The Vistas at Oxnard Senior Living

Allegation investigated: Insufficient staffing Resident's incontinence needs not being met

Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 3:37 p.m., the LPA met with Administrator, Kortnie Spitznogle and explained the reason for the visit. During the initial visit on 06/14/2022, LPAs Emily Peraldi and Zabel Chochian interviewed the Administrator, requested and reviewed pertinent documents between 10:50 a.m. and 1:25 p.m. Additionally, on 06/14/2022, LPA Peraldi and the Administrator conducted a physical plant tour and LPA Peraldi interviewed six (6) out of fifty-three (53) residents and staff between 1:24 p.m. and 3:25 p.m. On 06/24/2022, LPA Peraldi conducted an interview with hospice nurse. In addition, LPA Peraldi subpoenaed hospice agency records and reviewed documents pertinent to the case on 08/04/2022. Continued on LIC 9099-C. Substantiated Regarding the allegation: Insufficient staffing. It was alleged that at the time the complaint was received, the facility had insufficient staffing due to staff quitting. Interview with Administrator on 06/14/2022, revealed that direct care staff/caregivers often call off or quit. Since direct care staff/caregivers call off or quit, it leads to the Administrator and other Administrative staff covering as caregivers, cooks and bus drivers. The Administrator stated that the Dining Service Director quit on the spot on 05/29/2022, which the Administrator began to act as a cook once a week until the replacement was found on 07/01/2022. The LPAs emphasized that due to the Administrator stepping in and acting as a direct care staff that it takes time away from completing Administrator duties. The Administrator explained that the facility is currently hiring, but the hiring process and training process is not fast enough. Additionally, four (4) out of six (6) residents interviewed on 06/14/2022, stated that the facility is short staffed and that the facility needs more staff. The resident interviews also revealed that the shortage in staffing is causing a delay in getting to the residents on time and meeting the resident’s needs. Staff interview on 06/14/2022, also confirmed the facility has a shortage in staffing and that direct care staff often work one (1) week and quit. Record review conducted on 06/14/2022 of staff schedules for June 2022, confirmed that staff often call off or quit since some shifts are crossed off or staff names are completely crossed off. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Regarding the allegation: Resident's incontinence needs not being met It was alleged that the facility staff did not meet Resident #1 (R1) incontinence needs. Interview with Administrator on 06/14/2022, revealed that the facility staff check on and reposition R1 every 2 hours per shift since R1 was bedridden. During the physical plant tour on 06/14/2022, LPA Peraldi observed a Two (2) Hour Reposition Log and a Bowel Movement Log for June 2022 taped onto R1’s wall near R1’s bed. The Two (2) Hour Reposition Log had missing dates or incomplete dates on 06/03/2022, 06/04/2022, 06/05/2022 and 06/06/2022. Additionally, on 08/04/2022, LPA Peraldi reviewed R1’s hospice records. Hospice records revealed that on 06/06/2022 hospice nurse found R1 saturated in urine, dry stool in groin area, and stool under draw sheet. Interview with hospice nurse conducted on 06/24/2022, confirmed that R1 was found saturated in urine and stool. Based on record review and interview, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated. Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview conducted with Administrator. A copy of the report and appeal rights was provided. Regarding the allegation: Staff did not provide resident with clean linens. It was alleged that the facility does not clean residents’ linens. Interview with Administrator on 06/14/2022, revealed that the facility does not provide linens to residents upon admission and the residents bring their own linens. The Administrator explained that once residents are moved in and have linens, the facility does wash them. The Administrator stated that the facility does wash resident’s linens weekly and ensures that residents have clean linens. Interviews with staff and residents on 06/14/2022, confirmed that the facility does laundry once a week. None of the six (6) residents interviewed complained about the laundry services or about the uncleaned linens. During the physical plant tour on 06/14/2022, LPA Peraldi did not observe dirty or uncleaned linens. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Administrator. A copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 31, 2022 · control 29-AS-20220607135730

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 1, 2022

87411(a)Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2022

Plan of correction: The Administrator agreed to do the following: 1. Submit a Staffing Plan to CCL and updated schedule by 09/01/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Sep 1, 2022

87625(b)(3)Managed Incontinence (b)General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry... This requirement is not met as evidenced by: Based on interview and record review, licensee failed to ensure/meet R1’s incontinence needs which led to R1 being found not clean and dry, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2022

Plan of correction: The Administrator agreed to do the following: Submit a plan of action of how staff manages residents incontinence needs to CCL no later than 09/01/2022.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 7/22/22. LPA met with staff Cynthia Garcia - Business Office Manager. On 7/22/22 Community Care Licensing (CCL) received an incident report from the Administrator Kortnie Spitznogle indicating that resident #1 (R1) was at a music event in the Assisted Living side and Memory Care staff was with the residents. R1 was then found by bystanders on the side of the road. Cops were called to the Community. ED/RSD ran to get R1. R1 was brought home and monitored every 2 hours that day and night. R1 was checked out by EMT. R1 was not taken to the hospital. R1's responsible person was notified. Administrator stated that staff were counciled and they have already set up retraining for 8/3/22 for all care staff. During today’s visit LPA toured the facility with staff Garcia, review resident records and obtained copies of pertinent documents. During the facility tour at 2:24 pm with staff Garcia LPA observed 2 bottles of Weber grill cleaner in back area behind kitchen door accessible to residents. During the facility tour starting at 2:26 pm with staff Garcia LPA observed dish soap, 2 bottles of windex multisurface cleaner, and spic and span antibacterial cleaner in the activity room accessible to residents. During the facility tour starting at 2:41 pm with staff Garcia LPA observed 4 shovels in the back area of the memory care unit accessible to residents. During the facility tour starting at 2:45 pm with staff Garcia LPA observed peroxide multi surface cleaner and disinfectant, asepticare aerosol-disinfectant virucide, and a lighter in the memory care unit food service station accessible to residents. During the facility tour at 3:23 pm with staff Garcia LPA observed a paper cutter in the 1st floor copy room accessible to residents. LPA reviewed R1's records starting at 3:32 pm which revealed that R1 should be escorted by staff when leaving the community. On 7/22/22 staff failed to Continued on 809C supervise R1 as R1 eloped from the facility. Interview with Resident Care Director Kelly Newcomb starting at 4:31 pm revealed that S1 was found approximately 4 blocks away from the facility. R1 did not sustain any injuries. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted, todays reports were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jul 26, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Jul 27, 2022

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2022

Plan of correction: Staff stated that R1 was placed on frequent checks and they have started staff retraining regarding elopement protocols. Staff stated that they will conduct a reappraisal for R1 and will provide a copy of reappraisal and staff training to CCL by 8/5/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(1) · Plan of correction due date: Jul 27, 2022

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as a lighter, shovels and a paper cutter were observed accessible to residents which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2022

Plan of correction: Staff placed items in a locked office during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 8/5/22.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jul 27, 2022

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as toxic items were accessible to residents which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2022

Plan of correction: Staff placed toxic substances in a locked office during facility visit. Staff stated that they will provide documentation of staff training to CCL by 8/5/22.

Allegation investigated: Facility did not meet reporting requirements

Licensing Program Analyst (LPA) Emily Peraldi conducted an initial 10-day complaint visit at the facility today. At 10:20 a.m., the LPA was greeted and screened by staff. At 11:08 a.m., the LPA met with the Administrator, Kortnie Spitznogle and explained the reason for the visit. Between 11:50 a.m. and 12:15 p.m., LPA Peraldi and the Business Office Manager, Cynthia Garcia conducted a physical plant tour. Between 10:27 a.m. and 12:10 p.m., LPA Peraldi interviewed six (6) out of fifty-four (54) residents and three (3) staff. At 11:10 a.m., LPA Peraldi conducted an interview with the Administrator. At 12:28 p.m., LPA Peraldi reviewed records and obtained copies of pertinent documents. Continued on LIC 9099-C. Substantiated Regarding the allegation: Facility did not meet reporting requirements On 07/11/2022, it was alleged that the facility did not report Resident #1’s (R1’s) death to Resident #1’s responsible party. On 06/30/2022, R1 passed away and the facility contacted R1’s Hospice Agency. On 07/01/2022, the facility sent R1’s death report (LIC 624A) to Community Care Licensing (CCL). On 07/11/2022, the Administrator and Business Office Manager contacted R1’s responsible party via email to coordinate the removal of the R1’s personal property. However, no phone call or a written report was submitted to the person responsible for the R1 within seven days of R1’s death. Interviews with staff and the Administrator revealed that R1’s Hospice agency contacted person responsible for R1 about R1 death. Interview with the Administrator revealed that the Administrator assumed that staff at the facility had already contacted person responsible for R1. During the time of R1’s death, the Administrator was on personal time off and was not physically at the facility. Furthermore, R1’s death report (LIC 624A) did not include or specify the person notified about R1’s death. The Administrator explained the miscommunication that occurred and explained that going forward the Administrator will ensure that the facility is in compliance with all required reporting requirements. Based on the information gathered, the above allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 809-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 report reviewed with the Administrator. A copy of report and appeal rights will be provided via email.the state’s words, verbatim · CDSS document, Jul 13, 2022 · control 29-AS-20220711082056

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jul 22, 2022

87211(a)(1)(A) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: (A)Death of any resident from any cause regardless of where the death occurred… This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the facility failed to notify the person responsible for R1 of R1’s death which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 13, 2022

Plan of correction: The Administrator agreed to do the following: - Agreed to submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87211 and submit to CCL by 07/22/2022.

