The Gardens at Park Balboa

Allegation investigated: . Facility staff failed to provide timely access to resident's records

LIcensing Program Analyst (LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and met with Katia Arriaga, Business Manager. Dion Gallarza was off today. The reason for today's visit was explained. During today's visit, LPA Yee interviewed the Business Manager at 9:40am, the Administrator via telephone at 10:25am and Adam Khalifa, CEO at 10:56am regarding the request for documents for Resident #1. Per complaint received, a formal request to provide a copy of Resident #1's records were faxed over to the facility on 10/6/23 by the legal representatives of Resident #1. Also included with the request were supporting authorization documents: a Declaration of Successor in Interest, a Authorization for Release of Medical Information signed by the next of kin and a copy of Resident #1'a death certificate was faxed over Substantiated to the facility on 10/6/23. Attached to the complaint received, was a fax confirmation that the 8 page fax was successfully sent to the facility at 1:24pm with a connection time of 8.22 minutes. Per complainant, as of the filing date of this complaint, the legal representatives of Resident #1 have not been provided with the requested documents or have not been contacted by the facility to make arrangements to allow for the copying of the requested documents within the required time frame that is not to exceed 2 business days. Per interviews conducted, with Katia Arriaga, Business Manager, the facility received a four page fax from the legal firm hired by the family to represent Resident #1 on 10/6/23. The four pages consisted of the fax cover, a blank page, a one page Declaration that the son was the beneficiary to Resident #1's estate and a copy of an illegible death certificate. The fax did not include a copy of the letter requesting Resident #1's file. The fax was given to the Administrator. Per review of the fax received, the fax cover indicates that the fax consisted of a 8 pages, which includes the fax cover. There is also a note on the fax cover that advises the recipient that if you do not receive the number of pages stated above or if re-transmission is necessary, to please contact the firm at the telephone numbers provided on the letterhead. No telephone call was made to obtain the missing pages not received on 10/6/23. Per the Administrator, contact with the legal representatives was not made until 10/12/23 to request a legible copy of the death certificate and he was advised that the death certificate would still be dark and illegible. The documents were requested to be emailed and was not received until 10/13/23. The documents were then forwarded to the corporate office for handling by the facility's attorney since the documents were related to a pending lawsuit against the facility. Per interview with the facility CEO, the request was not received until 10/13/23 and they are in the process of providing the documents. They did not refuse to provide the documents. LPA Yee and Katia advised the CEO that the request was originally faxed over on 10/6/23 and they had 2 days to make Resident #1's file available for copying. As of this visit, Resident #1's file has not been provided or made available to the legal representatives. Based on the information received from interviews conducted on today's visit, the above allegation is substantiated. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted with Katia Arriaga, Appeals Rights discussed and a copy was given.the state’s words, verbatim · CDSS document, Oct 16, 2023 · control 29-AS-20231011072146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Oct 23, 2023

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, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. Facility failed to provide timely access to Resident #1's filesthe state’s words, verbatim · CDSS document, Oct 16, 2023

Plan of correction: The Licensee will immediately contact the contact person noted on the request at the law firm to schedule a time when they may have access to Resident #1's file for copying. Licensee will provide a signed statement to Licensing stating the arrangements that have been made and agreed to by the facility and the legal representative to allow access to Resident #1's files by no later than POC date - 10/23/23,

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced subsequent required Annual Inspection to continue the annual inspection that was initiated on 9/27/23. The complete CARE Inspection Tool was used and the visit was conducted with Dion Gallarza, Administrator. The reason for the return visit was explained. On today's visit the following domains were reviewed: Personnel Records Training, Resident Rec-Incident Reports, Resident Rights Information, Planned Activities, Food Service, Incidental M &D, Disaster Preparedness and Residents with SHN. Due to time constraints, LPA Yee was not able to review the Physical Plant and Environmental Safety Domain. A return visit will have to be conducted to complete the last domain. Facility files, training records, 10 resident files and the Emergency Disaster Plan were also reviewed during today's visit. Per review of the information requested for in each domain reviewed, there were no deficiencies observed. On today's visit, LPA Yee also delivered the Immediate Civil Penalties that were assessed for the deficiency cited as a result of the substantiated findings for complaint #29-AS-20220601142537 on 4/7/23. No deficiencies were cited on today's visit. Exit interview was conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Sep 28, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. The visit was conducted with Dion Gallarza, Administrator and the reason for today's visit was explained. The facility is a large 2 storey commercial building that consists of 101 resident bedrooms, 59 rooms are located downstairs and 42 rooms are upstairs. Bedrooms all have full private bathrooms. The first floor houses the main offices, dining room, kitchen and the lounge in addition to the resident bedrooms and the second floor has 2 offices, activity room for arts and crafts and the remaining resident rooms. The facility is licensed for 120 residents and 40 may be Non-ambulatory. The following domains were reviewed on today's visit: Infection Control, Operational Requirements and Staffing. Due to time constraints, the remaining domains will be reviewed on a return visit. During today's visit, LPA Yee reviewed the Infection Control Plan and portions of the Plan of Operations relevant to the 3 domains reviewed. 10 staff files were also reviewed. Citations were issued based on the deficiencies observed during the review of the 3 domains. Any deficiencies not cited on today's visit will be cited on a return visit. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview was conducted, Appeals Rights were discussed and a copy was given. .the state’s words, verbatim · CDSS document, Sep 27, 2023

Allegation investigated: Staff stole residents personal belongings. Staff stole residents medication.

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit to deliver the findings on the above allegations. The LPA met with Buisness Office Manager Katia Arriaga and explained the reason for the visit. On 6/1/2022, LPA Salia Walker, conducted an interview with the Administrator from 9:30 a.m. until 10:06 a.m. From 10:20 a.m. until 11:45 a.m., the LPA conducted interviews with facility residents. On 2/15/2023, LPA Campos spoke with Administrator Dion Gallarza, collected documents at 11:00 a.m., conducted interviews with facility staff at 11:35 a.m.,11:41 a.m. and 2:57 p.m. and conducted interview with resident at 3:09 p.m. **Continued on LIC 9099-C** Unsubstantiated Regarding the allegation: Staff stole residents personal belongings. It is being alleged that staff stole Resident’s personal belongings. To investigate, the LPA conducted interviews with residents and staff. Interviews revealed that the staff in question is no longer employed at the facility for unrelated reasons and was dismissed from their position about 3 years ago. Interviews with resident’s denied claims of any missing belongings. Initial complaint report with the name of the staff who allegedly took resident’s property, date when the incident possibly occurred were not consistent. Of the staff named, interviews with staff denied witnessing staff taking and/or stealing any resident belongings. Administrator Dion Gallarza informed and confirmed to the LPA that they do not have a staff by the name that was provided or that they have had any incidents of residents missing personal belongings. Residents further expressed positive experiences at this facility and denied otherwise observing or experiencing staff stealing personal belongings from residents. Based on the information obtained, there is insufficient evidence to support the claim that facility staff stole residents’ personal belongings. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Staff stole residents medication It is being alleged that staff stole Resident’s medication. To investigate, the LPA conducted interviews with residents and staff. Interviews revealed that the staff in question is no longer employed at the facility for unrelated reasons and was dismissed from their position about 3 years ago. Interviews with resident’s denied claims of any missing medications. Initial complaint report with the name of the staff who allegedly took resident’s medication, date when the incident possibly occurred were not consistent. Of the staff named, interviews with staff denied witnessing staff taking and/or stealing any resident medication. Administrator Dion Gallarza informed and confirmed to LPA that they do not have a staff by the name that was provided or that they have had any incidents of residents missing medication. Residents further expressed positive experiences at this facility and denied otherwise observing or experiencing staff stealing residents’ medication. Based on the information obtained, there is insufficient evidence to support the claim that facility staff stole residents’ medication. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 7, 2023 · control 29-AS-20220531101335

