Ventura Villa Assisted Living

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident visit to the facility. The LPA was greeted by Staff Catalina Gonzalez and informed them of the reason for the visit. Office Manger Angelica Arambulo was unable to be at the facility during today’s visit and authorized Catalina Gonzales to sign and receive the report. The purpose of today's visit is to address a self reported Unusual Incident/Injury Report (LIC 624) reported to CCL on 09/19/2023. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred on 9/06/2023 regarding Residents #1 (R1), two staff (S1, S2), and a visitor. It was documented that on the evening of 9/6/2023 R1 did not want to be changed and S1 asked a visitor to hold R1, then S1 and S2 continued to to change R1 in front of the visitor, violating R1's personal rights. It was further reported that R1 had been combative due to not being provided their 1 p.m. and 5 p.m. medications by S1. S1 was terminated on 9/06/2023. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 809-D). Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 22, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 29, 2023

87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by: Based on Records obtained. The licensee did not comply with the above cited section as R1 was held down by a visitor and S1 and S2 changed R1 infront of the visitor which poses an immidiate personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2023

Plan of correction: Office Manager Angelica Arambulo terminated S1 on the day of the incident, and S2 will be given a write up. Ofifice Manager agress to conduct an all staff trainning on personal rights and submit proof to CCL by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent Case Management - Incident visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA during a Case Management- Incident visit conducted on 08/17/2023. The LPA was greeted by Staff Catalina Gonzalez and informed them of the reason for the visit. Office Manger Angelica Arambulo was unable to be at the facility during today’s visit and authorized Catalina Gonzales to sign and receive the report. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred approximately the weekend of 8/07/2023 regarding Residents #1,2 and 3 (R1, R2, R3). On 8/17/2023, the LPA conducted interviews with two staff and four residents (R1, R2, R3, R4). The LPA interviewed the Office Manager Angelica Arambula throughout the visit. At 10:45 a.m. the LPA reviewed facility records and obtained copies of pertinent records. It was reported that staff (S1, S2) was witnessed hitting R1, R2, R3. On 8/17/2023 Office Manager Angelica Arambula stated that both staff had been suspended. Although a violation of Title 22 of the CA Code of Regulations was noted, the deficiency was cited on a separate report from a case-management visit on 9/22/2023. Exit interview conducted. Copy of report and appeal rights issued at the time of the visit.the state’s words, verbatim · CDSS document, Sep 22, 2023

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection pertaining to a self reported Unusual Incident/Injury Report (LIC 624) received on 08/17/2023. The LPA was greeted by Med Tech Dora Islas and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly. The self reported Unusual Incident/Injury Report (LIC 624) pertains to an incident that occurred approximately the weekend of 8/07/2023 regarding Residents #1,2 and 3 (R1, R2, R3). During today's inspection, the LPA conducted interviews with two staff and four residents (R1, R2, R3, R4). The LPA interviewed the Office Manager Angelica Arambula throughout the visit. At 10:45 a.m. the LPA reviewed facility records and obtained copies of pertinent records. No immediate health and safety concerns were observed during today's inspection. The LPA has determined further investigation is needed. The report was issued to Office Manager Angelica Arambula.the state’s words, verbatim · CDSS document, Aug 17, 2023