Allegation investigated: Facility staff did not provide new facility with resident's personal belongings. Facility staff did not clean resident's room. Facility did not provide resident with proper refund.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver final findings. LPA met with Business Office Manager (BOM) Cinthia Garcia at 9:45 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 07/13/2020 alleging that facility staff did not clean resident’s room, facility staff did not provide new facility with resident belonging, and facility staff did not provide proper refund. On 07/22/2020 starting at approximately 11:20 a.m., LPA Kelly Dulek conducted an interview with former ED. During the interview, it was revealed that the facility cleans all the common areas daily and the housekeepers have a schedule for room cleaning with each room being serviced once (1) a week. The housekeepers go into the resident’s rooms and pick up trash, vacuums and clean the restrooms. Continued on LIC 9099 - C Unsubstantiated If resident’s refuse the room cleaning, our staff will try to take out the trash. Further interview also revealed that the bus driver has been relocated to clean and disinfect since there are no outings. Later that same day, LPA Dulek also conducted staff interviews which revealed that housekeeping job entails cleaning hardwood floor, bathrooms, and dusting if possible. If a resident does not want to be disturbed, they will try to come back or come another day. If residents refuse, they would tell their manager and it would be documented. Further interview also revealed that Resident #1 (R1) always like their room being cleaned and they do not recall the room being messy or dirty while R1 lived at the facility. On 10/21/2021 and on 10/26/2021 LPA Ascencio conducted resident interviews. Interviews with residents revealed that the rooms are kept clean by housekeeping, who come to their room at least once (1) a week. The housekeepers clean, mop and vacuum the rooms. While conducting resident interviews, LPA Ascencio observed all resident rooms and restrooms clean, odor free and free from any clutter. LPA also reviewed the housekeeping schedule and observed resident room number being scheduled for service on a daily basis. Based on evidence gathered, this allegation is deemed unsubstantiated. It is also being alleged that facility staff did not provide new facility with resident belonging. On 07/22/2020, LPA Dulek conducted an interview with former ED at approximately 11:20 a.m. During the interview it was revealed that former ED did not know about Resident #1 (R1) moving out until the day they moved out. ED added, I believe R1 was picked up by their Hospice company on Thursday June 10th and family came the next day to pick up R1’s items. Interview with R1’s representative on 07/13/2020, 07/23/2020, 08/25/2020 and 12/04/2020 revealed that R1 moved out of the facility on 06/08/2020 to be closer to family. R1’s representative attempted to communicate with Resident Care Director (RCD) the day before, 06/07/2020 but was not available at the time. R1’s representative called Pacifica Senior Living Oxnard the following day and told the facility R1was moving out the same day. R1’s representative continued, the new and old hospice companies arranged the transportation. The new company transported her in a wheelchair. The facility also had the medication ready but did not release it to the hospice company. R1 left with what they had on. LPA Dulek asked R1’s representative if they had instructed the facility to gather and pack up R1’s belonging. R1’s representative stated no, I assumed the facility would do so. LPA Dulek asked R1’s representative if they instructed the hospice company to gather and pack up R1’s belongings. R1’s representative stated no. LIC 9099-C R1’s representative went to the facility the following day, 06/08/2020, and gathered all of R1’s belongings. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is unsubstantiated. Lastly, it is also being alleged that facility staff did not provide proper refund. Interview with R1’s representative on 07/13/2020 starting at approximately 10:05 a.m. revealed that on 06/07/2020 was the date R1 moved out from Pacifica Senior Living. The following day, 06/08/2020, R1’s representative removed all personal belonging from the room R1 was living in. On 03/18/2022 at approximately 2:30 p.m., LPA interviewed Business Office Manager (BOM). During the interview, it was revealed that there was an email between BOM, Former ED and Senior Regional Manager on 07/09/2020, which stated that the balance of R1 was approved to be "zero" our for teh month of May and June. LPA also received the balanced ledger for R1’s stay at the facility dating from 06/28/2018 through 07/09/2020. The ledger states room charge and care fee charges were stopped 06/06/2020. There was also a zero-balance statement for 07/2020. Further interview revealed that R1's representative gave a 30-day notice on 06/08/2020 and the Resident Agreements Form that was signed on 06/07/2018 states " You will continue to be responsible for your full Monthly Fee until the thirty (30) day period has expired. Based on evidence gathered, this allegation is deemed unsubstantiated. Exit interview conducted. Copy of report provided to BOM and Admin via email. R1’s representative also added that R1 was initiated on Hospice services at the end of April 2020. R1 was taken out of the facility and relocated closer to family on 06/08/2020. R1 passed away August 2020. Interview with Former Administrator on 06/15/2020 starting at approximately 4:13 p.m. revealed that Administrator did not have any knowledge of any injury R1 had sustained. During a facility visit on 03/18/2022, LPA Ascencio received R1’s Needs and Services, Physician Communication Forms, Physicians Report LIC 602, Resident Assessment, Physician’s Orders and Residence and Care Agreement form. Review of R1’s Resident Assessment dated 01/08/2020 and signed by R1’s responsible party and Authorized Community Representative on 01/12/2020, revealed that R1’s Care Level for Bathing required one (1) Person Total Assistance two (2) times per week, Dressing required 1 Person Total Assistance, Toileting required stand-by assistance, Ambulation required 1 Person Total Assist or Wheelchair escort to and from, and Transfers required stand-by assistance. Review of R1’s Physician Report LIC 602 dated 04/27/2020 revealed that R1 had a diagnosis of Alzheimer’s Dementia, and their physician did not know the capacity for self-care due to knot being able to see R1 since December 20219. LPA Ascencio also reviewed R1’s Needs and Service Plan dated 05/06/2020 revealed that Bathing required total assist, Dressing required total assist, Toileting required stand-by assist, Ambulation required total assist, Transfers required standby assist, Hospice was initiated 4/29/2020, and Skin Integrity was added on 01/09/2020 and had care staff report any changes in condition to physician. LPA reviewed Narrative Charting Notes for R1 on 03/18/2022 and revealed that on 04/23/2020 R1’s representative was notified of putting R1 on hospice services. On 12-8-2020, LPA Sager interviewed Hospice Social Worker (SW) and it was revealed that R1 had skin tear and sores on both leg and staff would not give any information regarding R1 injuries. SW went back to the community and staff were not cooperating in telling us how R1 received the sores and skin tears. On 11/10/2021 and 05/04/2022, LPA Ascencio received Hospice care notes and pictures. Review of Hospice notes revealed that on 05/29/2020 the Hospice Agency received a call regarding a concern in skin tear and sore on R1’s body. SW stated that the facility staff do not know how it happened and would not give out any information to the SW. On 06/03/2020, the wound specialist arrived and since facility staff was uncooperative and unwilling to provide details regarding injuries, an Adult Protective Service report was filled and will be forwarded to Community Care Licensing (CCL). Continued on LIC 9099 - C Further review of the Hospice Notes revealed that on 05/02/2020, R1’a wounds included bilateral heel decubitus at a stage II (2)/ III (3), on 05/04/2020 staff not getting R1 up into wheelchair due to leaning over, staff are afraid R1 will fall, on 05/06/2020 bilateral heel decubitus progressed to Stage III with both heels appearing the same with small yellowing drainage on dressing with dressing sticking to heel, on 05/12/2020 right heel decubitus appears reddened with more purulent drainage and outer aspect of foot has a new pressure area stage 2 while the left heel decubitus has small drainage on dressing with new reddened area on inner aspect of big toe. Hospice nurse discussed with staff the importance or turning R1 every 2-3 hours to keep pressure decubitus from happening and end explained new pressure areas. Continued Hospice notes revealed that on 05/19/2020 bilateral heel ulcers are unstageable, on 05/22/2020 noted additional opened wounds on outer site aspect of right foot and instructed staff to continue with repositioning R1 every 2 hours and to ensure heels protectors are on to alleviate pressures on heels, on 05/23/2020 another pressure reddened area on outer aspect mid foot on left heel and right heel has another pressure area, scabbed outer area, on 05/26/2020 bilateral heel decubitus and pressure areas on both feet and wearing foam boots while in bed, on 05/30/2020 left heel outer aspect of foot, midway has pressure area 1 centimeter (cm) x 1 cm with open skin while right foot has pressure area outer aspect midway reddened all around but skin intact, on 06/02/2020 right outer buttocks has large reddened area, 5 cm x 7 cm skin intact still, on 06/04/2020 reminded staff to continue with repositioning R1 every 2 hours, to keep heel protectors on at all times and to continue elevating extremities, and on 06/06/2020 it was noted that a few days back, a med-tech called and reported redness around hips and buttocks area. No additional entries were made after this point as R1 was moved away from facility and discharged from Hospice services. Interview with Hospice Nurse on 05/23/2022 stating at approximately 2:55 p.m. revealed that R1 needed a higher level of care than what the facility was providing. I suggest to the R1’s representative to have R1 move to a Skilled Nursing Facility (SNF) but they did not want to. The facility R1 lived at was not a SNF. I believe R1 needed more. Yes, I educated the staff in repositioning, but I know it was tough. It’s tough to do that in a SNF, I believe it would be more difficult in a setting R1 was at. The staff tried but it wasn’t enough. Based on evidence gathered, the allegation resident developed pressure injuries while in care is substantiated at this time. Continued on LIC 9099-C Regarding the allegation that facility staff did not safeguard resident’s personal belongings. Interview with R1’s representative on 07/13/2020, 10/20/2020, and 12/04/2020 revealed that the facility lost a hearing aid worth about two-thousand seven hundred dollars ($2,700) that the Senior Audiologist from UCLA Health quoted for. We sent the bill over to Pacifica. Interview on 07/22/2020 with Former Administrator at approximately 11:20 a.m. revealed that Administrator did not know about the missing hearing aid until about 1 week ago. Admin stated they have been looking for it but haven’t been successful. An entry from Hospice Notes dated 05/23/2020 revealed that the hospice nurse was unable to find the residents hearing aids when previously R1 has been wearing them. LPA reviewed R1’s LIC 602 Physician Report and stated R1 has an auditory impairment and needs assistance with putting them on. Interview with Business Office Manger on 05/23/2022 starting at approximately 5:15 p.m. revealed that when a resident loses an item, family is encouraged to submit a copy of the receipt with the cost of the item. BOM will submit that receipt to the Cooperate office who will issue refund. The families are encouraged to sign and fill out the Personal Property form, but some don’t. R1 did have hearing aids but we aren’t sure what happened to them. LPA Ascencio reviewed R1’s Resident Agreement form and stated on page seventeen (17), “ We shall not be responsible for the loss of any personal property belonging to you due to the theft, fire, or any cause, unless the loss or damage was caused by our own negligence or that of our employees. We strongly recommend that you obtain, at your own expense, insurance for the replacement value of your personal property, at adequate coverage and liability limits.” LPA Ascencio was provided by R1’s representative a letter sent to a Senior Managing Director in San Diego, Ca regarding the missing hearing aid and the cost of replacement. On an interview with former ED on 07/22/2020 starting at around 11:20 a.m. revealed that ED did have knowledge of the missing hearing aid after the Corporate office informed the ED of the letter and missing hearing aid. Based on record review and interviews, the allegation, that facility staff did not safeguard resident’s personal belongings is deemed substantiated at this time. 2 citation were issued during today's visit. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). 2 civil penalty of $250 each, for a total of $500.00, is also assessed today for the facility repeating the same violation within a 12 month period. The Business Office Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued via email.the state’s words, verbatim · CDSS document, May 24, 2022 · control 29-AS-20200713160044

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: May 25, 2022

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as the licensee did not provide adequate care and supervision or seek higher level of care to R1 which attributed to R1 sustaining pressure injuries which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 24, 2022

Plan of correction: Admin stated they will conduct training and provide copies to LPA via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 31, 2022

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.... This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that was need as part of their care which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 24, 2022

Plan of correction: Admin stated they will be sending the reciept of the missing hearing aid to the cooprorate office to initiate a refund.

Allegation investigated: Staff are not wearing masks

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver final findings. LPA met with Business Office Manager (BOM) Cinthia Garcia at 9:45 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 05/12/2022 alleging that facility staff are not wearing masks. On 05/17/2022, LPA Ascencio toured the facility at 09:55 a.m. and observed all staff and visitors wearing their mask propely around the community. LPA also witnessed the front desk have a box of surgical mask readily available for staff and visitors if needed. On 05/24/2022 starting at approximately 9:30 a.m., LPA Ascencio toured the comnunity and interviewed staff and residents. Interview with four (4) residents starting at 9:33 a.m. revealed that staff are always seen wearing their mask. Visitors typically wear their mask also but sometimes they just run in real quick and leave. Mask are always available at the front desk. Continued on LIC 9099-C Unsubstantiated Six (6) staff interviews beginning at 09:43 a.m. revealed that it is mandated for staff and visitors to wear a mask. Interviews with staff also confirmed that staff has had training on mask requirements and personal protective equipment (PPE) and that they have seen posted throughout the facility about having to wear a mask. Additional information from the staff interviews revealed that the facility provides staff with mask if they are in need of one and the mask can be found at the front desk, in the medication room or in any of the directors office. Based on information gathered, the allegation of staff are not wearing masks is deemed unsubstantiated at this time. Exit interview conducted and copy of the report provided via email.the state’s words, verbatim · CDSS document, May 24, 2022 · control 29-AS-20220512103100

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Incident visit regarding a phone call and an incident report that was received on 05/05/2022 regarding an inappropriate touching between staff and resident. LPA met with Executive Director (ED) Kortnie Spitznogle. During today’s visit on 05/06/2022, LPA Ascencio interviewed ED Spitznogle starting at 1:02 p.m. During the interview, it was revealed that Resident #1 (R1) and Staff #1 (S1) were sitting in the Memory Care activity room by the window. R2 came over to see R1 for dinner, witnessed S1’s hand on the inner thigh of R1. R2 did not say anything to S1 but proceeded to head to dinner with R1. About one (1) week later, R2 notified the Memory Care Director (MCD) of what he had witnessed. MCD proceeded to notify Resident Care Director (RCD) who then proceeded to let ED know on 05/04/2022, who then notified LPA Ascencio that same day at approximately 7:00 p.m. Further interview with ED revealed that on 05/05/2022, ED and Business Office Manager (BOD) had a conversation with R1 and R2. During their interview, R2 stated that S1’s hand placement was on the upper thigh region, on the outside of R1’s pants. R2 added that S1’s hand placement was too close for R2’s comfort. R2 also added that they believe it was an innocent act, but it made R2 feel uncomfortable. Interviews with R1 and R2 on 05/06/2022, starting at approximately 2:05 p.m. revealed that everything that was discussed with ED was accurate. R2 added that they saw the act as innocent but that S1 had no business putting their hands in between R1 thigh. R1 added that they have not been touched inappropriately by any staff or resident. R1 also stated they would report any act of inappropriateness to a person with authority. Later that day, starting at 2:20 p.m., staff interviews revealed that they have not heard or witnessed any resident make comment regarding inappropriate behavior from a resident or staff member. Staff interviews also revealed that if they were to hear of any misconduct from staff or residents, they would directly notify their manager, community care licensing or the ombudsman office. Based on evidence gathered, there was no citation made during today’s visit. Copy of the report provided to ED via email.the state’s words, verbatim · CDSS document, May 6, 2022