Allegation investigated: Staff handled resident in a rough manner resulting in injury

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit to deliver the findings on the above allegation. The LPA met with Buisness Office Manager Katia Arriaga and explained the reason for the visit. On 6/6/2022, LPA Salia Walker conducted a physical plant tour with Administrator Dion Gallarza at 9:58 a.m. From 10:07 a.m. until 10:20 a.m., the LPA conducted an interview with facility staff. From 10:22 a.m. until 10:25 a.m., the LPA conducted an interview with the complainant. On 2/15/2023 LPA Campos spoke with Administrator Dion Gallarza, collected documents and reviewed police report at 11:00 a.m., conducted interviews with facility staff at 2:20 p.m. and 3:30 p.m. **Continued on LIC 9099-C** Substantiated Regarding the allegation: Staff handled resident in rough manner resulting in injury. Concerns were that a facility staff handled a resident in a rough manner resulting in injury. It was alleged that resident #1 (R1) was pushed to the ground by staff #1 (S1). Witness to the incident, Staff #2 (S2), indicated that as they were approaching R1’s room and they could hear that R1 and S1 were arguing. S2 observed that S1 was blocking R1 from exiting their room as R1 was allegedly trying to leave their room to look for their family member. R1’s family member was not present in the facility; this urge was generated by R1’s dementia. The resident became agitated and reportedly pushed S1 and then S1 became agitated with R1 and subsequently pushed them, resulting in R1 falling to the ground. As a result of the fall, R1 sustained a minor cut above the corner of their left eye. R1 has dementia, refused to be interviewed by LPA Walker and had no memory of the incident based on other interviews. Interviews revealed that Staff #3 (S3) arrived to help S2 after S1 had pushed R1, resulting in a fall. S3 stayed with R1 until paramedics arrived while S2 went to get the in touch with the Administrator. The Administrator contacted the police on the day of the incident, the police report indicated that R1 was upset due to a Dementia episode and pushed S1. S1 became upset and grabbed R1’s right arm and pushed R1 to the ground causing their head to bleed. Paramedics arrived and administered First Aid to R1 at the facility. The paramedics cleared R1 to remain at the facility as per R1’s request. Interviews with S2 confirmed that S1 had pushed R1 to the ground. S2 stated that when they asked S1 ‘why did you do that?, S1 denied that they knew what happened. The LPA’s interview with S1 did not confirm or deny the above allegation as they stated that they did not recall the incident. The Administrator conducted an investigation into the incident and indicated that S1 had recognized that R1 had fallen but claimed their mind had gone blank and did not provide further explanation to the administrator. The administrator further explained that S1 did not defend themselves against the allegation or say it was an accident and only continued to claim that their mind went blank. **Continued on LIC 9099-C** The administrators interview with S2 explains that S2 confirmed that they saw S1 shove R1. The Administrator interviewed R1; however, R1 was unable to recall the incident as they were diagnosed with Dementia. The LPA’s interview with the Administrator Dion Gallarza confirmed that S1 was sent home, suspended, pending an investigation, and ultimately terminated from their position with the belief that they did violate company policy 4.2 Standards of Conduct and 8.4 Policy against workplace violence by pushing R1 back after being pushed by R1, which resulted in R1 sustaining a fall. Based on the information obtained during the course of the investigation and interview conducted, it was confirmed that staff #1 (S1) did handle the resident roughly which resulted in an injury. Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):the state’s words, verbatim · CDSS document, Apr 7, 2023 · control 29-AS-20220601142537

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Apr 11, 2023

1569.269 Enumerated rights; severability (a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from ... verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the resident was handled roughly by staff resulting in an injury which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 7, 2023

Plan of correction: The administrator agreed to the following: To provide a scheduled date for staff in-service regarding regulation 1569.269(a)(10) to CCL by 4/11/23. Administrator will provide documentation of staff in-service to CCL by 4/21/23.

Allegation investigated: Staff failed to prevent resident from being bullied by another resident Staff failed to provide a safe and comfortable environment for resident

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver findings to the above facility. LPA Ascencio met with Executive Director (ED) Dion Gallarza at 10:40 a.m. Entrance interview conducted. On 01/23/2023, the Department received a complaint alleging that staff failed to prevent from being bullied, and staff failed to provide a safe and comfortable environment for resident. On 01/27/2023, LPA Ascencio met with Executive Director (ED) Dion Gallarza at 12:32 p.m. Interview with ED Gallarza revealed that Resident #1 (R1) and R2 had a verbal altercation during breakfast on 01/21/2023. R1 was sitting at a dining room table, were R2 normally sits. Around 7:00 a.m., R2 walked into the dinning screaming and yelling at R1 after observing R1 at the table. ED Gallarza stated that there is open seating at the dining room, but R2 is adamant on sitting at this table. R1 and R2, at one point in time were friends, then it changed. Continued on LIC 9099 - C Unsubstantiated ED Gallarza added that they obtained reports of the altercation from a kitchen staff and Activity Director who stepped in to stop R1 and R2. ED Gallarza lastly added that they spoke to R1 and R2 separate and re-iterated the importance of code of conduct from resident and the facility house rules. ED Gallarza said they have tried to keep R1 and R2 apart during meals, and activities but it is a difficult challenge if both want to attend the same event. Staff are aware of the situation between them and if in the same room, staff are instructed to seat residents at opposite sides of room. Although resident have the right to attend any event within the facility, staff are fully aware of the history between R1 and R2 if both are in an activity, thus with staff knowledge, it minimizes the opportunity of residents being bullied. That same day, interview with Staff #1(S1) at 1:25 p.m. and S2 at 2:00 p.m., confirmed what ED Gallarza stated. Interviews with staff revealed that they observed R2 walk up to R1 and started to yell during breakfast. S1 stated they walked between the R1 and R2 and told them to stop yelling as the dining room is open seating. S2 added that R2 was yelling while R1 sat there at the table. Staff stated that after intervening, R2 stopped yelling, and sat at the opposite side of the dining with no further incident. Later that same day, interview with R2 at 2:30 p.m., confirmed what ED Gallarza and staff stated. Additionally, R2 added that they do not recall what was said, but R2 confirmed that they yelled at R1 for sitting at this table. R2 lastly added that a staff and another resident intervened and walked R2 out of the dining room. Even though R2 presented with behaviors during the morning mealtime, staff was quick to respond and intervene to provide a safe environment for all residents in the dinning room. Interview with R1, on 03/14/2023 at 1:50 p.m., confirmed what was previously stated by the ED, staff and R2. Lastly, R1 added that staff have been doing a great job separating both residents to prevent any future altercations. Staff interviews on 03/27/2023, starting at 12:30 p.m., revealed that staff are helpful and due their diligence to provide the best care possible for resident. Additionally, they have not heard of any staff yelling at residents. Lastly, staff communicated the procedure if there were to be any verbal or physical altercations between the residents. That same day, resident interviews, starting at 12:37 p.m. revealed that the staff are very nice and helpful. Additionally, staff have not yelled, or been disrespectful in any way toward any resident. Lastly, resident interviews added that do not feel bullied or intimidated, but instead, feel safe and comfortable living at this facility. Continued on LIC 9099 - C The Department acknowledges the staff are unable to be present during all incidents, as R1 and R2 do not require 1:1 supervision. Yet, when staff were alerted to the disagreement between R1 and R2, staff appropriately intervened with the intention of creating a safe environment for all residents, including R1 and R2. Staff and resident interviews supported claims that resident felt safe and supported while residing in this community. Residents feel that if disagreements occur, staff appropriately intervene and prevent other residents and or other parties from feeling intimidated or bullied. Based on evidence gathered throughout the investigation, there is insufficient evidence to support the claims of staff failed to prevent resident from being bullied and staff failed to provide a safe and comfortable environment for residents. Thus, the allegations are deemed Unsubstantiated at this time. Exit interview conducted and copy of the report was issued to ED.the state’s words, verbatim · CDSS document, Mar 27, 2023 · control 29-AS-20230123092638

