direct care staff, described in Section 87706(a)(1), who provide care to residents with dementia, meet the following training requirements:... Direct care staff shall complete six hours of orientation specific to the care of residents with dementia within the first four weeks of working in the facility. This requirement was not met as evidenced by: based on file review 3 employees did not have supporting dementia training documents. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Facility Staff agrees to complete an employee training audit by POC date 04/14/2022.Facility staff agrees to implement dementia training for all care staff by 04/14/2022. LPA will return to the facility to clear POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Apr 14, 2022

87224(a) Eviction Proceduresthe licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirment was not met as evidenced by: Based on record review and interviews, R1 was evicted due to Responsible Party's conduct and requests In addition, eviction letter did not have all the required information. Also, R1 did not violate title 22 eviction reasons. This posed a potential health and safety risk to R1the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Facility staff agrees to review eviction regulations by POC date 04/14/2022. Facility staff agrees to provide a written statment to LPA that states the review of eviction regulations has been completed by POC Date 04/14/2022.

Type of visit: Case Management - Other

On 3/24/2022 at 1:30 pm, Licensing Program Analysts (LPAs) Tung Truong and Avelina Martinez conducted an unannounced case management visit. LPAs met with Executive Director Irene Charnell, Office Manager Jennifer Valcazar and explained the purpose of today's visit. During this visit, LPAs discovered during review of the Licensing Information System (LIS) Facility Personnel Report that staff S1, S2 and S3 (LIC 811) are not fingerprint cleared as required. In addition, the facility does not have a certified administrator associated to the facility. The following documents were requested to be submitted to LPA: -Designation of Administrative Responsibility (LIC 308) -Administrator Certificate -LIC501 Per California Code of Regulations, Title 22, the following deficiencies are cited. See LIC 809-D. Exit interview was held, a copy of the report was given and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 24, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 25, 2022

Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met by as evidenced by: Based on Licensing Information System (LIS) reviewed staff S1, S2 and S3 are not currently fingerprint cleared or associated to the facility. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Effective immediately, the Administrator shall ensure that S1 and S2 do not work until fingerprint clearance and association is obtained. Administrator shall send proof to CCL prior to allowing S1 and S2 to work at this facility and shall send proof to CCL of fingerprint clearance and association. Staff S3 has been associated during this visit. Civil penalties have been assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405 · Plan of correction due date: Mar 25, 2022

Administrator - Qualifications and Duties (a) All facilities shall have a certified administrator. This requirement was not met by as evidenced by: LPAs reviewed administrators’ documentation and Licensing Information System (LIS), the facility did not have a certified administrator. This poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 24, 2022

Plan of correction: Facility agrees to provide LPA by 3/25/2022 the following: LIC 200, LIC 308, LIC 501, administrator schedule, and certificates.

Type of visit: Required - 1 Year

On 12/13/2021 at 8:45 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called the facility and spoke to staff, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. Upon LPAs arrival, staff Serena Marquez was present at the front desk and contacted Administrator Lisa Poole-Johnson who arrived a bit later. LPA met with Administrator Lisa Poole-Johnson explained the purpose of today’s visit. Administrator holds current certification #6033977740 and expires on 2/2/2023. The facility is licensed to serve seventy (70) non-ambulatory residents. Hospice waiver approved for 15. There are currently nineteen (19) residents who reside at this facility. LPA toured the facility with Lisa Poole-Johnson on 12/13/2021 at 9:40 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry rooms, medication room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water measured in the kitchen, restroom and resident’s room were within the required range of 105-120 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. Medications, toxins, and knives were inaccessible to residents. Report continued on 809-C Smoke detectors are present in every room and throughout the facility. Facility also has carbon monoxide detectors. Fire extinguishers and first aid kit were up to date. LPA also conducted the infection control domain tool. The facility mitigation plan was submitted to CCLD, and it was approved on 6/17/2021. Facility has digital sign-in/screening system for residents, staff, and visitors. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan. Administrator was informed to send updated copies of the following documents to CCL within 15 days: (1) LIC308 Designation of Administrative Responsibility (2) LIC500 Personnel Report (3) Copy of Administrator Certificate (4) LIC610 Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC309 Administrative Organization Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. An exit interview was held and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2021