Allegation investigated: Facility staff is not dispensing medication as prescribed

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 10:01AM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegation listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted. During today's visit, LPA Ascencio toured the facility at 12:30PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and concuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then determined: Report Continued on LIC 9099-C Substantiated During the subsequent complaint visit conducted on 05/27/2020, LPA Dulek conducted FaceTime video call to conduct a medication audit for Resident #1 (R1) and review of Resident #2 (R2)’s medication at 3:43PM. LPA observed that although Staff #1 (S1) stated that R1’s routine medication Atropine was discontinued as of Friday 5/22/2020, documentation on the MAR reflects the medication was administered at 5:00PM on 5/26/2020. S1 indicated this is an error on the electronic MAR, but there is handwritten documentation of the error. Handwritten documentation was unable to be provided to the LPA upon request. Additionally, R1’s Senna-Docusate was not initialed as administered on 5/13/2020 and 5/16/2020. Further review of the MAR pass notes indicates that on 5/14, 5/15, 5/18, 5/19, 5/20, and 5/21/2020 “waiting for med delivery.” Staff #1 (S1) indicated that the new pack of R1’s Senna Docusate was started on 5/20/2020 and LPA observed 21 pills remaining in the bubble pack. LPA Dulek requested a copy of the physician’s orders to discontinue R1’s daily Atropine and a copy of the medication destruction record for the Atropine. The LPA also requested a copy of the documentation indicating the electronic MAR error for R1’s Atropine on 5/26/2020. Administrator agreed to email all requested documentation by the end of business on 5/27/2020. Documentation was later discussed with the facility Executive Director, but no additional documentation was received. Therefore, based on record review and observation, the allegation that "Facility staff is not dispensing medication as prescribed" is deemed SUBSTANTIATED at this time. This allegation was previously substantiated for R1 and R2 on 03/25/2022 via complaint control # 29-AS-20200519123141. Therefore, no citation will be issued today. Exit interview conducted with Executive Director Kortnie Spitznogle. A copy of the report was provided via email. Regarding the allegation: "Facility staff did not notice a change in the resident's condition:" Record review revealed that Resident #1 (R1) was admitted to hospice 02/27/2020 and moved into the facility on 02/29/2020. R1 had a private caregiver working with them the entirety of the resident's stay at the facility. Hospice physician changed R1's orders based on R1's changes in condition. Care notes indicated that R1 was changed to a puree diet on 05/22/2020 as well as a medication change on this date. Records indicate when new orders were made through hospice, the orders were provided and reviewed with the facility staff. No additional significant change in condition was noted during R1's time residing at the facility. Interview with R1 and R2, who was R1's spouse, indicated staff are able to assist R1 out of bed and into a wheelchair. R1's physician's report dated 02/06/2020 indicates R1 is non-ambulatory. Care notes indicated R1 preferred to remain in bed, however there was no documentation that this was a change in condition rather than a preference. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore the allegation that "facility staff did not notice a change in the resident's condition" is deemed UNSUBSTANTIATED at this time. Regarding the allegation: "Facility staff do not allow resident to have guests:" At the time of the complaint, due to Coronovirus-19 (COVID-19) and to implement mitigation measures, Ventura County Public Health had issued orders for limited visitation in congregate living facilities. Public Health orders did allow for visitation for end of life situations and R1 was on hospice the entirety of their stay at the facility. Visitation logs were provided and reviewed for 5/18/2020 - 05/26/2020. Care notes reviewed indicated R1's family members called on 05/22/2020 and requested a visit with R1. Visitation logs indicate R1 had visitors signed into the facility on 05/23/2020. Interviews revealed that R1 did have a private caregiver daily and this private caregiver did not allow R1 additional visitors, but the facility was following Ventura County Public Health orders and did not restrict R1's guests. Based on interview and record review, although the allegation may be valid, there is insufficient evidence to prove a violation occurred, therefore the allegation that "facility staff do not allow resident to have guests" is deemed UNSUBSTANTIATED at this time. Exit interview conducted with Executive Director Kortnie Spitznogle. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20200519114053

Allegation investigated: Personnel were not trained for the job(s) assigned to them. Facility did not maintain adequate staffing to meet resident(s) needs. Resident(s) call lights are not being answered.

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today with the purpose of delivering findings for the above allegations. The LPA arrived at 10:01AM and met with Executive Director Kortnie Spitznogle. The LPA informed Executive Director of the reason for today's inspection. During today's visit, LPA Ascencio conducted a facilty tour beginning at 12:30PM. During the initial complaint visit on 01/06/2021, LPA Dulek conducted a telephone interview with the administrator at 4:05PM, a video call at 4:24PM, and LPA requested copies of pertinent documents. During a subsequent complaint inspection on 10/26/2021, LPA conducted resident interviews between 11:05AM and 12:50PM. During a previous visit on 10/21/2021, LPA Dulek conducted a facility tour with Business Office Manager Cynthia Garcia and Resident Care Director Marta Tapia at 12:09PM, conducted staff interviews between 12:33PM and 2:30PM and resident interviews between 2:48PM and 3:35PM and gathered copies of pertinent documents. The following was then concluded: REPORT CONTINUED ON LIC 9099-C Substantiated Regarding the allegation "personnel were not trained for the job(s) assigned to them:" Interviews with Management revealed that during the time period surrounding the complaint allegations, the facility was experiencing staffing shortages. The Administrator had called the LPA and let her know there were no dining room staff, the cook had also left the facility. During that time period, other facility staff, including management, helped with cooking while the facility searched to hire new cooks. Administrator stated to LPA that they were not trained to work in the kitchen and the management staff were filling in and had made sandwiches for the residents. Additionally, the management staff cooked the holiday meal for the residents. Another staff interview revealed they were "thrown into the kitchen to cook." Staff interviews revealed that while there is a plan for training staff prior to working in the facility, due to lack of available staff, staff are asked to cover shifts in other departments prior to receiving the appropriate cross-training. Based on interview, the allegation that "personnel were not trained for the job(s) assigned to them is deemed SUBSTANTIATED at this time. Regarding the allegation "Facility did not maintain adequate staffing to meet resident(s) needs:" LPA reviewed staffing records provided for December 2020. The following was found: only one caregiver working from 6:00AM-8:31AM on 12/30/2020. A second caregiver arrived at 8:31AM and a third caregiver arrived at 10:02AM. The facility's Mitigation Plan indicated staff were not to be shared between Memory Care and Assisted Living, but on 12/30/2020, there was only one caregiving staff working for all residents in the building. Additionally, on 12/20/2020 and 12/17/2020 during the NOC shift, there was only 1 caregiver working overnight. Interviews with staff revealed the facility was short staffed due to staff calling out for their scheduled shifts. Sometimes management would come in and cover the shifts, but not always. When caregivers call out, the medication technician can help out with caregiving tasks. At the time of the complaint, caregiver duties included assisting residents with ADLs, showering residents, and doing laundry for the residents, as well as light housekeeping duties. Staff interviews revealed that 2 or 3 caregivers for Assisted Living and one for Memory Care are scheduled during the am and pm shifts and one on each side for the NOC shift. According to staff, there were 3-4 residents that required a 2-person assist and at the time of the complaint there were 53 residents in the facility. One resident indicated "some days they don't have enough people" which results in long wait times for the residents who require assistance. Therefore, based on interview and record review, the allegation "facility did not maintain adequate staffing to meet resident(s) needs" is deemed SUBSTANTIATED at this time. Report continued on LIC 9099-C Regarding the allegation "resident(s) call lights are not being answered:" LPA Dulek reviewed SMARTcare records for call lights during the time period of 12/31/2020 - 1/7/2021. The following was noted: over 100 times during the one-week period, response time was greater than 15 minutes. An additional 16 times the call was marked as "response required but not received...This alert was never responded to." Staff interview revealed that staff are required to respond to calls within 2-3 announcements, which allows for approximately 15-minute response. Staff stated that sometimes if all staff are busy assisting other residents, residents calling for assistance need to wait longer. Resident interviews revealed that often residents are waiting for half-hour to 45 minutes for assistance and that "it depends on the day how long the response time is. Some days they don't have enough people." 5 of 5 residents interviewed agreed that call response times vary and are often too long. Therefore, based on record review and interview, the allegation that "resident(s) call lights are not being answered" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20201230085801

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 9, 2022

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on interview and record review, the facility only had only one caregiver working on 3 different dates, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Administrator agreed to maintain adequate staffing and will send a copy of facility's staffing plan to include positions facility is recruiting for, plan to hire and train staff, and staff schedule to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(18) · Plan of correction due date: May 9, 2022

87555 General Food Service Requirements(b) The following food service requirements shall apply: (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement is not met as evidenced by: Based on interview, during COVID, the facility did not have any kitchen staff nor cooks and the Administrator and other untrained staff were cooking the food for the facility, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Administrator will provide proof of sufficient kitchen and dining room staff, along with their training records to CCL by POC due date.

Allegation investigated: Staff failed to observe changes in resident's health Facility has ant infestation

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Kortnie Spitznogle and discussed the reason for the visit. Entrance interview conducted. During today's visit, LPA Ascencio toured the facility at 12:30PM. Previously, on 09/02/2020, LPA conducted an initial complaint investigation telephonically, which consisted of a telephone interview with the Resident Care Director, and a video call to conduct a virtual facility tour at 5:27 PM and a review of the pendant/resident call system at 5:36 PM. The LPA requested pertinent documents at that time. LPA then reviewed the documents and interviewed both residents and staff. The following was then determined: REPORT CONTINUED on LIC 9099-C Substantiated Regarding the allegation "staff failed to observe changes in resident's health:" Assisted Living Resident Assessment dated 06/09/2020 indicates R1 requires 1-person assist with bathing, 1-person assist with dressing, grooming reminders, stand-by assistance with toileting, 1-person escort to and from activities, and 1-person assist with transfers, as well as medication assistance. Needs and service plan for R1 dated 09/03/2020 indicates total assist with dressing and grooming, 2-person assist with bathing, toileting, ambulation and transfers, as well as R1 is a fall risk and requires total assist with medications. Although the new needs and service plan does indicate a change in condition, the plan is not signed by the resident nor the resident’s responsible party so there is no indication this change of condition was communicated to R1’s responsible party nor R1's physician. On 08/19/2020, charting notes indicate R1’s tremors seem to be worsening and MD notified. Faxed note indicates “family notified,” however the note indicating “family notified” does not indicate who was told or when. Physician communication reviewed contained faxed notes to R1's physician, but none prior to 11/12/2020, during the time period of the complaint. Interview with resident’s responsible party revealed that the responsible party was not contacted nor made aware by the facility that R1 had a change in condition. Interview with Administrator on 12/17/2020, revealed that at the time of the complaint the facility was short-staffed and that communication with families and other pertinent parties was delayed at that time due to the staffing issues. Therefore, based on interview and record review, the allegation that "staff failed to observe changes in resident's health" is deemed SUBSTANTIATED at this time. Regarding the allegation "Facility has ant infestation:" During the virtual initial complaint inspection, LPA interviewed Resident Care Director (RCD) throughout the inspection. RCD indicated "yes, I have seen ants in the facility." RCD is aware of ants in the Directors' Offices, as well as in resident rooms. She has heard from at least 3-4 residents recently who complained of ants. RCD called a pest control company, who came last week to spray the exterior, but RCD indicated everything inside was not treated. RCD provided invoice from the pest control company which does reflect "exterior general pest control" was completed on 08/28/2020. Interview with residents revealed that 5 of 7 residents interviewed have seen ants and indicated there is an ant problem in the facility. Therefore, based on interview, the allegation "facility has ant infestation" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided via email. caregivers," "they (caregivers) are nice not rude or disrespectful," and "are all very nice and kind." Staff interview revealed there are some residents who are a "bit feisty" but staff still treat them with dignity and respect. No staff interviewed have ever heard another staff say anything disrespectful to any resident. Based on interviews, although the allegation may be valid, at this time there is insufficient evidence to support the allegation. Therefore, the allegation that "staff not treating resident with dignity" is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff not assisting resident with ADLs:" Record review revealed that R1 had a change of condition, which was reflected in a 09/03/2020 care plan. R1 then became a 2-person assist with most ADLs. Care notes indicated staff assisting R1 regularly. Staff interviews revealed staff assist with incontinence needs every 2 hours, or as needed. Residents who are on a 2-person assist, they call on the walkie-talkies for an additional care staff when needed. LPA observed staff attending to residents during facility visits. Resident interviews revealed that care staff do assist with ADLs regularly and residents stated they feel their needs are being met. Although the allegation may be valid, at this time, based on interview, there is insufficient evidence to support the allegation. Therefore the allegation "staff not assisting resident with ADLs is deemed UNSUBSTANTIATED at this time. No citations issued. Exit interview conducted with Executive Director. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20200827142152