Allegation investigated: Staff do not ensure a safe and healthful environment by accord dignity in their relationship with a resident Staff yelled at a resident

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver findings to the above facility. LPA Ascencio met with Executive Director (ED) Dion Gallarza at 10:40 a.m. Entrance interview conducted. On 01/23/2023, the Department received a complaint alleging that staff do not ensure a safe and healthful environment by according to dignity in their relationship with a resident and staff yelled at a resident. On 01/27/2023, LPA Ascencio met with Executive Director (ED) Dion Gallarza at 12:32 p.m. Interview with ED Gallarza revealed that Resident #1 (R1) has been wanting a room upgrade for some time, but the rooms R1 would like to move into were unavailable. Eventually a room became available, and our Marketing Director (MD) gave R1 a tour of the room. Continued on LIC 9099 - C Unsubstantiated MD called asking me to join them. ED Gallarza added that R1 has a history of accusation towards the staff, because of this, two (2) staff are always present when speaking with R1. When ED Gallarza arrived, R1 was visibly upset and yelling at MD. ED Gallarza added that R1 wanted to paint their new room a different color than what the facility provides. ED Gallarza gave R1 the choice to buy their own paint and would be happy to paint the room in that color, free of charge. R1 left the room yelling and cursing at MD and ED Gallarza. That same day, interview with MD, at 1:40 p.m. confirmed what ED Gallarza stated. MD added that R1 was yelling and cursing at ED Gallarza and MD, both of which acted professional as they attempted to explain the situation to R1. MD stated they have been professional towards every resident, staff and visitor and has not witness anyone yell at residents. Interview with R1 on 03/27/2023, starting at 12:43 p.m. confirmed what ED Gallarza and MD stated, but , R1 added that ED Gallarza and MD yelled, intimidated and threatened R1. R1 added that they are unhappy living here and would prefer to move to another place. R1 added that they eventually moved into the new room, but despite not having the room painted the way they wanted, it is nice to have a bigger room with an outdoor area. Staff interviews on 03/27/2023, starting at 12:30 p.m., revealed that staff are helpful and due their diligence to provide the best care possible for resident. Additionally, they have not heard of any staff yelling at residents. Lastly, staff stated they are always respectful and professional at all times when helping residents. That same day, resident interviews, starting at 12:37 p.m. revealed that the staff are very nice, helpful, and professional. Additionally, staff have not yelled, or been disrespectful in any way toward any resident. Lastly, resident interviews added that they feel safe and comfortable living at this facility. Although R1 stated that ED Gallarza and MD yelled and threatened R1, interviews with ED Gallarza and MD stated differently by being respectful and professional towards R1. Additionally, staff and resident interviews supported claims that resident felt safe and supported while residing in this community and that staff and management are always professional when dealing with residents. Based on evidence gathered throughout the investigation, there is insufficient evidence to support the claims that staff do not ensure a safe and healthful environment by according to dignity in their relationship with a resident and staff yelled at a resident. Thus, the allegations are deemed Unsubstantiated at this time.Although there was insufficient evidence, LPA Ascencio spoke with ED Gallarza regarding resident rights and code of conduct for staff and residents. ED Gallarza stated they will have staff training on resident rights, as well as having the Long Term Care Ombudsman (LTCO) conduct a presentation with staff and resident regarding resident rights and code of conduct. Exit interview conducted and a copy of the report was issued to ED Gallarza.the state’s words, verbatim · CDSS document, Mar 27, 2023 · control 29-AS-20230124155934

Allegation investigated: Facility staff do not intervene in resident on resident verbal altercations Financial abuse

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint investigation. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit. On 5/16/2022, LPA Salia Walker conducted a physical plant tour, obtained documents pertinent to the investigation, interviewed staff at 1:20 p.m., and 3:00 p.m., interviewed the Administrator at 2:00 p.m.; and interviewed resident(s) at 3:26 p.m. On 1/27/2023, the LPA interviewed staff at 10:00 a.m., toured the facility at 10:15 a.m., interviewed residents at 2:22 p.m., 2:27 p.m. and 2:30 p.m. During today’s visit the LPA interviewed residents at 10:57 a.m. and staff at 11:11 a.m. Continued on LIC 9099-C Unsubstantiated Regarding the allegation: Facility staff do not intervene in resident on resident verbal altercations On the allegation, “Facility staff do not intervene in resident on resident verbal altercations.” – The complainant alleged that Resident #1 (R1) is always screaming and yelling at Resident #2 (R2) for sitting in their place in the dining room and further alleged that staff do not want to do anything about it. Interviews with staff reveled that R1 and R2 have a history of disagreements with one another, which centers around seating in the dining room. R2 denied claims that R1 was ever physically assaultive and began to avoid the dining room to stay away from R1. Interviews with residents revealed that R1 and R2 do not agree on common issues such as seating arrangements in the dining room. Residents denied claims that R2 was verbally abusive. Residents further expressed positive experiences at this facility and denied otherwise the lack of response from staff. Information obtained through other resident interviews found that if residents argue staff intervene when needed. Staff noted that in order to mitigate concerns between R1 and R2, staff will talk to the involved parties and de-escalate the situation at the time if required. The administrator further confirmed that an investigation is conducted with parties involved to find resolution amongst residents who are in the disagreement. Based on the information obtained, there is insufficient evidence to support the claim that facility staff do not intervene in resident on resident verbal altercations. This allegation is deemed Unsubstantiated at this time. Continued on LIC 9099-C Regarding the allegation: Financial abuse On the allegation, “Financial abuse.” – The complainant alleged that Resident #2 (R2) was charged $100 for tray service for the month of March 2022 which they were not in need of. R2 stated that they were told that they would be provided with tray service at no charge if they could not go to the dining room. Interviews with R2 revealed that they were not feeling well and had requested tray service but were told they would not be charged. Interviews with staff denied claims that R2 would not be charged. The facility will waive a tray passing charge if the resident is in fact sick or unable to go to dining room for medical reasons. Interviews with staff revealed that R2 was credited back five (5) tray passing services for the month of March 2022 and charged for the remainder of the services as R2 simply did not want to go to the dining room to avoid another resident. Staff confirmed that a conversation was had with R2 to clarify the discrepancy. A record review confirmed that R2 was tray passed fifteen (15) times in the month of March and charged for ten (10) instances. The complainant further alleged that R2 was told that the administration of medication would be three hundred ($300) a month but is being billed four hundred ($400) a month. A record review revealed that R2 had signed an agreement agreeing to the administration of medication being billed at four hundred and eleven dollars ($411) a month. Based on the information obtained, there is insufficient evidence to support the claim of financial abuse. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued to the Administrator.the state’s words, verbatim · CDSS document, Jan 31, 2023 · control 29-AS-20220511104201

Allegation investigated: Due to lack of care and supervision resident was verbally abused by another resident.

Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for a subsequent complaint investigation. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit. On 4/28/2022, LPA Ashley Smith obtained documents, interviewed staff at 9:19 a.m., 9:40 a.m., 9:50 a.m., and 9:54 a.m.; and interviewed residents at 10:03 a.m., 10:34 a.m., 10:57 a.m., and 11:08 a.m. During today's visit, the LPA interviewed staff at 10:00 a.m. and toured the facility at 10:15 a.m. Continued on LIC 9099-C Unsubstantiated Regarding the allegation: Due to lack of care and supervision resident was verbally abused by another resident. The complainant alleged that a resident was being verbally abused by another resident. To investigate, the LPA conducted interviews with residents and staff. Interviews revealed that the residents have a history of picking fights with one another however it is not due to a lack of care and supervision. Resident #1 (R1) indicated that although they tried to establish a friendship with Resident #2 (R2) they just did not click. R1 stated that they only wanted to be left alone and denied claims that R2 was ever physically assaultive and began to avoid the dining room to stay away from R2. R2 expressed that R1 now sits with a group of residents that R2 used to sit with and were friends with. R2 indicated that they believe R1 did not want them to have any friends. Interviews with residents revealed that R1 and R2 do not agree on common issues such as seating arrangements in the dining room. Residents denied claims that R2 was verbally abusive. Residents further expressed positive experiences at this facility and denied otherwise overhearing, observing, or experiencing any verbal abuse from residents. Based on the information obtained, there is insufficient evidence to support the claim that due to lack of care and supervision resident was verbally abused by another resident. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued to the Administrator.the state’s words, verbatim · CDSS document, Jan 27, 2023 · control 29-AS-20220422093102

Allegation investigated: Staff failed to treat resident with dignity and respect Licensee is not assisting resident with arranging transportation for medical care Grab bars not placed appropriately

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue findings for the above allegations. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit. On 11/7/2022, the LPA and the Executive Director toured the facility from 10:30 a.m. – 12:00 p.m. During the tour, the LPA and the Executive Director entered thirteen (13) randomly selected rooms and inspected the installed grab bars, tested the wall pendants, and checked the water temperature. In addition, the LPA interviewed seven (7) residents from 10:30 a.m. – 12:00 p.m. The LPA also reviewed documents pertinent to the investigation, and conducted staff interviews at 9:42 a.m. and 11:00 a.m. The LPA spoke with Resident #1 (R1) on 11/7/2022 at 3:55 p.m. and on 11/22/2022 at 11:25 a.m. Unsubstantiated Regarding the allegation: Staff failed to treat resident with dignity and respect It was alleged that staff were disrespectful to Resident #1 (R1). Interviews confirmed that there had been interactions between staff and R1, in which R1 felt that they were accused of lying. Staff said that they had attempted to clarify situations with R1, but staff denied claims that they had ever accused R1 of lying and said they never called R1 a ‘liar’. Staff claimed that in discussion with R1, staff has attempted to clarify situations and provide additional context yet did not perceive their interactions as disrespectful. Staff denied ever cutting R1 off or speaking to R1 in a rude tone. Information obtained from interviews revealed that residents felt that staff were respectful in their approach and denied claims of ever feeling disrespected by the staff. Residents did not have any negative things to say about the staff. Based on the information obtained, there is insufficient evidence to support the claim that staff failed to treat resident with dignity and respect. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Licensee is not assisting resident with arranging transportation for medical care. It was alleged that staff failed to assist the resident with arranging transportation for medical care. The Executive Director confirmed that if there are changes to the transportation schedule or the availability, they will send out a memo to the residents. The Executive Director communicated that in the event that there is an issue with the facility provided transportation, they will assist residents with securing transportation from a third party, or in some cases, they will arrange transportation for residents free of charge. During the tour, the LPA observed that the transportation notices are posted on the bulletin board in the front hallway. An interview with Resident #1 (R1) confirmed that R1 believed the transportation schedule was not conducive to residents with multiple doctor’s appointments and personal appointments. However, interviews with residents confirmed that they are aware of the transportation protocol and have communicated no issues with utilizing the transportation provided by the facility. Residents interviewed stated that they are aware that for the most part, appointments to use transportation must be scheduled in advance. Based on the information obtained, there is insufficient evidence to support the claim that the licensee failed to assist the resident with arranging transportation for medical care. This allegation is deemed Unsubstantiated at this time. Regarding the allegation: Grab bars not placed appropriately. It was alleged that the grab bars in R1’s room were not appropriately placed. Interviews confirmed that the resident bathrooms are equipped with two grab bars in the shower. Interviews confirmed that at the request of the resident, the facility will install additional grab bars per their preference. Staff claimed that consistent conversation was had with R1 regarding where R1 wanted the grab bars to be placed. Per the request, the facility installed three (3) additional grab bars. However, R1 did not like the width of the newly installed bars and requested three (3) new grab bars to replace the ones that were installed. Conflicting information was shared regarding the installation of the grab bars; whereas staff claimed that they attempted to accommodate R1’s specifications, R1 felt that the staff failed to follow R1’s instructions to ensure proper placement. The LPA reviewed a document entitled ‘Grab Bar Modification’, in which the facility documented their efforts in accommodating R1’s request for additional grab bars and documented the specifications of the newly placed grab bars. This document was signed by both the Executive Director and R1 and was dated 10/17/2022. Although R1 is moving into a new room in the coming weeks, the staff agreed to install additional grab bars in R1’s new room per R1’s request. During the LPA’s tour on 11/07/2022, the LPA observed that grab bars were placed in the shower/bathtub unit. Staff claimed they were placed per the direction of R1. Each grab bar observed appeared to be in good condition and securely fastened. Based on the information obtained, there is insufficient evidence to support the claim that grab bars were not appropriately placed. At R1’s request for additional grab bars, the facility accommodated. Per Title 22 Regulations, the grab bars in the resident showering unit shall be appropriately placed. This allegation is deemed Unsubstantiated at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 22, 2022 · control 29-AS-20221104114834

Allegation investigated: Call buttons not working Water temperature not within required range.