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 06/15/2023. The LPA was greeted by Med Tech Dora Islas and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly. Today the LPA conducted a file review, a medication audit, four (4) resident and three (3) staff interviews. Record Review: At 10:45 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of sixteen (16) Resident Files. The following was noted: Resident #1’s (R1’s) file was observed to be missing their functional capability assessment, R2’s file was observed to be missing a preplacement appraisal, and R3 and R4’s file was observed to be missing their personal rights (LIC613). The LPA reviewed five (5) of twenty-one (21) staff files. The following was noted: One staff (S1) file out of five was observed to be missing a first aid certificate, health screening, and documentation of Tuberculosis. Four out of five staff files (S1, S2, S3, S4) were missing four hours of training which shall be specific to postural supports, restricted health conditions and hospice care. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 5/26/2023). The LPA obtained Resident and Staff Rosters. Medications: At 1:30 p.m. a medications review was initiated. The following was observed: R1’s Expiration date and date filled for Nifedipine ER did not match the Facility Centrally Stored Medication and Destruction Record (CSMDR), R2’s expiration date and date filled for Losartan POT and Memantine HCL did not match the CSMDR, and R3’s CSMDR records were observed to be missing. R3’s Risperidone medication was counted in front of the LPA and was observed to have three more pills than needed based on the quantity on the medication’s label, in addition on the Medication Administration Record, medication for August 14, 2023 was unaccounted for. Upon observation, Med Tech Dora initiated correcting all of the missing information for residents (R1,R2, and R3). Interviews: During the visit the LPA conducted four (4) resident Interviews and three staff interviews Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Office Manager Angelica.the state’s words, verbatim · CDSS document, Aug 17, 2023

Type of visit: Required - 1 Year

At 10:20 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrative Assistant Erendira Guadarrama and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly. At 10:40 a.m. the LPA conducted a tour of the physical plant with Administrative Assistant Guadarrama and Office Manager Arambulo to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of twenty-five (25) resident bedrooms (thirteen (13) being occupied by residents), one (1) staff room, sixteen (16) bathrooms and four (4) shower rooms. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 11/14/2022. All smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings in the entrance area. Kitchen: During the facility tour, at 10:46 a.m. the LPA observed the kitchen to be kept inaccessible to the residents. The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. The LPA observed food containers not properly labeled with no expiration dates in the kitchen. At 11:05 a.m. the LPA observed the following expired food in the pantry: - One (1) Sesame Oil with the expiration date of 07/23/2022 - One (1) Pad Thai Sauce with the expiration date of 7/31/2022 - One (1) box of Stevia Sweetener with the expiration date of 12/01/2022 - One (1) Powdered Pure Cane Sugar bag with the expiration date of 11/2022 - One (1) Distilled White Vinegar bottle wit the expiration date of 7/24/2022 Report will continue on LIC809-C The Administrative Assistant stated they will discard all expired food today and properly label all food containers with expiration dates. There was a sufficient supply of cooking and dining ware. There were no visible immediate hazards observed. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night-stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 11:45 a.m. the LPA observed room #406 (not bedridden cleared) who was documented to have a bedridden resident on the resident roster. After observation the administrative assistant stated that resident #1 (R1) was not bedridden and resident roster had not been updated. The LPA verified with R1'S Physician report to not be bedridden but non-ambulatory. Bathrooms: At 11:36 a.m., the LPA observed the bathroom between rooms #101 and #103, with no trash can lid. At 11:41 a.m., the LPA observed the restroom between rooms #406 and #408 with a broken cabinet door in the bottom right of the sink. At 11:44 a.m., the LPA observed the bathroom between rooms #409 and #411, with no trash can lid, a toilet plunger over the sink, a walker next to the toilet and a wheelchair in front of the sink. At 12:08 p.m., the LPA observed the bathroom between rooms #402 and #404 with no trash can available. The office manager designated a staff personnel to clear the restrooms of any items and showed the LPA the new trash can with lid they had purchased for residents bathrooms. The LPA observed grab bars and non-skid tiles in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. At 12:05 p.m., water temperature in the bathroom between rooms #302 and #304 was measured at 97.2 degrees Fahrenheit. At 12:16 p.m., water temperature in room #105's restroom was measured at 99.2 degrees Fahrenheit. The water measured was not within the required limit of 105-120 degrees Fahrenheit. Office Manager delegated staff to adjust the hot water upon observation. Common Areas: These included the, hallways, living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a television, piano, puzzles and other indoor activities available for resident use. The facility maintained a comfortable temperature of 71 degrees. At 11:16 a.m., the LPA observed a rolling cart being used as a door stopper and blocking the door exit next to the kitchen leading to the outside patio. Administrative Assistant removed the rolling cart upon observation and LPA discussed safety hazards with them. They later found out that a resident had placed the cart at the door. Report will continue on LIC809-C At 11:28 a.m., the LPA observed a wooden rolling physical activity cart more than 5 feet in height blocking the exit door between rooms #209 and #207. Office Manager delegated staff to move the wooden cart to another location upon observation. LPA discussed safety hazards with the Administrative Assistant. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. There are no bodies of water on the premises. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Due to time constraints the LPA will return to complete the annual at a later date.the state’s words, verbatim · CDSS document, Jun 15, 2023