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: May 9, 2022

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes...ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not notify R1's responsible party nor physician of a change in condition, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: Administrator agreed to provide training to all staff on observing residents and will provide proof of training, including date, topics covered, names of attendees to CCL by POC due date.

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

87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services....for the safety and well-being of residents, This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not assure that the facility remins free of ants, as 5 of 7 residents interviewed indicated the facility has an "ant problem" and Resident Care Director corroborated the facility has ants, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 25, 2022

Plan of correction: The Administrator will create a plan for ongoing pest control for the building and will provide the plan to CCL by POC due date.

Allegation investigated: Resident's apartment is not kept at a comfortable temperature

This report was amended on 02/22/2022 to add pertinent information. Licensing Program Analyst (LPA) Angel Ascencio and Kelly Dulek conducted an unannounced complaint visit to the facility above. LPA’s met with Administrator Kortnie Spitznogle at 10:05 am. Entrance interview conducted. It is being alleged that resident's apartment is not kept at a comfortable temperature. On 4/25/2022 starting at 12:32 p.m. to 1:52 p.m. interviews with Resident #1 (R1), R2 and R3 revealed that they have not had any issues with their temperature being to high or too low. When the temperature is needing to be adjusted, resident will call staff for help if they cannot figure it out themselves. During a visit on 02/22/2023, the LPAs checked the temperature in R1’s room and throughout the facility, and conducted additional resident interviews. Room temperatures in six (6) resident rooms and two (2) common areas were tested and was at a comfortable range between 67.5 degree F and 72.7 degree F. Resident interviews and temperature readings in resident rooms and common areas indicated that the rooms were in a range of 68 degree F and 85 degree F per regulation. Based on the investigation, the above allegation is unsubstantiated at this time. Exit interview conducted. Copy of the report provided to BOM. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 25, 2022 · control 29-AS-20220425095729

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to handle outbreak appropriately.

Licensing Program Analyst (LPA) Angel Ascencio conducted an initial complaint investigation to the above facility. LPA met with Administrator Kortnie Spitznogle at 2:35 p.m. LPA and Admin toured the community at 4:30p.m. Entrance interview conducted. It is being alleged that facility failed to handle outbreak appropriately. LPA Ascencio received a telephone call on 4/4/22 at approximately 11:33 a.m from Ventura Public Health Registered Nurse (VCPH). VCPH informed LPA they received an anonymous tip that there was an outbreak at the facility, and it had not been reported and that the building is not doing anything about that. On 4/4/22, LPM Kristin Heffernan, LPA JoAnn Rosales and Ascencio received an email from Long-Term Care Ombudsman (LTCO) that they have been notified anonymously in the morning about a flu or virus outbreak at Pacifica. The anonymous tip described at least 12 residents in memory care. LPA Ascencio reached out to communicate with Admin Kortnie regarding a possible outbreak. Continued on LIC 9099-C Substantiated LPA KaSandra Lopez spoke to Admin Kortnie on 4/4/22 and confirmed to LPA Lopez the facility does have an outbreak. Admin added that it started last week with residents in Memory Care and then on Thursday 3/31/22, a few more residents were sick with vomit and diarrhea. Admin continued; over the weekend we increase our dinning room tray service from seven (7) to eleven (11) in Assisted Living residents. Monday 4/4/22, Admin was told by staff that there are more resident that are sick and was going to follow up with LPA Ascencio. Admin continued, I am unsure how many residents and staff are sick, but we had about three (3) call out from staff last week. LPA Lopez asked Admin to complete incident repots and to report to VCPH since they had called Admin and left message. LPA Lopez reminded Admin to notify VCPH of any outbreak. As of 4/12/22, LPA Ascencio has yet to receive incident reports regarding staff and residents involved in the outbreak. LPA Ascencio reviewed the Illness Tracking form at 3:51 p.m. on 4/12/22, and it revealed the five (5) resident with symptoms started on 3/28/22 with vomiting and/or diarrhea; two (2) more resident on 3/29/22 with vomiting; three (3) staff with vomiting and diarrhea on 3/30/22; three (3) more residents on 3/31/22 with vomiting; one (1) staff and two (2) more residents on 4/1/22 with vomiting; five (5) residents presented with vomit and/or diarrhea on 4/2/22; nine (9) residents on 4/3/22 presented with vomit and diarrhea; six (6) residents on 4/4/22 presented with vomit; on 4/8/22 one (1) resident presented with vomit; and as of 4/10/22 two (2) resident were present with vomit. Ongoing communications with VCPH on 4/12/22 stated that they have been out to the facility twice (2). They have complied with our request and recommendations. However, VCPH has had to make multiple request for information and samples, so communication has been difficult. As of Sunday 4/10/22's update, thirty-six (36) residents and four (4) employees present sick or with symptoms. VCPH added, the facility did not self-report. VCPH received an anonymous phone call stating there was a large number of memory care residents sick with symptoms. The outbreak had been going on for a week before VCPH got involved. VCPH did provide sample kits and instruction on how to collect samples. As of 4/12/22, the facility has not provided stool samples. Interview with Admin Kortnie at 3:30 p.m. on 4/12/22, stated that some resident’s family members were informed of the symptoms, isolation and outbreak of the facility. Around 1/3 of the resident were notified but the others I’m not sure. We have had isolation gowns, gloves and mask to take care of those with symptoms. We placed a basket outside their room with all the Personal Protective Equipment (PPE) for staff to use. Continued on LIC 9099-C We stopped communal dinning and all activities at the building. We have been following the guidance and recommendation from VCPH since the day we notified them on 4/4/22. Starting at 4:33 p.m., interviews with seven (7) residents out of the thirty-seven (37) that presented with symptoms stated that they isolated in their rooms, there was no communal dinning or activities and that their responsible party were informed of the outbreak situation. On 4/12/22, at 4:36 p.m., LPA reviewed the med-tech communications log from residents that reside in Memory Care and noted that one (1) resident out of eleven (11) residents that presented symptoms from the Illness log, were called and documented. On 4/12/22, at 5:32 p.m. , LPA reviewed the med-tech communication log from residents that reside in Assisted Living and noted that eleven (11) out of twenty-five (25) resident that presented symptoms from the Illness log, were called and documented. At 5:12 p.m., LPA received two (2) letters to families and residents, one dating 4/4/22 and 4/10/22, regarding the outbreak and the recommendation measure put in place by VCPH. Based on interviews, document gathered, and observations, the allegation, facility failed to handle outbreak appropriately is deemed substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 29-AS-20220404114101

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Apr 13, 2022

87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility did not report an outbreak to the appropriate agencies in a timely manner which posses and immediate health, safety and personnal rights risk to person in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Admin stated they will submit Incidents reports. Admin will conduct training regarding reporting requirements and documentation. Admin will submit a mitigation plan by 04/27/22 to LPA Ascencio via email.

Allegation investigated: Facility has no Administrator

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA met with Administrator Kortnie Spitznogle and explained the reason for the visit. The report was signed by Resident Service Director Kelly Newcomb as the Administrator had to leave the facility. Based on interviews and record review, the facility administrator at the time of this complaint was Paul Markovich. From approximately 1/13/2021 through approximately 2/8/2021 the administrator was out of the facility due to COVID-19 infection. Two qualified staff were left in charge as acting administrators during that time: Sara Gutierrez and Marta Tapia under the guidance of Paul Markovich by phone. Based on the documentation and interviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued. Unsubstantiated LPA Camara interviewed residents and staff on 11/04/2021. During the COVID-19 outbreaks at the facility all residents were served meals in their room due to isolation protocols set forth by the Department of Public Health. During that time period the facility lost nearly all of their cooks. Other facility staff, including management, helped with cooking while the facility searched to hire new cooks. They offered menu items suggested by their corporate office, they were taught how to make the menu items and they offered alternative menu items. However, residents who were interviewed indicated there was a short period of time when all they received were sandwiches. In addition, residents indicated that some of the food they received was cold when it should have been hot. One caregiver indicated that was a possibility depending on where the resident's room was located as they may have been served last. Based on interviews with staff and residents, this allegation is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Apr 12, 2022 · control 29-AS-20210203122326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8755(a) · Plan of correction due date: Apr 12, 2022

8755(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on interviews, while tray service was being provided to all residents due to COVID-19, some residents were receiving cold food which should have been served hot, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Licensee previously submitted on 03/28/2022 evidence of management training regarding a plan for future instances where all residents must receive tray service due to an isolation order.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required annual visit at 11:50 AM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Kortnie Spitznogle and discussed the reason for the visit. The LPA, along with Administrator, toured the physical plant areas inside and outside at 12:00 p.m. to ensure there are no health and safety hazards. Entrance interview conducted. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 64 total bedrooms – eighteen (18) bedrooms are in memory care and forty-six (46) bedrooms are in assisted living. RESTROOMS: Six (6) public restrooms were observed to be clean and sanitary and in operating condition. Six (6) resident bathrooms and showers were also observed to have grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products in each restroom, as well as hand washing posters. Water temperature was tested and was within normal ranges. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. Smoke detectors and carbon monoxide was observed to be in operable condition at the time of visit. LPA received an invoice dated February 1st, 2022, for Fire Alarm System monitoring. The outdoor areas have a covered area equipped with furniture for resident use. There are two (2) water fountains observed which had two (2) inches of water clearance. Continued on LIC 809 - C KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Water temperature was observed to be within normal limits. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 1:10 p.m. There is one (1) entry into the facility. Upon entry, the facility has a central point for symptom screening. LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and is able to obtain more if needed The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. No citations were issued today's visit. Exit interview conducted. Copy of the report provided to Admin via email.the state’s words, verbatim · CDSS document, Mar 28, 2022

Allegation investigated: Staff isolating residents from authorized representatives while in care Staff emotionally abuses residents while in care Staff creates fictitious medical reasons for residents without authorization Staff mishandles resident while in care Staff retaliates against residents while in care