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day complaint visit. The LPA met with Executive Director Dion Gallarza and explained the reason for the visit. During today’s visit, the LPA and the Executive Director toured the facility from 10:30 a.m. – 12:00 p.m. During the tour, the LPA and the Executive Director entered fourteen (14) randomly selected rooms and inspected the installed grab bars, tested the wall pendants, and checked the water temperature. In addition, the LPA interviewed seven (7) residents from 10:30 a.m. – 12:00 p.m. The LPA also reviewed documents pertinent to the investigation, and conducted staff interviews at 9:42 a.m. and 11:00 a.m. CONT 9099-C Substantiated Regarding the allegation: Call buttons not working It was alleged that Resident #1’s call button was not working. Interviews confirmed that Resident #1 (R1) suffered a fall on 11/03/2022, in which S1 and S2 responded to the incident. Interviews noted that R1 had pressed their call button on the wall, yet upon pressing it, discovered it was not working. Interviews with S1 and S2 confirmed that they observed that R1’s call button on the wall was not working and attempted to fix it in the moment. The LPA checked the call button on the wall in R1's bathroom at 11:55 a.m. and it was operable at the time of observation. During today’s physical plant tour, the LPA and Executive Director identified that Rooms 100, 104, and 260 did not have a call button installed in the unit. It was communicated that it was possible that the call buttons in those rooms were being repaired or checked. Based on the information obtained from observations and interviews, there is sufficient evidence to support the claim that the call buttons were not working. This allegation is deemed Substantiated at this time. Regarding the allegation: Water temperature not within required range It was alleged that the water temperature was registering above 120 degrees Fahrenheit, which is outside of the range per regulation. During today’s physical plant tour, the LPA and Executive Director identified that the water temperature registered above 120 degrees Fahrenheit in rooms 104, 122, 126, and Room 212, which is R1’s room. Based on the information obtained from observations and interviews, there is sufficient evidence to support the claim that the water temperature was not within the required range as per regulation. This allegation is deemed Substantiated at this time. Pursuant to the California Code of Regulations, Title 22, Division 6, the following deficiency was observed and cited during the visit. See LIC 9099-D. Exit interview conducted. Appeal rights discussed. Copy of report issued.the state’s words, verbatim · CDSS document, Nov 7, 2022 · control 29-AS-20221104114834

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 9, 2022

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above, as R1's call button was inoperable on 11/3/2022 and 3 out of 14 rooms did not have a call button in the resident unit, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Check all signal units in each resident room to ensure the signal unit is operational. Inform CCL when this has been completed, but no later than 11/09/2022, end of day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Nov 8, 2022

87303(e)(2) Maintenance and Operation. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as water temperature measured above 120 degree F in four (4) out of fourteen (14) rooms, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2022

Plan of correction: The Administrator has agreed to do the following: 1. Adjust the water boilers within the next 24 hours. 2. Conduct a 3 day water temperature log for ten rooms spread throughout the facility. Include rooms 104, 122, 126, and 212. Submit log no later than 7/16/2022.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Dion Gallarza and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: The LPA toured the common spaces in the Assisted Living community and in the Safe Haven (Memory Care) community. Common areas were observed to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 75 degrees Fahrenheit. There are fire extinguishers throughout the community, which were fully charged. The Executive Director communicated that the fire extinguishers, generator, and sprinkler system would be inspected by an outside company in September 2022. Laundry room(s) were locked at the time of the visit. Activities: Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging with residents in the Assisted Living and Safe Haven (Memory Care) community. Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The facility uses Sysco and US Foods for food delivery. The menu was posted, and the facility offers an alternate menu. Restrooms: Common restrooms were observed, and the LPA observed signs in the restrooms that promoted good hand hygiene. Restrooms were fully stocked with paper towels and soap. The LPA tested the water temperature in the common restroom on the first floor, which measured at 120.8 F. Exterior Grounds: The LPA observed several courtyards throughout the community, which had adequate furniture with a covered shaded area for residents. No bodies of water noted at this time. Infection Control: Throughout the visit, the LPA observed signs in common areas that promoted guidance around COVID-19, appropriate masking, physical distancing, and the disinfection protocol. Staff were observed wearing the appropriate face coverings. In addition, the LPA observed hand sanitizer interspersed throughout the common grounds. The community continues to monitor the vitals, symptomatic screening, and temperatures of the staff and visitors that come into the community. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The cleaning and sanitation protocol is adequate. The community is not experiencing any issues with staffing or obtaining Personal Protection Equipment (PPE) at this time. The LPA will submit a request for additional N95 masks and gloves. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The community's policies and procedures as it pertains to infection control are adequate. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 26, 2022

Allegation investigated: Faucets used by residents for personal care such as shaving and grooming do not deliver hot water

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for an initial complaint inspection for the above allegation. The LPA met with Administrator Dion Gallarza at 8:25 a.m., and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour with Dion Gallarza, Administrator at 11:00 a.m. From 8:40 a.m. until 9:00 a.m., the LPA conducted an interview with the administrator; and obtained copies of documents pertinent to the investigation. From 9:15 a.m. until 11:00 a.m., the LPA conducted interviews with facility residents. Continue on LIC9099C.. Unsubstantiated Regarding the allegation, ‘Faucets used by residents for personal care such as shaving and grooming do not deliver hot water,’ the complainant’s concern is that the facility had no hot water for 10 days. The complainant is also concerned that the facility is not following Title 22 Regulation section 87303(e)(2), and maintaining the hot water temperature between 105 and 120 degrees Fahrenheit. According to the complainant, the facility’s hot water temperature is usually ‘130 degrees F.’ To conduct the investigation, the LPA conducted a physical plan tour from 11:00 a.m. until 12:00 p.m. During the physical plant tour, a random selection of ten (10) resident rooms were inspected, and water temperatures were measured. Ten (10) out of ten (10) resident rooms hot water temperatures measure between 110.2 and 118.7 degrees Fahrenheit. During the investigation, LPA Walker conducted a record review, interviews with the Administrator, and facility residents. Record review revealed that the facility had one (1) water heater removed which was damaged, and replaced on 06/29/22. Interview with the administrator revealed that on or about 06/21/22, residents notified the front desk that they had no hot water. Interview with the Administrator also revealed that the facility had four (4) different plumbing companies attempt to fix one (1) out of four (4) boilers, when a leak was discovered in the facility boiler room. According to the Administrator, from 06/22/22 through 06/29/22, the facility provided residents with updating Letters notifying residents of disrepair, and offered the residents alternative rooms with hot water while repairs were being made; as well as notification on 06/29/22, that ‘the Boiler was replaced, and the hot water should be up and running.’ Interviews with facility residents revealed that the facility hot water was working on half of the building, and that staff offered the residents the next day vacant rooms to shower. Interviews with facility residents also revealed that staff ‘assisted in helping the residents that did not have hot water by bringing the shower chairs and all supplies’ to the vacant room. Although, one (1) out of four (4) facility’s hot water boilers were in disrepairs causing no hot water to be delivered on half of the building. The facility took immediate action, had the boiler replaced, notified facility residents, and provided alternative means by offering the residents vacant rooms on the half of the building which was delivering hot water until the boiler/water heater was replaced. Continue on LIC9099C.. Additionally, the facility is following Title 22 Regulation section 87303(e)(2), as faucets used by residents for personal care such as shaving and grooming hot water temperature measured not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on LPAs observation, record review, and interviews which were conducted. There is insufficient evidence to support the allegation ‘Faucets used by residents for personal care such as shaving and grooming do not deliver hot water.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted, and a copy of the report was emailed.the state’s words, verbatim · CDSS document, Jul 7, 2022 · control 29-AS-20220629161030