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff failed to provide timely medical attention Lack of supervision resulted in fracture

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to issue the findings for the above allegations. The LPA met with staff Endy Guadarrama and explained the reason for the visit. On 11/10/2022, the Department received a complaint, which alleged that staff failed to seek timely medical attention for Resident #1 (R1) after R1 suffered a fall. Community Care Licensing Division’s Investigation’s Branch (IB) Investigator Heidy Bendana was assigned to the case. On 11/15/2022, the LPA conducted the initial visit, and the LPA toured the facility, reviewed video footage at 11:55 a.m., and interviewed staff at 9:35 a.m., 9:50 a.m., 11:11 a.m., and 11:40 a.m. Investigator Bendana obtained facility video footage on 12/08/2022, interviewed three (3) staff members on 12/08/2022, interviewed R1’s responsible party on 1/12/2023 and 1/24/2023; interviewed a hospice nurse on 1/12/2023; and, interviewed two (2) staff members on 1/12/2023. Investigator Bendana obtained and reviewed medical records pertinent to the case. Substantiated CONT - PAGE 2 Regarding the allegation: Staff failed to provide timely medical attention It was alleged that staff failed to obtain timely medical attention for R1. Records review revealed that R1 was admitted to the facility on 07/05/2022 with hospice services, with the admitting diagnosis of metastatic cancer, hypertension, and dementia. Prior to admission to the facility, R1 was hospitalized and was diagnosed with lung cancer that had metastasized to the bone. Medical records indicated that R1 had multiple malignant masses throughout R1’s right lung, one of which that had progressively increased in size. As a result, R1’s appraisal dated 07/10/2022 noted that R1 was in ‘constant pain’ due to the masses. The investigation revealed that R1 suffered an unwitnessed fall in the facility courtyard on 11/05/2022. The staff whom assisted R1 after R1’s fall claimed that R1 was checked for immediate injuries and then placed back in their wheelchair. Staff mentioned that R1 sustained a cut on their forehead and mentioned that R1’s forehead hurt. Another staff whom assisted R1 indicated that R1 complained of hip pain. Staff reported that they informed the House Manager via phone and left a handwritten note, indicating that R1 had fallen. Interviews with the House Manager confirmed that staff had called them the evening of 11/05/2022 and reported R1’s fall; yet, the House Manager admitted that they notified the hospice agency and R1’s responsible party of R1’s fall the next morning, 11/06/2022. Staff indicated that they had assumed that R1 was ‘ok’ and did not require immediate medical attention. A hospice nurse assessed R1 on 11/06/2022. Interviews with the hospice nurse revealed that R1’s vitals and heart was checked. Although the nurse claimed that they checked R1’s range of motion, additional witnesses stated that R1 had complained of hip pain during the assessment. The information obtained from the hospice nurse supported claims that they recalled R1 expressing pain; however, they did not recall where the pain was located. The LPA also reviewed facility charting notes regarding R1. It was documented on 11/06/2022 that R1 ‘had some swelling on [R1’s] left temple area and scrape… no visible injuries on [R1’s] body but appears to have pain on [R1’s] left side, left shoulder particularly.’ Staff interviews and R1’s appraisal dated 07/10/2022 stated that R1 was ‘always’ in pain due to R1’s tumor. R1’s responsible party indicated that R1’s cancer was in their chest and had spread to their lungs. Yet, records review and interview revealed that R1’s hip pain was unrelated to R1’s cancer diagnosis. Records and interviews confirmed that R1 suffered another unwitnessed fall in R1’s room on either 11/06/2022 or on 11/07/2022 at approximately 4:00 a.m. CONT - PAGE 3 R1 was placed back into bed. Staff claimed R1 was ‘crying in pain’ when R1 lifted their arms and chose to contact hospice. Whereas hospice wanted to send a nurse, staff indicated that R1’s responsible party wanted R1 to be sent to the hospital. On 11/07/2022, R1’s responsible party took R1 to the hospital. Upon admission to the hospital, it was discovered that R1 sustained a left hip fracture. R1 did not return to the facility. Based on the investigation, there is sufficient evidence to support claims that the facility failed to provide timely medical attention for R1. R1 suffered two unwitnessed falls and complained of pain. Facility staff felt they fulfilled their due diligence by contacting the hospice