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 01:47PM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegations listed above. LPA met with facility Sales Director Matthew Girardot. Facility Executive Director was not available during today’s visit. Entrance interview conducted. During today's visit, LPA, along with Sales Director Matthew Girardot, toured the facility at 01:55PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and conducuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then determined: REPORT CONTINUED ON LIC 9099-C Unfounded LPA Dulek spoke with relevant parties, including R1's family members, complainant, R1, R2, as well as facility staff and Administrator. Additionally, LPA reviewed a staff roster provided by the facility. LPA then determined the individual named by the complainant was not currently nor had the individual ever been employed by the facility. The individual in question was employed by R1's family as a private duty aide for R1. This individual never worked for the facility, and therefore does not qualify as facility staff. Therefore, based on interview and record review, the allegations that "Staff isolating residents from authorized representatives while in care," "Staff emotionally abuses residents while in care," "Staff creates fictitious medical reasons for residents without authorization," "Staff mishandles resident while in care," and "Staff retaliates against residents while in care" are deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of the report was provided via email. During the subsequent complaint visit conducted on 05/27/2020, LPA Dulek conducted FaceTime video call to conduct a medication audit for Resident #1 (R1) and review of Resident #2 (R2)’s medication at 3:43PM. LPA observed that although Staff #1 (S1) stated that R1’s routine medication Atropine was discontinued as of Friday 5/22/2020, documentation on the MAR reflects the medication was administered at 5:00PM on 5/26/2020. S1 indicated this is an error on the electronic MAR, but there is handwritten documentation of the error. Handwritten documentation was unable to be provided to the LPA upon request. Additionally, R1’s Senna-Docusate was not initialed as administered on 5/13/2020 and 5/16/2020. Further review of the MAR pass notes indicates that on 5/14, 5/15, 5/18, 5/19, 5/20, and 5/21/2020 “waiting for med delivery.” Staff #1 (S1) indicated that the new pack of R1’s Senna Docusate was started on 5/20/2020 and LPA observed 21 pills remaining in the bubble pack. LPA Dulek requested a copy of the physician’s orders to discontinue R1’s daily Atropine and a copy of the medication destruction record for the Atropine. The LPA also requested a copy of the documentation indicating the electronic MAR error for R1’s Atropine on 5/26/2020. Administrator agreed to email all requested documentation by the end of business on 5/27/2020. Documentation was later discussed with the facility Executive Director, but no additional documentation was received. Therefore, based on record review and observation, the allegation that "Staff mishandling resident's medication" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were issued via email.the state’s words, verbatim · CDSS document, Mar 25, 2022 · control 29-AS-20200519123141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 28, 2022

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the facility did not assist R1 with their medications as prescribed, as medications were waiting for refill and unable to be administered, as well as discontinued medication was marked as administered, which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: Licensee will provide vendorized medication training to all staff who assist with medication and provide proof, to include signed roster of attendees, name and credentials of trainer, date of training, and training agenda to CCL by 04/08/2022.

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.

Allegation investigated: Resident sustained bed sore while in care Resident not administered medication as prescribed Staff left resident in soiled clothing for extended period of time Facility staff not responding to resident's call button Facility staff not safeguarding resident’s property

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 01:47PM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegations listed above. LPA met with facility Sales Director Matthew Girardot. Facility Executive Director was not available during today’s visit. Entrance interview conducted. During today's visit, LPA, along with Sales Director Matthew Girardot, toured the facility at 01:55PM. No health and safety hazards were observed during today's tour. Previously, on 12/04/2020, between 4:22 p.m. and 5:05 p.m., LPA Dulek conducted an initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with facility designee Sara Gutierrez. The LPA conducted an interview and physical plant tour with the Resident Care Director at 4:25 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. During the course REPORT CONTINUED ON LIC 9099-C Substantiated of the investigation, staff and resident interviews were conducted both in person at the facility as well as over the telephone on the following dates: 08/24/2020, 08/25/2020, 12/14/2020, 12/17/2020, 05/26/2021, and 10/21/2021. The following was then determined: Regarding the allegation “Resident sustained bed sore while in care: Resident #1 (R1) moved into the facility on 06/01/2020. Resident’s paperwork filled out upon admission was reviewed and did not contain any indication of existing wounds upon admission to the facility. Interview with R1’s family member confirmed R1 had no pressure injuries prior to residing at the facility. Care notes reviewed did not indicate any wounds on R1’s body. The resident was admitted to hospice on 08/20/2020, at which point a Stage 2 wound was noted on R1’s coccyx, as well as skin tears on R1’s legs and both arms. Photographs of the wounds were provided to the LPA. Staff interviews revealed that R1’s pressure injuries were “real deep” and a “real bad wound.” Former administrator indicated they were unaware the resident had any wounds until R1 was admitted to hospice. Therefore, based on interview and record review, the allegation that “resident sustained bed sore while in care” is deemed SUBSTANTIATED at this time. Regarding the allegation “Resident not administered medication as prescribed: LPA reviewed R1’s medication administration record as well as care notes. Two times in June, on both the 26th and 27th, it was noted that R1 was unable to receive medications as prescribed, as the medications had not yet been refilled. Medication records reviewed indicated PRN acetaminophen was administered only one time in the month of August 2020 and PRN morphine was administered on 3 dates in August 2020. Interview with former Administrator revealed that the facility did not have a PRN authorization on file for R1. Therefore, based on interview and record review, the allegation that “resident not administered medication as prescribed” is deemed SUBSTANTIATED at this time. Regarding the allegation “Resident left in soiled clothing for extended period of time:" Review of R1’s Needs and Service Appraisal indicated that R1 requires assistance with ADLs including toileting assistance, dressing, bathing, and grooming. Interview revealed that on 08/24/2020, R1 was observed to have urine leaking from their pants and noted to be soiled in urine and feces. Staff interview indicated R1 had not been changed for some time, which resulted in the soiled clothing. The exact amount of time the resident was left in soiled clothing is unknown, however the feces was noted to be dried under the Report Continued on LIC 9099-C resident’s nails and on the resident’s clothing. Therefore, based on interview, the allegation “resident left in soiled clothing for extended period of time” is deemed SUBSTANTIATED at this time. Regarding the allegation “Facility staff not responding to resident’s call button:” Interview with a witness revealed that on 08/24/2020, the witness pressed the resident’s pendant while in R1’s room. The witness waited for over 30 minutes for a response and only received a response when using the telephone to call for assistance. R1’s call button was replaced that same day. However, the following day, on 08/25/2020, R1’s visitor pressed the pendant and again received no response for approximately 30 minutes. Staff interview revealed that according to facility policy, care staff should respond to a resident’s request for assistance within 2 alerts on the call system, which equates to 10 minutes or less. 6 (six) of 6 (six) residents interviewed all stated that call times vary, but all have had to wait upwards or 20 minutes to an hour for a response. SMARTCare records reviewed for a one-week period indicated a wait time or greater than 10 minutes for 175 calls during a one-week period. Additionally, during that same one-week period, there was no response to the call button at all 65 times. Therefore, based on record review and interview, the allegation “facility staff not responding to the resident’s call button” is deemed SUBSTANTIATED at this time. Regarding the allegation “Facility staff not safeguarding resident’s property:” Interviews conducted during the course of the investigation revealed that medical supplies were left in the resident’s room as of 08/22/2020. Those supplies were unable to be located as of 08/24/2020. Staff interview revealed that “caregivers take patient supplies for use on other patients” and Administrator added that “things should not be left in patients’ rooms because they have been found to go missing.” In addition to medical supplies missing, R1's family left an electronic item for R1 which was also unable to be located. Based on interview, the allegation that “facility staff not safeguarding resident’s property” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D.) The Sales Director was informed that civil penalties may be assessed at a later date based on Health and Safety Code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report was issued via email.the state’s words, verbatim · CDSS document, Mar 25, 2022 · control 29-AS-20201125144906

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Mar 28, 2022

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as the licensee failed to provide adequate care and supervision to R1 which contributed to R1 sustaining pressure injuries and R1's clothing observed with dried fecal matter, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 03/28/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 28, 2022

87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes...appropriate supervision is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to observe, document and communicate R1's pressure injuries/wounds which contributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 03/28/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1) · Plan of correction due date: Mar 28, 2022

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...PRN medication and is unable to communicate his/her symptoms clearly...shall be permitted to assist the resident with self-administration provided (1) Facilty staff...dose of medication. This requirement is not met as evidenced by: Based on interviews and records review, R1 was in obvious pain, however staff failed to contact hospice or a physician for authorization to administer any PRN pain medication 8/21/20-8/23/20, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: Licensee will submit a plan to provide proper level of care and supervision to residents in need of PRN medications who cannot verbally communicate their needs to ensure resident needs are met. Submit to CCL by 03/28/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Apr 8, 2022

87303 Maintenance and Operation. (i)Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Based on interviews and record review, R1's call button was not working on 8/24/2020. In addition, other call button alerts went unresponded for other residents during the period of August 2020 - September 2020, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: Licensee will submit a plan to conduct testing on the call buttons to ensure they are all functioning properly and provide staff training regarding call button alert response times. Submit to CCL by 04/08/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Apr 8, 2022

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures to safeguard residents'...personal property... which have been entrusted to the licensee or facility staff...articles or cash resources. This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that had been left by a skilled nursing professional, as well as a remote left by family, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 25, 2022

Plan of correction: Licensee will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by 04/08/2022.

Allegation investigated: Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care Neglect/Lack of Supervisiion: Facility staff did not seek medical attention for Resident #1 (R1) Staff mismanaging resident’s medication Staff not responding to resident’s call button in a timely manner Resident was left in soiled diaper for extended period of time Staff not providing adequate food service to resident Staff did not safeguard personal belongings