Allegation investigated: Dining hall heater is in disrepair Transportation is not available to residents

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit. The purpose of the visit is to deliver the findings for the above allegations. Upon entry, the LPA met with Administrator Dion Gallarza, and explained the reason for the visit. On 12/21/2021, LPA Walker conducted an initial complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with the Business Office Manager, Katia Arriaga, at 11:36 a.m. From 12:16 p.m. until 12:43 p.m.; and between 3:08 p.m. until 4:12 p.m., the LPA conducted interviews with three (3) staff. From 12:54 p.m. until 1:40 p.m., the LPA conducted an interview with the administrator. From 2:20 p.m. until 3:08 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 4:30 p.m. until 4:49 p.m., the LPA conducted interviews with two (2) facility residents. The LPA determined further investigation was needed at that time. Contine on LIC9099C.. Unsubstantiated On 06/01/2022, LPA Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted interviews with facility residents from 10:20 a.m. until 11:45 a.m. From 12:28 p.m. until 12:40 p.m., the LPA conducted an interview with the Administrator. The LPA determined further investigation was required prior to issuing findings. Regarding the allegation, ‘Dining hall heater is in disrepair,’ the complainant’s concern is that the facility heater in the dining room was in disrepair for 3 weeks. According to the complainant space heaters were provided by the facility. However, the complainant is concerned that the space heaters were placed in an area hazardous to resident. On 12/21/21, LPA Walker conducted a physical plant tour and observed temporary space heaters in the facility dining room. The LPA noted that the facility placed ‘warning signs’ next to all space heaters, and ensured the location of the space heaters were not a hazard to facility residents. During the investigation, LPA Walker conducted a record review, interviews with the Administrator, facility staff, and residents. Record review revealed that the facility had the dining room heater fixed in a timely manner. Interview with the Administrator revealed that the facility provided temporary space heaters to accommodate facility residents until the dining room heater was fixed. Interview with the Administrator also revealed that the company contacted initially came to the facility and fixed the heater. According to the Administrator, after the initial fixture of the dining room heater ‘it broke down again.’ The Administrator stated that the company was contacted once more, and they repaired the dining room heater. However, ‘had to order a new part,’ and it ‘took a while to arrive.’ Interviews with facility staff revealed that the Administrator contacted ‘the company to have the heater fixed,’ and due to the heater needing a part ordered the repairs delayed. Interviews with facility residents revealed that the Administrator informed the residents of the attempts to repair the dining hall heater, and ‘put space heaters’ meanwhile. Interviews with facility residents also revealed that the heater ‘was fixed, but went out again a few days later.’ Based on LPAs observation, record review, and interviews which were conducted. There is insufficient evidence to support the allegation ‘Dining hall heater is in disrepair.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Continue on LIC9099C.. Regarding the allegation, ‘Transportation is not available to residents,’ the complainant’s concern is that the facility bus service was down for a month, and that there is no driver now that the bus is fixed. During the investigation, LPA Walker conducted a record review, interviews with the Administrator, facility staff, and residents. Record review revealed that the facility transportation vehicle is a ‘2006’ year model. Record review also revealed that the facility has had multiple repairs done to the transportation vehicle varying from maintenance, to body parts. Interview with the Administrator revealed that the ‘facility van was in the shop’ for a couple of weeks, and that is has been in disrepair on and off due to it being and older vehicle. Interview with the Administrator also revealed that there was a short period when the facility did not have a driver. However, the Administrator stated that additional staff who were crossed trained assisted in transporting residents to appointments, while the facility hired a new driver. Additionally, the Administrator advised the LPA that the facility provided all residents with alternative transportation services through the means of ride share companies paid by the facility. Interviews with facility staff revealed that the facility ‘bus’ was not operating for approximately a month. Interviews with facility staff also revealed that residents were provided ‘other options of transportation,’ such as ‘Uber, Lyft, and Access’ which was either paid by the facility; or ‘reimbursed to the residents if the ride was placed on their account.’ Interviews with facility residents revealed that the Administrator notified the residents of the ‘bus’ being out of service. Interviews with facility residents also revealed that the facility provided ‘Access, Uber or Lyft’ transportation ‘free of charge.’ Interviews with facility residents revealed that ‘the bus had on going issues, but the staff announced every time if it needed fixing,’ and the ‘facility reimbursed [the residents] for the times they used Uber, Lyft, or Access.’ Based on record review, and interviews which were conducted. There is insufficient evidence to support the allegation ‘Transportation is not available to residents.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted, and a copy of the report was emailed.the state’s words, verbatim · CDSS document, Jul 7, 2022 · control 29-AS-20211217112145

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Salia Walker initiated a Case Management-Incident visit to the facility above. The purpose of this visit is to follow up on a self-reported suspected dependent adult/elder abuse (SOC341), and Unusual Incident Report submitted to the department on 05/28/2022. Upon entry, the LPA met with Administrator Dion Gallarza and explained the reason for the visit. On 5/28/2022, the facility submitted a suspected dependent adult/elder abuse (SOC341), and Unusual Incident Report, alleging that on 5/27/2022, Staff #1 (S1) reported that they witnessed Staff #2 (S2) physically abuse Resident #1 (R1). It was alleged that R1 became aggressive towards S2, to which S2 allegedly reacted and grabbed R1 by the right arm and then pushed R1 to the ground causing bleeding to the left side of R1’s face. S1 alleged that this incident took place in the facility’s “safe Haven” area during a shift switch. S1 notified management of this incident on 5/27/2022. In response, the facility notified the Local Ombudsman, Community Care Licensing, the Los Angeles Police Department, and attempted to contact responsible party for R1 to reported the incident. During today’s visit, the LPA conducted a physical plant tour; interviewed the Administrator at 2:38 p.m.; conducted an interview with staff at 3:30 p.m.; and obtained copies of documents pertinent to the investigation. The LPA observed R1, whom appeared in good health and with no immediate concerns. No immediate health and safety concerns were observed during today’s visit. Further investigation is required prior to issuing findings. Exit interview conducted, and a copy of the report was emailed.the state’s words, verbatim · CDSS document, Jun 1, 2022