agency regarding R1’s fall. As directed per regulation, the facility is expected to notify R1’s hospice agency instead of calling 9-1-1 if R1 was experiencing an emergency that was directly related to the expected course of R1’s terminal illness. R1 was receiving hospice services due to their terminal diagnosis of cancer and dementia. R1 fell on two occasions and was experiencing hip pain. This pain was not directly related to the reason as to why R1 was admitted to hospice. The allegation, ‘staff failed to provide timely medical attention’ was Substantiated at this time. Regarding the allegation: Lack of supervision resulted in R1 sustaining a fracture It was alleged that staff failed to supervise R1, which resulted in R1 falling and sustaining a fracture. Records review revealed that R1 was admitted to the facility on 07/05/2022 with hospice services, with the admitting diagnosis of metastatic cancer, hypertension, and dementia. R1’s physician’s report dated 7/7/2022 stated that R1 had an unsteady gait, had auditory and visual impairment, needed assistance to transfer to and from bed, exhibited confusion and wandering behavior, and required assistance with all aspects of care besides feeding oneself. Staff claimed that R1 ambulated with a wheelchair and stated they would have to remind R1 to utilize their wheelchair when ambulating through the facility. Staff stated that R1 would oftentimes get out of their wheelchair and use it as a walker. Medical records dated 07/01/2022 indicated that prior to R1 being admitted to the facility, R1 was deemed a fall risk due to R1’s mental status and condition. R1 suffered an un-witnessed fall in the facility courtyard on 11/05/2022. Staff interviews stated that R1 would regularly sit out on the courtyard after dinner. Staff claimed when they put R1 out on the courtyard, they told R1 ‘not to get up’ and said they left R1 alone because there were cameras in the courtyard. CONT - PAGE 4 A review of facility camera footage confirmed that at approximately 4:48 p.m. on 11/05/2022, R1 was observed sitting in their wheelchair in the courtyard .R1 was observed to be alone, and the footage did not capture staff ‘making rounds’ or checking in on R1. The camera footage skips to 5:48 p.m., where R1 is seen laying on their side in the courtyard, shoes scattered above their head, and two caregivers were lifting R1 up into the wheelchair. As the camera footage jumps from the time stamp of 4:48 p.m. to 5:48 p.m., one is unable to determine the time in which R1 fell, or the time that staff found R1 on the ground. Records and interviews confirmed that R1 suffered another un-witnessed fall in R1’s room on either 11/06/2022 or on 11/07/2022 at approximately 4:00 a.m. R1 was placed back into bed. Per the interviews conducted, there was no indication that staff implemented any fall precautions to decrease the likelihood of R1 suffering a fall at the facility. Although the Administrator claimed that R1 had a pendant and call button to ask for assistance, the investigation revealed that R1 did not wear a pendant while residing at the facility. There was no additional evidence to confirm whether R1 had a fall mat, bed alarm, or other fall prevention measures in place. Whereas the Administrator indicated that the facility did not provide 1:1 care, information obtained from other staff interviews revealed that staff believed that R1 either required 24-hour supervision, or 1:1 care. Whereas R1’s hospice nurse did not deny R1’s need for 1:1 care, it was communicated that R1 did not ‘necessarily need’ 1:1 care. R1’s family member also indicated that R1 required 1:1 care but knew R1 was not receiving 1:1 care when R1 resided at the facility. Based on the information obtained in interviews, observations, and records review, there is sufficient evidence to support the claim that due to lack of supervision, R1 suffered a fall and subsequently sustained a fracture. Staff stated they left R1 in the courtyard alone because there were ‘cameras in the courtyard’. Multiple staff stated that R1 either required 1:1 care or 24-hour care. Lastly, the facility did not implement fall preventative measures to lessen the likelihood of R1 sustaining a fall. This allegation is deemed Substantiated at this time. Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. An immediate civil penalty of $500 is also assessed. The licensee was informed that a civil penalty might be assessed based on the Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f). Exit interview conducted. A copy of the report was issued, along with appeal rights.the state’s words, verbatim · CDSS document, Mar 6, 2023 · control 29-AS-20221110164437