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 03/18/2022 to deliver final findings for the above allegations. The initial visit was conducted on 09/02/2020 by LPA Kelly Dulek and subsequent visits were conducted on 11/4/2021 and 03/15/2022 by LPA Camara. During today’s visit, Administrator Kortnie Spitznogle left the facility to pick up a resident so LPA met with Business Office Manager Cynthia Garcia and explained the reason for the visit. On 09/02/2020, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that former Resident #1 (R1) sustained multiple pressure injuries while in care and facility staff did not seek medical attention for R1. It was reported that the pressure injuries were not discovered until the hospice care intake on 08/20/2020. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson. (continued on page 2; 9099-C) Substantiated (continued from page 1; 9099) On 09/02/2020, between 4:47 p.m. and 6:40 p.m., LPA Dulek conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Resident Care Director Sara Gutierrez. The LPA conducted an interview and physical plant tour with the Resident Care Director at 5:27 p.m. and reviewed the pendant/resident call system at 5:36 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. On 11/04/2021, LPA Camara conducted an unannounced subsequent complaint visit. LPA met with Administrator/Executive Director Kortnie Spitznogle and Resident Care Director Marta Tapia and explained the reason for the visit. During the visit LPA conducted a brief physical plant tour at 12:53 p.m., interviewed staff starting at 1:20 p.m., interviewed residents starting at 2:25 p.m., reviewed records at 3:58 p.m. and noted further investigation was required. Investigator Patterson conducted interviews with R1’s representative on 10/21/2020, at approximately 4:16 p.m. and on 11/09/2020, at approximately 3:33 p.m.; with the Long Term Care Ombudsman (LTCO) on 11/11/2020, at approximately 2:17 p.m.; with TLC Hospice on 12/10/2020, at approximately 4:42 p.m.; with facility staff on 12/14/2020, from approximately 2:35 p.m. to 3:48 p.m.; and with Facility Administrator Sara Gutierrez on 12/17/2020, at approximately 9:10 a.m. Additionally, Investigator Patterson obtained and reviewed copies of facility records, hospice records and photographs of wounds/pressure injuries related to R1. Information gathered reflected R1 was admitted to the facility on 06/01/2020. At that time R1 was ambulatory and able to articulate their needs in spite of having had a stroke and showing signs and symptoms of dementia. R1’s medical history included depression, frequent urinary tract infections, heart disease, stroke, and dysphagia. The narrative charting record for R1 indicated on 07/25/2020, R1 was found by a caregiver sitting on the floor in the middle of their living room. R1 was noted to becoming weaker and in need of total assistance with toileting and feeding. On 08/02/2020, R1’s Doctor was contacted to obtain authorization for (continued on page 3; 9099-C) (continued from page 2; 9099-C) medical assistance as R1 “seemed a lot weaker” and in need of “a lot” more assistance. On 08/15/2020, R1’s representative came and bandaged R1’s legs due to R1’s itching and scratching, which caused bleeding. Band-aids were placed on R1’s arms; however, R1 took them off twice and R1’s representative was notified. R1’s representative was not informed by facility staff until approximately 08/15/2020, that R1 had not been ambulating on R1’s own in over a few weeks. On 08/20/2020, R1 was assessed and admitted to TLC Hospice Care due to Alzheimer’s disease and rapid decline in health. During the hospice assessment, R1 was observed to have a large stage 1 area to the coccyx with multiple scabs, and stage 2 areas within; large skin tear to left lower leg; and multiple open sores to both forearms. The assessment also noted that since being admitted to the facility, R1 had rapidly declined, required support with all activities of daily living, and was in severe discomfort and significant pain. Information gathered further revealed that it was not until the hospice care was initiated that R1’s pressure injuries and wounds were diagnosed, treated and reported to R1’s representative. On the allegation: Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care. The Residential Care Director stated she was never made aware that R1 had a pressure injury or scattered skin tears until R1 was accepted into hospice care. She admitted that the facility staff’s lack of documentation and communication, but also failing to provide appropriate supervision and care, attributed to neglecting R1’s change of condition and pressure injury/wound care needs going unmet. Based on records reviewed, interviews conducted, and photographic evidence of R1’s wounds/pressure injuries, neglect/lack of supervision and care was found to have attributed to R1 sustaining pressure injuries which went unreported and not cared for, therefore, the allegation is deemed Substantiated at this time. On the allegation: Neglect/Lack of Supervision: Facility staff did not seek medical attention for Resident #1 (R1). On 08/20/2020, during the hospice care intake R1 was discovered to have pressure injuries to coccyx area and scattered wounds to arms and legs. It was further reported R1 was in significant pain. Investigator Patterson conducted interviews with the facility staff who reported that the facility does not assess or treat (continued on page 4; 9099-C) (continued from page 3; 9099-C) pressure injuries/wounds other than basic first aid; further pain medication, PRN (as needed) is not provided unless the resident asks for them. Information obtained during witness interviews found that R1 was in severe pain and believed the facility did not provide care, pain medication or did not seek out appropriate medical attention. The Resident Care Director stated once hospice care was implemented for R1, it was not the facility’s responsibility to care for R1’s wounds. She further stated she was never made aware by facility staff that R1 was in pain or had pressure injuries or multiple skin tears which continued to exacerbate while in care. She admitted the facility’s failure to communicate attributed to failing to seek out medical attention. Based on witness statements and documents obtain and reviewed, the allegation is deemed Substantiated at this time. On the allegation: Staff mismanaging resident's medication: On 12/17/2020, Investigator Lorraine Patterson interviewed administrator Sara Gutierrez who indicated if a resident appears to be in pain but cannot verbalize their need for PRN pain medication, the medication technician should contact the resident's physician for approval to provide the PRN pain medication. R1 had acute pain due to pressure injuries and multiple skin tears. According to witnesses, R1 was in obvious pain. R1's PRN pain medication was delivered to the facility on 08/21/2020. Records show R1 was prescribed two PRN narcotic pain medications which were administered on 08/24,25,27,28,29/2020. According to administrator Sara Gutierrez there was no evidence the facility staff attempted to contact anyone (physician or hospice) over the weekend of 08/22-23/2020 for approval to administer the prescribed PRN pain medications. In addition, a medication technician interviewed by the Investigator confirmed the discovery that R1 went without this pain medication for an entire weekend. Based on the administrator's statement to the Investigator and documentation showing the medication was not administered, the allegation is deemed Substantiated at this time. On the allegation: Staff not responding to resident’s call button in a timely manner. On 12/17/2020, Investigator Lorraine Patterson requested copies of the call button service alerts for R1 from facility administrator Sara Gutierrez, however these logs were never provided to the Investigator. On 11/4/2021, LPA (continued on page 5; 9099-C) (continued from page 4; 9099-C) Camara requested call button service alert records for the facility from June 2020 through September 2020. LPA was provided logs from 06/04/2020 - 09/27/2020. Upon closer review, LPA noted records were missing from 06/23/2020 through 09/18/2020. During LPA's visit on 03/18/2022, call button records were requested for the month of August 2020. LPA was provided 537 pages of records. There was only one call noted from R1 which occurred on 08/24/2020 at 1:36 p.m.; it was announced to caregivers eight times before someone responded and it took 39 minutes for the caregivers to respond. LPA reviewed the other alert records provided by the facility and noted there were numerous alerts for other residents to which staff never responded or where response times ranged from 28 - 44 minutes. In addition, based on witnesses' accounts who had visited R1 multiple times in August of 2020, staff would not respond when R1's call button was pushed and the visitors would have to locate staff by calling the main phone number. On 08/24/2020 a caregiver brought a new call button to R1 as it seemed the one R1 had was not working. Based on witness statements, this allegation is deemed Substantiated at this time. On the allegation: Resident was left in soiled diaper for extended period of time: On 08/24/2020 a witness observed R1 was sitting for an extended period in a soiled diaper (soaked in urine, urine leaked out of diaper, and the diaper was smeared with feces). The witness also pointed out R1's call button seemed inoperable. The caregiver brought a new call button and told the witness to speak with the next caregiver coming on shift about any other concerns. Other witnesses interviewed had observed R1 was left in soiled diapers for extended periods as well as feces under R1's fingernails. Based on witness statements, this allegation is deemed Substantiated at this time. On the allegation: Staff not providing adequate food service to resident: LPA Camara interviewed residents and staff on 11/04/2021. During the COVID-19 outbreaks at the facility all residents were served meals in their room due to isolation protocols set forth by the Department of Public Health. During that time period the facility lost nearly all of their cooks. Other facility staff, including management, helped with cooking while the facility searched to hire new cooks. They offered menu items suggested by their corporate office, they were taught how to make the menu items and they offered alternative menu items. However, residents who were (continued on page 6; 9099-C) (continued from page 5; 9099-C) interviewed indicated there was a short period of time when all they received were sandwiches. In addition, residents indicated that some of the food they received was cold when it should have been hot. One caregiver indicated that was a possibility depending on where the resident's room was located as they may have been served last. Based on interviews with staff and residents, this allegation is deemed Substantiated at this time. On the allegation: Staff did not safeguard personal belongings: Based on witness interviews by Investigator Lorraine Patterson, one witness discovered on 08/24/2020 R1's personal care supplies, which had been left in R1's room, were missing. The witness reported the missing items to administrator Sara Gutierrez who told the witness things should not be left in residents' rooms because things go missing. The witness was told by a medication technician that caregivers tend take such supplies for use on other residents. In addition, R1's family left an electronic item for R1 which was also missing. Based on witness statements, this allegation is deemed Substantiated at this time. A $500 immediate civil penalty is assessed today. The Business Office Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D) Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Mar 18, 2022 · control 29-AS-20200902093912

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 25, 2022

87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to observe, document and communicate R1's pressure injuries/wounds which attributed tothe state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: LIcensee will submit a plan to provide proper observation of residents and communication of changes of in condition to ensure residents' needs are met. Plan must be submitted to CCL on or before 03/25/2022. failing to seek out medical attention for R1, which posed an immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Mar 25, 2022

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 03/25/2022.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1) · Plan of correction due date: Mar 25, 2022

87465(d)(1) Incidental Medical and Dental Care. If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement is not met as evidenced by: Based on interviews and records reviewthe state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: Licensee will submit a plan to provide proper level of care and supervision to residents in need of PRN medications who cannot verbally communicate their needs to ensure resident needs are met. Submit to CCL by 3/25/2022. R1 was in obvious pain, however staff failed to contact hospice or a physician for authorization to administer any PRN pain medication 8/21/20-8/23/20, which posed an immediate health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(A) · Plan of correction due date: Mar 25, 2022

87303(i)(1)(A) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Operate from each resident's living unit. This requirement was not met as evidenced by: Based on interviews and record review, R1's call button was not working on 8/24/2020. In addition, other call button alerts went unresponded for other residents during the period of June 2020 - September 2020, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: Licensee will submit a plan to conduct testing on the call buttons to ensure they are all functioning properly and provide staff training regarding call button alert response times. Submit to CCL by 3/25/2022.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 25, 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, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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 not met as evidenced by: Based on interviews and record review of alert response times, some responses were not completed in a timely manner and otehr calls went unanswered, which posed a potentialthe state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: Licensee will submit a plan to conduct testing on the call buttons to ensure they are all functioning properly and provide staff training regarding call button alert response time expectations. Submit to CCL by 3/25/2022. health and safety risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Mar 25, 2022

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that had been left by a skilled nursing professional, as well as a remote left by family, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: Licensee will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by 3/25/2022. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8755(a) · Plan of correction due date: Mar 25, 2022

8755(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on interviews, while tray service was being provided to all residents due to COVID-19, some residents were receiving cold food which should have been served hot, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2022

Plan of correction: Licensee will submit a plan for future instances where all residents must receive tray service due to an isolation order. The plan should describe how licensee will ensure all residents are served quality food that is safe and healthful. Submit to CCL by 3/25/2022.

Allegation investigated: Facility did not provide adequate staff to meet resident needs Facility staff did not provide a sanitary environment for residents Resident requires a higher level of care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Kortnie Spitznogel and Cynthia Garcia, Business Office Manager and explained the purpose for the visit is to conclude an investigation initiated on 04/04/2020 by LPA Kelly Dulek. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 03/23/2020, alleging that facility staff did not provide a sanitary environment for residents. LPA Ascencio conducted interviews on 10/21/21 and 10/26/21 with residents and staff. Resident interviews revealed that facility housekeeping comes into the resident rooms to clean the rooms, bathrooms, sweeps and mop at least one (1) time per week. During an interview in resident #1’s (R1) room on 10/26/21, LPA observed a dirty and sticky floor and little bits of paper on the floor. When questioning R1 regarding their room not being clean, R1 responded with “staff was just in my room to clean it. They just left. I don’t know why it is sticky and dirty.” Continues on LIC 9099 - C Unsubstantiated The LPA informed Admin of LPA’s observation. Admin proceeded to call housekeeping and clean the room again. The LPA’s observation throughout the facility and other residents’ rooms revealed a clean and sanitary environment for residents. Based on observation and interviews, the allegation is unsubstantiated at this time. The complaint also alleged that resident requires a higher level of care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 10/20/2020, 12/10/2020, 08/12/2021 and 10/06/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents. Interviews stated that resident #2 (R2) had a fall on or around 03/23/2020. File review and interviews on 10/06/2021 confirmed R1 was receiving hospice services before the fall. R2 had a hospice diagnosis of Alzheimer’s Disease unspecified. R2 was regularly monitored and seen by a hospice nurse 2-3 times a week. Interview with R2 could not be conducted as they passed on 09/20/2020. On 08/12/2021, LPA obtained photographs of R2 from facility file between the dates of 03/23/2020 and 03/30/2020, which revealed puffiness and yellow, green, red and purple discoloration on the right side of the face above and below eye. Review of R2’s facility file and chart notes revealed that following the fall, R2 was placed on hourly checks and was given as needed medication for pain management. Review of R2’s hospice notes on 10/06/2021 confirmed R2’s fall on 03/21/2020 and hospice visit on day of and days following of fall. Hospice note on 03/30/2020 states that “R2 continues to walk with eyes closed and needs constant redirection.” Based on interviews and file reviews, the allegation is unsubstantiated at this time. It was also alleged that facility did not provide adequate staff to meet residents' needs. During the course of the investigations, LPA Ascencio conducted staff interviews on 10/21/21 and 10/26/21. During the interviews, it was revealed that in the morning (am) and evening (pm) shifts, there is a total of three (3) staff members always present. During the night (noc) shift, the facility is staffed with two (2) staff members. Further interviews revealed that there are times that the facility only has two (2) staff members, but the medication tech helps out as caregivers. During resident interviews on 10/21/21 and 10/26/21, it was revealed that when a resident pushes their pendant, the wait time can take between 10-20 minutes before they receive help from a staff. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted. Copy of the report provided via email to Adminthe state’s words, verbatim · CDSS document, Mar 18, 2022 · control 31-AS-20200323162113