Allegation investigated: Staff did not respond to residents call button

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint inspection to deliver the findings for the above allegations. The LPA met with Administrator Dion Gallarza at 9:35 a.m., and explained the reason for the visit. On 02/03/2021, LPA Aja Richardson initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with Administrator Dion Gallarza. At 12:00 p.m., LPA Richardson conducted an interview with the Administrator as well as requested facility resident records. The LPA determined further investigation was required at that time. Continue on LIC9099C.. Substantiated On 04/20/2022, LPA Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with Business Office Manager, Katia Arriaga, at 9:31 a.m. From 9:55 a.m. until 10:45 a.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 11:10 a.m. until 12:30 p.m.; and, between 3:10 p.m. until 3:45 p.m., the LPA conducted interviews with facility staff. From 1:52 p.m. until 3:10 p.m., the LPA conducted interviews with facility residents. The LPA determined further investigation was required at that time. Regarding the allegation, ‘Staff did not respond to residents call button,’ the complainant’s concern is that Resident #1 (R1) had a device that is supposed to alert staff when R1 falls; however, the complainant alleged that they were informed that staff never came after the falls. The complainant is also concerned that when staff did not respond to the call button, R1 then had to yell for staff to assist R1. LPA Walker attempted to contact the complainant and R1’s family member, as R1 passed away, but did not receive a response. LPA Walker also conducted interviews with the administrator and facility staff; as well as a record review. The administrator revealed that R1 had a pendant provided by the facility that detects falls; so, it would have detected if R1 fell. The administrator also revealed that R1 would not wear the pendant. The administrator recalled an incident where R1 was found by the facility Medication Technician (Med Tech) on the floor; however, R1 was not wearing their pendant. According to the Administrator, staff response time to pendant calls is between 1 to 5 minutes; and, the highest wait time would be around 11 minutes. Interviews with staff revealed that facility staff are provided a “pager” that notifies all staff when residents press on their call button or a fall is detected. Staff also confirmed that R1 would take off the pendant and the Med Tech would ask R1 why they kept taking it off. R1 would state that they forgot. There were also times that R1 would take off their pendant and staff had to look everywhere to try and locate it. Interviews with staff also revealed that due to R1’s decline in health condition, the facility had to conduct more routine checks to monitor R1. Continue on LIC 9099C.. Record review revealed that R1 pressed on their pendant on different occasions, and there were times that facility staff responded well above 5 minutes of wait time. In the month of January 2021, there were thirteen (13) different dates R1 pressed on their pendant multiple times, and staff’s response time ranged from 5 minutes up to 26 minutes. Two (2) out of thirteen (13) of these dates’ a response was required, but R1 was never responded to. On 1/19/2021 at 10:11:22 a.m., R1 pressed their pendant “Announced” 9 times. A response was required, but not received; This alert was never responded to. On 1/13/2021 at 5:57:59 a.m., R1 pressed their pendant “Announced” 9 times. A response was required, but not received; this alert was never responded to. Based on interviews which were conducted and record review, facility staff often did not respond in a timely manner when R1 called or pressed their pendant during fall(s), which will be addressed in a case management visit; and, there were at least two occasions in the month of January 2021 that facility staff never responded at all. Therefore, there is sufficient evidence to support the allegation ‘Staff did not respond to residents call button’; as a result, the above allegation is found to be Substantiated. The following deficiency was 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, and appeal rights discussed. A copy of the report, and appeal rights were issued. On 04/20/2022, LPA Walker conducted a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with Business Office Manager, Katia Arriaga, at 9:31 a.m. From 9:55 a.m. until 10:45 a.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 11:10 a.m. until 12:30 p.m.; and, between 3:10 p.m. until 3:45 p.m., the LPA conducted interviews with facility staff. From 1:52 p.m. until 3:10 p.m., the LPA conducted interviews with facility residents. The LPA determined further investigation was required at that time. Regarding the allegation, ‘Facility staff did not seek medical attention for resident,’ the complainant’s concern is that on 01/14/21 resident #1 (R1) made staff aware they were having chest pains and asked the staff to take them to the hospital. The complainant is also concerned that the staff allegedly told R1 the facility had no staff to take R1 to the hospital. Therefore, R1 had to wheel themselves across the street in their wheelchair to the hospital. During the investigation, LPA’s Richardson and Walker conducted interviews with the administrator. LPA Walker also conducted interviews with facility staff and residents. To conduct a thorough investigation, LPA Walker attempted to contact the complainant and R1’s family member; as R1 had passed away. The LPA was unsuccessful in reaching the complainant or R1’s family member. Interviews with the administrator revealed that on 01/14/21, staff called 9-1-1 upon R1 informing them of R1 was not feeling well; however, R1 requested that the facility transport them to the hospital through the facility bus. The administrator revealed that staff advised R1 the facility could not transport R1 in emergency situations. The Administrator stated that the facility does not take residents to the hospital in emergency situations and that staff are to call 9-1-1/paramedics instead, for liability purposes. As a result, the Administrator revealed that R1 took off to the hospital in their motorized wheelchair/ scooter, because R1 did not want to pay for the ambulance. According to the administrator, R1 told staff that the facility could not tell R1 what to do, that R1 was independent, and can go where they wanted. The paramedics arrived at the facility shortly after R1 left. Continue on LIC 9099C.. Interviews with staff revealed that R1 ‘would use their electric wheelchair to go the store,’ and that R1 ‘was more on the independent side.’ Interviews with staff also revealed that R1 used an electric wheelchair to take themselves to the hospital, because R1 ‘did not want to wait for the paramedics,’ and left the facility stating, “I’m independent; if I want to take myself to the hospital, I can!” Interviews with staff confirmed that ‘the facility is not allowed to transport residents to hospitals; and, that staff should ‘call 9-1-1 or call private ambulance.’ Interviews with residents revealed that the facility provides transportation to doctor appointments and that ‘staff calls 9-1-1 if it is an emergency.’ Based on interviews with the administrator, staff, and facility residents, the facility staff do seek medical attention for facility residents by calling 9-1-1 or a private ambulance when needed or requested. Therefore, there is insufficient evidence to support the allegation that ‘Facility staff did not seek medical attention for resident.’ As a result, the allegation is Unsubstantiated at this time. No deficiencies cited. Exit interview conducted, and a copy of the report was emailed.the state’s words, verbatim · CDSS document, May 16, 2022 · control 29-AS-20210125142107

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 23, 2022

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on record review, and interviews conducted, the licensee did not comply with the section cited above as the facility did not respond to two (2) of R1’s calls for assistance, which poses an immediate health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2022

Plan of correction: The Licensee has agreed to do the following: 1. Provide training on Personal Rights and Process and Procedure on the call monitoring system for time efficiency to staff. 2. Submit proof of training to CCLD.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies visit in conjunction with complaint control # 29-AS-20210125142107. At 9:35 a.m., the LPA met with Administrator Dion Gallarza, and explained the reason for the visit. During the investigation of complaint control # 29-AS-20210125142107, LPA Walker spoke with the Administrator. The administrator informed the LPA that Resident #1 (R1) passed away. The LPA advised the administrator that CDSS does not have record of R1’s death report, and inquired as to whether the facility submitted the Death Report to Licensing or the previous assigned LPA. The administrator stated that R1 passed away in a Hospital, and not in the facility. The LPA advised the administrator that a written report shall be submitted to the licensing agency within seven days of any Death of any resident from any cause regardless of where the death occurred, including a hospital. During the investigation, the LPA conducted a record review. Record review revealed, that the facility staff often did not respond in a timely manner when Resident #1 (R1) called or pressed their pendant during fall(s), and/or for different purposes requesting service. On 12/24/2020 at 10:51:33 a.m., R1 pressed their pendant “Announced” 8 times, staff responded at 11:30 a.m. 39 mins after. On 12/22/2020 at 10:43:59 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 11:05 a.m. 22 mins after. On 1/20/2021 at 10:56:48 a.m., R1 pressed their pendant “Announced” 6 times, staff responded at 11:22 a.m. 26 mins after. On 1/17/2021 at 9:30:29 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 9:50 a.m. 20 mins after. On 1/30/2021 at 7:38:17 a.m., R1 pressed their pendant “Announced” 5 times, staff responded at 7:59 a.m. 21 mins after. On 2/18/2021 at 4:42:03 p.m., R1 pressed their pendant “Announced” 4 times, staff responded at 4:59 p.m. 17 mins. On 2/16/2021 at 4:51:10 p.m., R1 pressed their pendant “Announced” 6 times, staff responded at 5:20 p.m. 29 mins after. Continue on LIC 809C.. The LPA advised the Administrator that the facility is responsible for ensuring residents are provided 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. The LPA also advised the Administrator facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Pursuant to Title 22 of the California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were provided.the state’s words, verbatim · CDSS document, May 16, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: May 23, 2022