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87469(c)(3) · Plan of correction due date: Mar 8, 2023

87469(c)(3) Advanced Directives and Requests Regarding Resuscitative Measures. … For emergencies not directly related to the expected course of the resident’s terminal illness, the facility staff shall immediately telephone emergency response (9-1-1). This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as the facility did not call 9-1-1 and instead called R1's hospice agency after R1 fell and was in pain, even though the pain was unrelated to the terminal illness, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2023

Plan of correction: The Administrator agreed to do the following: 1. Submit a Statement of Understanding, explaining the steps the facility will follow to avoid similar issues from happening again and to ensure compliance to Title 22 Regulations regarding emergency medical assistance for residents receiving hospice services.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 8, 2023

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: 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 the investigation, licensee did not comply with the section cited above, as staff did not provide adequate supervision, resulting in R1 falling and sustaining injuries, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2023

Plan of correction: The Administrator agreed to do the following: 1. Submit a Plan of Action, detailing how staff are trained to respond to resident falls (witnessed and unwitnessed). In addition, detail the facility's protocol surrounding fall prevention. Submit protocol to CCL no later than 03/08/2023. 2. Review the protocol with all staff. Submit the sign-in sheet and all applicable documents to CCLD no later than 03/13/2023. A civil penalty in the amount of $500 is assessed.

Allegation investigated: Facility did not inform responsible party regarding change in resident’s physical therapy

Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Joy Ward-Michayluk, Administrstor. Concerns were that the facility did not inform resident #1 (R1)’s responsible party regarding change in resident’s physical therapy to Innerjoy Home Health. On 7/14/21 starting at 10:53 am interviews were conducted with staff, Administrator and residents. On 7/29/22 starting at 10:55 am interviews were conducted with resident family members. On 8/10/21 starting at 1:59 pm interviews were conducted with staff from Los Robles Home Care Services and staff from Doctor Steven Barr’s office. On 8/12/21 starting at 9:40 am interview was conducted with Licensee/Representative. Interview with Administrator revealed that R1’s responsible person did not want R1 to see any other physician besides Doctor Barr. Administrator stated that Doctor Barr was still R1’s physician. Interview with staff revealed that when Doctor Masongsong came to the facility in October 2020 they were using Inner Joy Health Home. Staff stated that they used to use Assisted Home Health and Los Robles Home Health. Contined on 9099-C Substantiated Interview with R2’s family member stated that they were not made aware of any physical therapy order for R2 until they received a phone call from a nurse at Heart 2 Home Health stating that they saw R2 that day. Interview with Los Robles Home Care Services staff revealed that R1 was discharged from PT on 12/4/19. Interview with R1’s physician’s office revealed that they did not refer R1 for physical therapy in 2020. Interview with Licensee/Representative revealed that Dr. Masongsong is the doctor that goes to their facility to see their residents. Licensee/Representative stated that Dr. Masongsong refers residents to Innerjoy Home Health as well as other places. A review of R1’s records on 7/28/22 starting at 12:52 pm revealed that R1’s Health Insurance approved Physical Therapy for R1 on 2/18/19, 2/25/19 and 11/13/19 with Los Robles Home Care Services. On 11/10/2020 facility staff faxed R1’s physician requesting a doctor order for physical therapy. Facility received an order for physical therapy to evaluate and treat R1 on 11/10/2020. On 11/24/2020 R1’s responsible party received notification of denial of medical coverage from their Health Insurance which indicated that Inner Joy Home Health asked if they could have physical therapy services and they are a non-contracted provider. They denied the request and approved PT services with a contracted provider Los Robles Home Care Services. A review of R2’s records revealed that on 3/20/21 Dr. Masongsong ordered HH (Innerjoy) to evaluate R2 for physical therapy. Based on the information obtained during the investigation, the allegation that the facility did not inform responsible party regarding change in resident’s physical therapy is substantiated at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D): Exit interview conducted, reports and appeal rights were reviewed and printed.the state’s words, verbatim · CDSS document, Feb 6, 2023 · control 29-NP-20210709071914