Allegation investigated: Staff speaking inappropriately to resident while in care Staff failed to effectively communicate with the residents while in care Unqualified staff is providing care and supervision Facility is not providing residents with adequate food Residents are left in soiled diapers for extended periods of time

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations initiated by LPA Kelly Dulek on 04/02/2020. LPA Ascencio met with Administratotr Kortnie Spitznogle and Cynthia Garcia, Business Office Manager at 2:09 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 04/02/2020, alleging that staff is speaking inappropriately to residents while in care. LPA Ascencio interviewed staff and residents between 10/21/21 and 10/26/2021. Interviews revealed that no one in the facility, including staff, have been rude, mean or spoke inappropriately to resident while in care. Residents stated that staff members work hard, are nice are not rude. Further interviews revealed that some care givers go out of their way to do more for residents and threat them with dignity and respect. Based on evidence gathered, the allegation is deemed unsubstantiated at this time. Continued on LIC 9099 - C Unsubstantiated It was also alleged that staff failed to effectively communicate with residents while in care. Staff interviews on 10/21/21 revealed that when residents push their pendant for help, caregivers come in to assist and communicate with them. The residents let the caregivers know what they need, and the caregivers help them out in any way possible. Most of the staff speak two (2) different languages with the most common being English. During care, the staff can communicate with all the resident in English with no problems with language barriers. During resident interview on 10/212/21 and 10/26/21, it was revealed that residents have not had any challenge with communication with any staff regarding language barriers. The staff speak to quickly, but resident tell staff to slow down. Some residents prefer that staff speak in Spanish as that is their native language. Based on evidence gathered, the allegation is deemed unsubstantiated. It was also alleged that unqualified staff is providing care and supervision. During staff interviews on 10/21/21, it was revealed that when a new staff is hired, they spend about one (1) week and a half training on the computer watching videos. Afterwards, they follow another staff member for about five (5) days to observe the duties, roles and responsibilities of the job. In accordance to Heath and Safety Code 1569.625, the department shall adopt regulations to require staff member of residential care facilities for elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter. The training shall include, but not limited to, the following: Physical limitations and needs of the elderly, importance of techniques for personal care services, residents’ rights, policies and procedure regarding medication and psychosocial needs of the elderly. LPA reviewed the California Direct Care Orientation Training Verification page received from the facility admin on 01/03/22. The training page is for new staff and states it must be completed before working independently with residents: 9.5 hours of General Caregiver Training, 12.5 hours of Dementia Training, 4.25 hours of Restricted Health Conditions, Postural Supports and Hospice Care. Additionally, page 2 stated that the following training must be completed within four weeks of employment: 16 Hours of Hands-On Skills, and First Aid and CPR Certification. LPA Ascencio reviewed staff files on 10/26/21 and it was revealed that staff members have their required training hours to be able to work independently with residents. Based on evidence gathered, the allegation is deemed unsubstantiated. Continued on LIC 9099-C Regarding the allegation of Facility is not providing residents with adequate food. LPA Ascencio interviewed residents on 12/13/21 and it was revealed that food quality can be good at times and bad at others. It feels like the quality of the products that they use are cheap. The only good meal that seems to not to be messed up is breakfast. LPA reviewed the Dinning Room menu for the week of March 2020. The menu revealed that on a daily basis, breakfast, lunch and dinner, facility offers a balanced meal that includes a protein, carbohydrates, and vegetables. LPA also reviewed menus for April, May, June, July, August and September of 2020 and it was revealed that all meals included a protein, carbohydrates and vegetables. Based on evidence gathered, this allegation is deemed unsubstantiated. It was also alleged that Residents are left in soiled diapers for extended periods of time. Interviews with residents on 10/21/21, 10/26/21 and 12/13/21 revealed that the staff help assist residents to use the restroom when the resident push their pendant. Interviews further revealed that it is on rare occasions that residents have to wait for staff to help them out. Interviews with staff on 10/21/21 revealed that staff check in resident about three (3) times a day or about every two (2) hours during their shift. Resident push their pendent, the staff respond to it as soon as possible by walking to the resident apartment and assisting them. Further interviews revealed that the majority of resident don’t require as much help but those that do, are kept in a two (2) hour check in or as needed for toileting needs. Interview with Resident #1 (R1) on 12/13/21, revealed that one-time R1 had to wait about one (1) hour and thirty (30) minutes before someone came up to assist. R1 complaint to the administrator for what had happened. R1 states ever since that day, R1 has not had any issues with staff coming to assist or waiting for toileting needs. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time. Exit interview conducted. Copy of the report was provided to Admin and Business Office Manager via email.the state’s words, verbatim · CDSS document, Mar 18, 2022 · control 31-AS-20200402092502

Allegation investigated: Resident is left in soiled diapers for extended periods of time Staff did not give medication to resident

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations initiated by LPA Brian Basili on 05/02/2020. LPA Ascencio met with Administrator Kortnie Spitznogle and Cynthia Garcia, Business Manager at 2:09 p.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 05/12/2020, alleging that resident is left in soiled diapers for extended periods of time and that staff did not give medication to resident. Interviews with residents on 10/21/21, 10/26/21 and 12/13/21 revealed that the staff help assist residents to use the restroom when the resident push their pendant. Interviews further revealed that it is on rare occasions that residents have to wait for staff to help them out. Interview with Resident #1 could not be conducted as resident no longer resides in facility. Interviews with staff on 10/21/21 revealed that staff check in resident about three (3) times a day or about every two (2) hours during their shift. Resident push their pendent, the staff respond to it as soon as possible by walking to the resident apartment and assisting them. Continued on LIC 9099 - C Unsubstantiated Further interviews revealed that the majority of resident don’t require as much help but those that do, are kept in a two (2) hour check in or as needed for toileting needs. Interview with previous Administrator stated that R1 had a machine in their room and did not know how to use it. Admin also said that R1 needed additional help but Family Member #1 (FM1) didn’t want to pay extra or have R1 on hospice services. Because R1 needed additional help, Admin wanted to move R1 to Memory Care but FM1 did not want to pay for those services. R1 was also not incontinence. Our staff helped R1 with stand-by toileting assistance. R1 would administer their own medication because the FM1 didn’t want to pay for a higher level of medication management. Admin added, R1 needed a higher level of med management because R1 didn’t know how to use the machine in their room. R1’s Physician Report dated 05/30/2019 indicates that R1 is able to administer own prescription medication, able to administer own PRN medication, and able to store own medication. The report also states that R1 can transfer independently from the bed, is non-ambulatory, does not have bowel or bladder impairment, and is able to care for own toileting needs. LPA also reviewed R1’s Preplacement Appraisal Information and revealed that R1 needs assistance with bathing, hair care, personal hygiene, and does not need assistance with toileting or incontinence control. LPA reviewed R1’s Needs and Services Plan signed and dated on 05/06/2020 revealed that R1 needed total assistance with bathing, and dressing, stand-by assist with transfers and toileting, and self administer of own medication. Interview with FM#1 on 05/12/2020 starting at around 11:00 am, revealed that R1 would tell FM1 that the staff don’t change R1’s diapers. FM1 also added that they would arrive at the facility to visit R1 and would find them in soiled diapers. Regarding medication, FM1 added that R1 had a medication machine in their room that dispensed medication. FM1 added there was one instance that FM1 dropped of medication for R1, staff was confused since the facility doesn’t help R1 with medication. FM1 personally went to R1’s room to refill the machine. LPA reviewed R1’s chart notes and a Narrative Chart note entry dated on 05/06/2020 stated “ Followed up with FM1. FM1 placed antibiotics in the machine. FM1 was called at 3:22 pm.” Although the allegations may have happened, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time. Exit interview conducted. Copy of the report was provided to Admin and Business Office Manager via email.the state’s words, verbatim · CDSS document, Mar 18, 2022 · control 29-AS-20200507130645

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Kortnie Spitznogle who is authorized to review and sign reports. During review of resident #1's facility file, LPA did not notice a Service Plan in the folder. LPA spoke with Resident Care Director (RCD) regarding missing Service Plan. RCD stated they completed an assessment for R1 and was signed by family. RCD proceeded to print a copy of the Needs and Service Plan dated and signed by family on 04/28/2021. Upon further review of resident file, LPA observed a Physician Communication sheets, dated 11/22/2021, stating "Resident was sent out to the hospital 11/22/21 @ 3:00 p.m. due to change in condition." Another Physician Communication sheet, dated 11/19/2021, stated " Resident was found on the floor for the 3rd time this week on the floor. Resident had an unwitnessed fall." Another Physician Communication sheet, dated 11/19/2021, stated " Resident returned from hospital 11/17/21 @ 10:30 a.m. w/ fractured ankle." LPA also observed Narrative Charting notes that mentioned R1's multiple falls, fractured ankle, and change in condition. LPA questioned RCD if a new Needs and Service Plan was created due to the change in condition R1 had been presenting. RCD stated " no we have not. But, we will do that right away." LPA educated staff on when a reappraisal is needed. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Copy of the report and appeal rights given to admin via email.the state’s words, verbatim · CDSS document, Dec 13, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Dec 24, 2021

87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Based on interviews, observation and record review, the licensee did not comply with the section cited above as there was no updated Needs and Service plan for R1 after returning from the hospital which poses a potential health, safety and personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Dec 13, 2021

Plan of correction: Admin and RCD will update the Needs and Services for R1 and present to family for signature. Admin will provide copy of signed Needs and Service Plan to LPA via email.

Allegation investigated: Resident sustained an unexplained injury while in care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Executive Director Kortnie Spitznogle at 10:20 AM. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 06/05/2020, alleging that a resident sustained unexplained injuries while in care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 06/15/2020, 10/20/2020, 12/04/2020, 12/08/2020, 10/4/2021, and 10/21/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents. Continued on LIC - 9099 - C Unsubstantiated Interview on 12/08/2020 with social worker #1 (SC) revealed that resident #1 (R1) had a skin tear in their arm around 06/05/2020. SC continued that staff present at the time did not know what happened and were not cooperative. Review of resident file chart notes on 10/06/2021 revealed that there was no recollection or written statement about a skin tear on R1’s arm. Interviews with staff revealed that R1 started hospice services on 04/28/2020 and was seen frequently by hospice services until R1 moved out of the facility in 06/08/2020. Also, R1 had multiple falls and frequent trips to the hospital between 04/28/2020 and 06/08/2020. Additional interviews revealed that R1 passed away August 2020. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is unsubstantiated. Exit interview conducted. A copy of this report provided to Executive Director via email.the state’s words, verbatim · CDSS document, Nov 10, 2021 · control 29-AS-20200605113632

Allegation investigated: Staff inappropriately restrained resident while in care.