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing Agency.. the following: (1)A written report.. within seven days of the occurrence of..(A) Death of any resident.. regardless of where the death occurred.. This requirement is not met as evidenced by: Based on record review and interview with the administrator, the licensee failed to comply with the section cited above as the facility failed to submit R1's Death Report as required, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2022

Plan of correction: The Licensee agreed to do the following: 1. Submit a written memo of understanding of the regulation 87211(a)(1)(A) to CCL by 5/23/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 23, 2022

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition.. residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services.. This requirement is not met as evidenced by: Based on record review, and interviews conducted, the licensee did not comply with the section cited above as the facility did not respond to R1’s calls for assistance in a timely manner, which poses an immediate health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2022

Plan of correction: The Licensee has agreed to do the following: 1. Provide training on Personal Rights and Process and Procedure on the call monitoring system for time efficiency to staff. 2. Submit proof of training to CCLD.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: May 23, 2022

87411(a)Personnel Requirements: Facility personnel shall at all times be sufficient in numbers..to provide the services necessary to meet resident needs..facilities licensed for sixteen or more, sufficient support staff.. to ensure..personal assistance and care.. This requirement is not met as evidenced by: Based on record review, and interviews conducted, the licensee did not comply with the section cited above as the facility did not respond to R1’s calls for assistance in a timely manner to meet R1’s needs, which poses an immediate health, safety, personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 16, 2022

Plan of correction: The Licensee has agreed to do the following: 1. Provide training on Personal Rights and Process and Procedure on the call monitoring system for time efficiency to staff. 2. Submit proof of training to CCLD.

Allegation investigated: Facility overcharged resident in care Facility did not provide an itemized statement for resident's care

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit. The purpose of the visit is to deliver the findings for an investigation initiated by LPA Aja Richardson on 03/24/2020. The LPA met with Administrator Dion Gallarza at 12:40 p.m., and explained the reason for the visit. On 03/24/2020, LPA Aja Richardson initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically. At 11:30 a.m., LPA Richardson conducted a telephonic interview with the administrator, John Perdue. The LPA determined, at that time, that further investigation was required. Continue on LIC9099C.. Unsubstantiated On 08/23/2021, LPA Salia Walker conducted an unannounced subsequent visit for the above allegations. Between 12:00 p.m. and 12:41 p.m., the LPA conducted a record review, and obtained copies of records pertinent to the investigation. The LPA determined, at that time, that further investigation was required. On 12/21/2021, LPA Walker conducted an unannounced subsequent visit. From 12:16 p.m. until 12:43 p.m.; and between 3:08 p.m. until 4:12 p.m., the LPA conducted interviews with three (3) staff. From 12:54 p.m. until 1:40 p.m., the LPA conducted an interview with the administrator. Additional copies of documents pertinent to the investigation were reviewed, and obtained The LPA determined, at that time, that further investigation was required. During today’s visit, the LPA conducted a physical plant tour with the Administrator at 1:00 p.m., to ensure there are no health and safety hazards. Regarding the allegation, ‘Facility overcharged resident in care,’ the complainant’s concern is that Resident #1 (R1) was overcharged for the months leading up to 03/2020. The complainant stated R1 received back-payment statements on 02/2020 and 03/2020, for additional services R1 allegedly did not require. To conduct the investigation, LPA Walker conducted a record review and an interview with the Administrator. The record review revealed that R1’s monthly rate was $2700 per month. A $500 deposit was applied to the first month’s rent. R1 had a remaining balance due of $643.80 thereafter. R1 was billed in April 2019, and the facility received payment of $3,232.50; which left a remaining balance of $111.30 due. In May 2019, the facility charged an additional $25 for laundry. That left the balance to be $2,836.30. R1 paid the $2700, however, with the $111.30 remaining due plus the $25, R1’s balances owed was $136.30. In June 2019, R1 was charged $2700. However, May 2019’s check for $2700 was returned, which left an outstanding balance of $5536.30. On June 24, 2019, the facility received payment for $2700. R1 still owed $2700 for the returned check in May, plus the $136.30 left over. It was in the month of June when it was determined that R1 required ‘Assisted Living Services.’ Continue on LIC9099C.. The LPA spoke with the administrator to discuss whether or not R1 had a re-appraisal to where it was determined that R1 required additional services which cost $272.17; and, if the responsible party was notified for the month of June. The administrator acknowledged that there were charge(s) the facility made to R1 for the month of June 2019. There was no record of a re-appraisal, specified charge(s), and that the responsible party was notified. In July 2019, R1 was charged $2700 plus $487.00 for Assisted Living Service, which consisted of incontinent care. The LPA again followed-up to determine if a reappraisal had been conducted and if the responsible party was notified. The facility did not receive any payment in July 2019, which added to the existing balance. On August 1, 2019, R1 was charged the monthly rate of $2700, plus the $487.00 Assisted Living Service, and a charge of $250 late payment fee. On August 12, 2019, the facility received a payment of $2700. On August 23, 2019, the facility issued another late payment fee of $250. From August 2019 through January 2020, the facility received monthly payments of $2700. However, the facility was still charging late payment fees that continued to accrue with an additional laundry charge of $30. Record review revealed that R1’s condition began declining, and the facility provided a pendant on January 2020 for an additional $200 per month. On January 10, 2020, R1’s Assisted Living Services increased to $760.10 due to a ‘Change in condition.’ The LPA followed-up to determine if another reappraisal had been conducted. Although R1’s payments accumulated in $1000 late charges, the facility stopped charging the $250 late fees in November 2019. As noted above, the interview with the Administrator revealed that if staff notice that a resident’s ‘needs and services’ have changed, a re-assessment evaluation is done by the nurse on duty. Interviews also revealed that the facility cannot stop Assisted Living Services to residents if changes in condition require the care. Based on record review, and interviews with the administrator, the facility determined that R1’s health condition was declining, and re-assessments were conducted to account for service charges that were made. The facility had evidence that they notified the responsible party of the reappraisals, and the required Assisted Living Service fee as required. Although in June 2019, there were no records of a re-appraisal, specified charge(s), and that the responsible party was notified in June 2019. The facility 'converted' all outstanding fees owed by R1. Therefore, there is insufficient evidence to support the allegation ‘Facility overcharged resident in care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Continue on LIC9099C.. Regarding the allegation, ‘Facility did not provide an itemized statement for resident's care,’ the complainant’s concern is that R1 did not receive any notices of payment in the previous months. During the investigation, LPA Walker conducted a record review. Record review revealed, that the facility provided invoices, and rent increase notifications to R1 who was responsible for themselves. Record review also revealed, the facility communicated with R1’s family via email regarding assessment and service plan explaining level of care requiring need for additional services. Based on record review, the facility did provide itemized statements for resident #1’s (R1’s) care, and was in communication with R1’s family. Therefore, there is insufficient evidence to support the allegation ‘Facility did not provide an itemized statement for resident's care.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 22, 2022 · control 31-AS-20200311163113