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(20) · Plan of correction due date: Feb 13, 2023

1569.269(a)(20) Enumerated rights; severability. To select their own physicians, pharmacies, privately paid personal assistants, hospice agency... in a manner that is consistent with the resident’s contract of admission or other rules of the facility, and in accordance with this act. 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 requested a change in Physical Therapist companies without prior notification to responsible parties which posed a potential personalthe state’s words, verbatim · CDSS document, Feb 6, 2023

Plan of correction: Administrator agreed to submit a statement of understanding of 1569.269(a)(20) to CCL by 2/13/2023 rights risk to persons in care.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Licensee Evangeline (Joy) Michayluk and informed them of the reason for the visit. At 09:20AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. Common Areas: There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature throughout the building. There are fire extinguishers throughout the facility, which were fully charged and last serviced 11/16/2021. The LPA observed staff engaging residents in group activities. All common spaces appeared clean and in good repair. At 09:21AM, the Storage closet, which contains Shampoo & Body Wash, Peri-Rinse, and other personal care items was observed to be unlocked and accessible to residents in care. At 09:42AM, the Linen Closet containing Shampoo & Body Wash, Peri-Rinse, Jergens body lotion, Dove Body Wash, incontinence care cart, and other personal care items was observed to be unlocked and accessible to residents in care. Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. Food is prepared based on the menu and modified as needed for individual residents. Administrator stated a large monthly food order will be delivered Monday and perishable foods are purchased as needed throughout the month. Snacks and beverages are available for residents at all times. Outside areas: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. Resident Rooms: The facility is a one story building. Resident rooms can be designated for either single or double occupancy. All resident rooms have either a private restroom or a "jack and jill" restroom shared with Report Continued on LIC 809-C the adjoining room. At 09:35AM, water temperature in room #105's restroom was measured at 99.8 degrees Fahrenheit. At 09:40AM, water temperature in the"jack and jill" restroom between rooms #103 and #101 was measured at 102.5 degrees Fahrenheit. Administrator indicated the water heater was replaced yesterday and had been set to 120 degrees Fahrenheit. Record Review: At 11:26AM, LPA reviewed records for three (3) residents for documents including but not limited to Physican's Report and Appraisal Needs and Service Plan. One (1) of three (3) residents, who has a diagnosis of Dementia, had a physician's report dated 04/07/2021. Infection Control: Prior to entry to the facility, there is a central entry point for symptom screening and temperature checks for staff, and visitors. Staff and visitors were observed wearing appropriate face coverings throughout the visit. During today’s visit, the LPA spoke with the Administrator regarding the community's infection control practices. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation rooms if there is a confirmed case of COVID-19, as well as a COVID-19 wing. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The community's policies and procedures pertaining to infection control were adequate. 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, and appeal rights were reviewed and emailed to the Licensee.the state’s words, verbatim · CDSS document, Jun 22, 2022

Allegation investigated: Facility failed to meet the needs of the residents Facility has insufficient staffing

Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced subsequent visit to deliver the final findings to the above facility. LPA met with Administrative Assistant Endy Guadarrama at 1:02 p.m. Administrator Evangeline Michayluk is unavailable due to family emergency. Entrance interview conducted. The Woodland Hills North Regional Office (RO) received a complaint on 03/18/2022 alleging that facility staff are failing to meet the needs of the residents and facility has insufficient staffing. On 03/23/2022 LPA Ascencio conducted staff interviews starting at 12:40 PM. During the staff interviews, it was revealed that they always work a four-two-four (4-2-4) schedule with 2 staff members scheduled daily. Further interviews revealed that the facility is using an outside agency ACE Compassionate Care, to assist when staffing needs are low. Continued on LIC 9099 - C Unsubstantiated LPA Ascencio received February and March 2022 staffing schedule. Review of the schedules revealed that there has been 2 staff members for the 1st shift (7:00 a.m. – 3:00 p.m.), 2 staff members for the 2nd shift (3:00 p.m. – 11:00 p.m.) and 2 staff members for the 3rd shift (11:00 p.m. – 7:00 a.m.). Further staff interviews also revealed that Resident #1 (R1) moved in early March 2022 and has had a hard time adjusting to the facility. When R1 moved in, they would wander within the community screaming and yelling for help. Staff would intervene and attempt to redirect with some days more successful than others. Continued staff interviews also revealed that they have cameras throughout the facility and when R1 yells for help, they notice on the cameras that R1 is not in any immediate danger. Further staff interviews also revealed that staff use various methods of interventions to redirect R1 including a calm demeanor, creative verbal responses and meaningful activities. One of the last interventions for R1 is the use of medication, which they are prescribed for agitation. Interview with R1 starting at approximately 2:10 p.m. on 03/23/2022 revealed that they like the place they currently live at. R1 also mentioned that they do not have a problem with any staff or residents in the facility. Further interview with R1 also revealed that they do not yell for help, they just let the staff know what they need and that the staff are good and treat them nice. Based on file review and staff and resident interviews, the allegations; Facility failed to meet the needs of the residents and facility has insufficient staffing are deemed Unsubstantiated at this time. Exit interview conducted and copy of the report provided to admin via email.the state’s words, verbatim · CDSS document, May 17, 2022 · control 29-AS-20220318084413

Allegation investigated: Facility failed to provide or assist with arranging timely medical transportation

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings on the above noted allegation. LPA met with administrator Joy Ward-Michayluk and explained the reason for the visit. LPA Camara had visited the facility on 09/03/2021 and conducted a plant tour at 10:25 a.m., reviewed records at 11:15 a.m., and interviewed Staff 1 (S1) at 12:40 p.m. and Staff 2 (S2) at 2:50 p.m. Resident 1 (R1) experienced severe abdominal pain on 08/26/2021. Staff called R1's doctor who asked for R1 to be sent to the hospital emergency room. Staff called R1's family who requested staff find free transportation for R1 rather than call 9-1-1. Staff indicated this was an emergency and there was not time to look for free transportation. After some back and forth with the family, staff called 9-1-1 to take R1 to the emergency room. Based on the records reviewed and staff interviews, this allegation is Unsubstantiated at this time. Exit interview conducted and a copy of the report was emailed to the administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 12, 2022 · control 29-NP-20210826165010

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

87303(c) Personal Accommodations and Services. Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met as evidenced by: LPA observed several resident bathrooms that lacked locks on bathroom doors. These are "Jack and Jill" style bathrooms where adjoining rooms use the same bathroom and can enter when someone else is using the bathroom, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Administrator has already ensured that all bathrooms have locks. This was completed in September of 2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(3)(D) · Plan of correction due date: Apr 25, 2022

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap andthe state’s words, verbatim · CDSS document, Apr 12, 2022

Plan of correction: Administrator will provide training to staff to ensure resident bathrooms have adequate supply of personal hygiene items, including toilet paper and paper towels. Supplies will be limited to smaller amounts due to several residents clogging plumbing with excess paper supplies. Evidence of training will be provided to CCL by 4/19/22. toilet paper. This requirement was not met as evidenced by: LPA observed resident bathrooms which lacked toilet paper and paper towels, which is a potential health and safety risk to residents in care.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted an unannounced case management inspection due to a death report submitted to the Regional Office on 08/31/2021. LPAs met with Assistant Administrator Jennifer Sharma and explained the reason for the visit. Administrator Evangeline "Joy" Ward-Michayluk arrived at 11:15AM. The reason for today's inspection was to follow up on the death report for resident #1 (R1) received in the Regional Office on 08/31/2021. During today's inspection, the LPAs toured the facility at 10:28AM, conducted staff interviews between 11:40AM and 2:50PM, reviewed resident records at 11:20AM, and gathered copies of pertinent documents. At this time further investigation is needed. A exit interview was conducted with Evangeline "Joy" Ward-Michayluk, and a hard copy was provided via email.the state’s words, verbatim · CDSS document, Sep 3, 2021