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to close out the allegation at the facility. LPA Ascencio met with Administrator Kortnie Spitznogle at 1:37 p.m. Entrance interview conducted. The Woodland Hills Regional Office (RO) received a complaint on 05/21/2021 alleging that staff inappropriately restrained resident while in care. During the course of the investigation, LPA Ascencio performed interviews, file review and received pertinent documents. Interviews with staff on 08/12/2021, 10/06/2021 and 10/21/021, and revealed that the facility has removed gait belts and other devices from the premise about a year ago. Continued on LIC 9099 - C Unsubstantiated Further interviews revealed that no resident have been restrained and it is not part of their training criteria via video training or shadow training. Additional interviews revealed that staff members have not seen, heard or participated in any type of restraining of the residents. Review of resident files on 08/12/2021 revealed that five (5) out of forty-eight (48) resident’s Annual Assessment and Physicians Report states that they do not require restraining devices to provide care. Interviews with residents on 10/21/2021 and 10/26/2021 revealed that eight (8) out of 48 residents have not been restrained while in care. Based on the evidence gathered, the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred , therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. Copy of the report provided to Admin via email.the state’s words, verbatim · CDSS document, Oct 28, 2021 · control 29-AS-20210521114142

Allegation investigated: Staff are not responding to residents calls for assistance in a timely manor

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to continue investigation. LPA met with Executive Director Kortnie Spitznogle at 10:30 a.m. Entrance interview conducted. It was alleged that staff are not responding to residents call for assistance in a timely manner. Interviews with staff #1 (S1), S2, S3 and S4 on 10/21/21 starting at 12:33 p.m. revealed that all residents in the assisted living side have a call button with them. When residents need help, they push the button alerting staff member on their pagers. Once a call button is pressed, staff head to the room as soon as possible or call for help, shut off the alert button with their own button they have, then help out resident in need. Further interviews revealed that the staff need to respond before the 3rd call on their pager. Continued on LIC-9099-C Substantiated LPA reviewed the facilities procedures and policy at it pertains to call response and it states at the bottom in handwritten black ink, “Note: 15 min response time. Do not forget to reset!! Time is crucial!!”. LPA could not find anything else regarding response time. Interviews with resident #1, (R1), and R2 on 10/21/21 starting at 2:55 p.m. and further interviews with R3, R4, R5, R6, R7 and R8 on 10/26/21 starting at 11:05 a.m revealed that wait times for staff can take a bit longer than normal with residents waiting for about 20-30 minutes. Some days, caregiver response can take more time like 30-45 minutes. There have been other occasion of residents waiting up to one (1) hour for staff to come by and help. On 10/21/21, LPA obtained SMARTcare logs for the last week of April 2020, all month of May 2020 and first week of June 2020. On 10/26/2021 at 1:00 p.m. it was revealed from the SMARTcare logs that a total of five hundred and seventy-seven (577) call buttons have elapsed passing the fifteen (15) minutes mark. There have also been three-hundred and seventy-one (371) calls that have not been responded to. Based on interviews and evidence gathered throughout the investigation, the allegation staff are not responding to residents call for assistance in a timely manner is substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email to the executive director.the state’s words, verbatim · CDSS document, Oct 26, 2021 · control 29-AS-20200507130645

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 12, 2021

87468.1 Personal Rights of Residents in All Facilities (a)(2) 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. Based on record review, interviewsand observations the licensee did not comly with teh section cited above as the facility did not not responding to residents calls for assistance in a timely manor.the state’s words, verbatim · CDSS document, Oct 26, 2021

Plan of correction: Admin will provide training on Personal Rights and Process and Procedure on the call monitoring system for time effeciency to staff. Admin will provide copy of training material and staff attendees to LPA via email. angel.ascencio@dss.ca.gov

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.

Allegation investigated: Resident sustained unexplained injuries while in care

Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegation. LPA Ascencio met with Business Office Manager, Cynthia Garcia at 10:19 a.m. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 03/23/2020, alleging that a resident sustained unexplained injuries while in care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 10/20/2020, 12/10/2020, 08/12/2021 and 10/06/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents. Continued on LIC - 9099-C Unsubstantiated Interviews stated that resident #1 (R1) had a fall on or around 03/23/2020. File review on 10/06/2021 revealed that R1 had fallen on 03/21/2020 in the afternoon shift. R1 was getting up from the couch in the living room. File review and interviews also confirmed R1 was receiving hospice services before the fall. R1 had a hospice diagnosis of Alzheimer’s Disease unspecified. Facility staff immediately called hospice agency to report and monitor R1. R1 was regularly monitored and seen by a hospice nurse 2-3 times a week. Interview with R1 could not be conducted as they passed on 09/20/2020. On 08/12/2021, LPA obtained photographs of R1 from facility file between the dates of 03/23/2020 and 03/30/2020, which revealed puffiness and yellow, green, red and purple discoloration on the right side of the face above and below eye. Interview on 08/12/2021 with staff #1 (S1) revealed that R1 would often wear non-fitting clothing thus causing R1 to stumble. Review of R1’s facility file and chart notes revealed that following the fall, R1 was placed on hourly checks and was given as needed medication for pain management. Review of R1’s hospice notes on 10/06/2021 confirmed R1’s fall on 03/21/2020 and hospice visit on day of and days following of fall. Hospice note on 03/30/2020 states that “R1 continues to walk wit eyes closed and needs constant redirection.” Based on the evidence gathered, there is insufficient evidence to prove the alleged violation occurred due to staff neglect and lack of supervision. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. A copy of this report provided to BOM via email.the state’s words, verbatim · CDSS document, Oct 6, 2021 · control 31-AS-20200323142453

Allegation investigated: Staff are overmedicating residents. Medications are not properly stored and locked. Staff handling residents in rough manner causing skin injury.

Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced, subsequent complaint visit to deliver final investigation findings for the above complaint allegations. Entrance interview conducted. It was alleged that staff were overmedicating residents, as resident #1 (R1) was overmedicated by staff and was transported to the emergency room on 10/13/19. During the course of the investigation, LPA conducted interviews with R1 on 11/22/19 at 1:08 pm, S4, S5 and S6 on 6/5/2020 starting at 12:03 pm. Interviews and information gathered revealed that R1 denied being overmedicated by staff and staff were not aware of R1 ever being over medicated. Furthermore, LPA also gathered and reviewed pertinent documentation on 11/22/19 starting at 10:45 am and on 11/22/19 starting at 10:45 am. Medication records did not reveal that staff were overmedicating R1, and hospital discharge records dated 11/22/19 did not reveal that R1 had any abnormal medication toxicity in R1’s body. Continued on LIC 9099-C Unsubstantiated Based on all information gathered the above allegation, “Staff are overmedicating residents” is deemed unsubstantiated at this time. It was further alleged that; staff did not properly store or lock medication (medications left on counters by S4). During the course of the investigation, LPA conducted interviews with S4, S5 and S6 on 6/5/2020 starting at 12:03 pm and S1 on 11/22/19 at 10:27 am. Interviews conducted revealed staff denied not properly storing resident medications or observing any medications left out on counters that should have been properly stored. Furthermore, LPA also toured the facility on 11/22/19 and 10/18/19 observing residents’ medications properly stored and locked. Based on all information gathered the above allegation, “Medications are not properly stored and locked” is deemed unsubstantiated at this time. An additional concern alleged that staff handle residents in a rough manner causing skin injuries (scratching residents causing skin tears). During the investigation, LPA conducted interviews with S1, S2 and S3 on 11/22/19 starting at 10:27 am, S4, S5 and S6 on 6/5/2020 starting at 12:03 pm, R2 and R3 on 11/22/19. Interviews conducted revealed that staff were not aware of any residents being handled in a rough manner causing skin injuries. Furthermore, residents interviewed denied being mistreated nor scratched by staff. Based on all information gathered the above allegation, “Staff handling residents in rough manner causing skin injury (scratching residents causing skin tears)” is deemed unsubstantiated at this time. Exit interview conducted. A copy of this report issued to the Administrator.the state’s words, verbatim · CDSS document, Aug 12, 2021 · control 31-AS-20191017141902

Allegation investigated: Severe neglect resulting in death of resident. Resident sustained a fracture while in care. Resident's left in soiled clothing for a long period of time. Resident's room is unsanitary. Facility has a foul odor. Staff failed to meet resident's hygiene needs.

Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced subsequent complaint visit to the above facility to amend technical errors on page 2 of complaint investigation report issued on 8/12/21. It was alleged that severe neglect resulted in the death of Resident #1 (R1). It was further reported that on 09/27/2019, R1 was found deceased in R1s bedroom after sustaining a fall and hitting R1s head. During the course of the investigation, interviews were conducted with S3 and S4 on 10/3/19 starting at 1:47 pm and Hospice Aide on 10/3/19 at 10:57 am. In addition, LPA obtained and reviewed facility documentation pertinent to the allegations on 10/3/19. LPA also obtained and reviewed Hospice documentation on 10/9/19. Continued on LIC 9099-C Unsubstantiated Interviews conducted and documents reviewed reflected that on 9/27/19 starting at 1:15 pm, R1 was assessed by Hospice staff and a significant decline was noted. R1 slept the entire visit. On 09/27/2019, R1 was found on the floor inside R1s bedroom by staff at around 10 pm. Staff did not observe any blood. Staff observed R1s head leaning upright beside their bedrail. Staff assessed R1 and asked if R1 was in pain and R1 stated “no”. R1 was placed back in bed by staff. R1s hospice agency was contacted at 10:38 pm. On 9/28/19 at 3:08 am staff called to report R1 passed away. R1’s certificate of death indicates immediate cause of death as congestive heart failure and hypertension. Based on all information gathered, the above allegation, “severe neglect resulting in death of resident #1 (R1)” is deemed unsubstantiated at this time. An additional concern was that R2 sustained a fracture while in care on 10/1/19 due to shortage in staff. A review of R2s records on revealed that on 9/30/19, R2 was found on the floor outside of the bathroom during room check at 9:50 pm complaining of pain and was sent out 911. Interview with S12 on 6/5/2020 at 11:37 am revealed that residents are checked every 2-hours and R2 was found on the floor in their room during room checks. S12 indicated that they had sufficient staffing that night to meet the resident’s needs. Interview with S14 on 7/20/2020 at 1:36 pm revealed that R2 was found on the floor while staff were during their final rounds. S14 stated that R2 had an unwitnessed fall. Based on all information gathered, the above allegation, “Resident #2 (R2) sustained a fracture while in care” is deemed unsubstantiated at this time. Another allegation is that R3’s room is unsanitary as R3’s room has feces inside of it with trash bin overflowing with toilet paper with feces on it therefore, causing a foul odor in the hallway outside of R3’s room. Interview with S1 and S2 on 10/3/19 starting at 9:51 am revealed that R3 needs special attention and staff are aware of R3’s hygiene issues. Interview with S14 on 7/20/2020 at 1:36 pm revealed that R3 would change themselves without letting staff know and would leave their depends under their bed. S14 stated that they would clean them up when they found them. S14 stated that the housekeepers would clean R3’s room daily. Interview with S2 on 10/3/19 at 1:28 pm revealed that R3s room is cleaned every other day or sooner if needed. Continued on LIC 9099-C During facility tour on 10/3/19, LPA did not observe a foul odor in the hallway outside of R3’s room, nor did LPA did observe R3’s room unsanitary with feces. Based on all information gathered, the above allegations, “Resident #3 (R3) room is unsanitary and is causing a foul odor in the hallway” are deemed unsubstantiated at this time. It was also alleged the facility failed to meet R3’s hygiene needs, as R3 had been covered in urine and feces. Written statement received from S5 on 11/22/19, revealed that if R3 was observed with feces, staff would shower R3 and any soiled clothing or linens were always taken to be washed. Interview with S14 revealed that R3 would not let care staff assist them and was non-complaint. Written statement received from S6 on 11/16/19, revealed that R3 was checked every 2-hours during the NOC shift and was observed to be removing their diaper, even when dry. A review of R3’s records on revealed that on 10/2/19, care staff responded to R3’s request for assistance and R3 was observed with feces on them. R3 was showered and R3’s room was thoroughly cleaned. R3’s Needs and Services Assessment indicates R3 requires a 2-person assist for bathing twice a week. R3 only requires grooming and dressing reminders. Toileting – cueing as R3 hides fecal matter and soiled toilet paper. Based on all information gathered, the above allegation, “Staff failed to meet resident #3 (R3) hygiene needs” is deemed unsubstantiated at this time. Copy of the report to be provided via email.the state’s words, verbatim · CDSS document, Aug 12, 2021 · control 31-AS-20191002133729