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted a Case Management-Deficiencies visit to issue citations for deficiencies observed during the investigation of complaint control #29-NP-20210826165010, unrelated to the complaint allegations. During the facility tour the LPAs conducted along with Assistant Administrator Jennifer Sharma at 10:28AM, LPAs observed an unlocked closet labeled "Telephone & Cable" at 10:32AM. Additionally, at 11:05AM, a resident restroom/toilet was observed to be dirty. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, report issued, and appeal rights provided via email.the state’s words, verbatim · CDSS document, Sep 3, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705 · Plan of correction due date: Sep 3, 2021

87705(f)(1) (f) The following shall be stored inaccessible to residents with dementia: (1) 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 observation, during facility tour, a closet containing facility electrical equipment was observed to be unlocked and unable to be closed, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2021

Plan of correction: Administrator repaired the door during today's visit. LPAs confirmed the door closes and locks. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Sep 6, 2021

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 and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation, during facility tour, resident restroom was observed to be dirty, which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2021

Plan of correction: The administrator ensured the resrtoom was cleaned during today's visit. Administrator will send a photo of cleaned toilet seat by POC due date.

Type of visit: Post Licensing

Licensing Program Analysts (LPAs) JoAnn Rosales and KaSandra Lopez arrived at the facility to conduct a Post Licensing visit. LPA's observed a COVID-19 screening station outside of the facility and were assisted by staff Jennifer Sharma. LPA's toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Today's evaluation included but was not limited to building and grounds, resident rooms, bathrooms, common areas, personal accommodations, hot water temperature (read at 113.7 and 114.5 degrees) in resident bathrooms, kitchen and food supplies. There is an adequate amount of perishable and nonperishable foods. LPA's observed fire extinguishers fully charged. Centrally stored medicines are kept in a locked medication room. First Aid kit is complete. Grab bars were present in the bathrooms. LPA observed appropriate and sufficient lighting in each room. Hygiene items are being provided. LPA's observed signal system which operates from each resident room. Carbon monoxide detectors were tested and operable. Administrator provided documentation of smoke detector test completed on 12/15/2020 with no defects found. Fire Alarm defects were found and were repaired and retested with no defects on 1/4/21. LPA's observed disaster plan posted hallway. LPA observed COVID-19 postings throughout the facility. LPA observed a 30 day supply of PPE. LPA reviewed a sampling of resident medications and records. LPA reviewed a sampling of staff records. During a review of resident records starting at 12:33 pm LPA's observed that resident #1 (R1), R2 and R3 do not have TB tests on file. LPA's observed that R3 and R4 do not have current physicians reports on file. During a review of staff records starting at 3:25 pm LPA observed that staff #1 (S1) and S2 do not have Continued on 809-C documented 40 hours of initial training on file. LPA observed that S1, S2 and S3 do not have a current first aid certificates on file. LPA observed that S4 does not have a health screening on file. 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. Today's reports and appeal rights were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Aug 11, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Aug 20, 2021

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 2 out of 6 resident records which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Administrator stated that they will provide documentation of R3 and R4's current physicians reports to CCL by 8/20/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(1) · Plan of correction due date: Aug 20, 2021

87458 Medical Assessment. (b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 3 out of 6 resident records which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Administrator stated that they will provide documentation of R1, R2 and R3's TB tests to CCL by 8/20/21.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Aug 20, 2021

1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 2 out of 6 staff records which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Administrator stated that they will provide documentation of S1 and S2's 40 hours initial training to CCL by 8/20/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Aug 18, 2021

87411 Personnel Requirements – General (c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 3 out of 6 staff records which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Administrator stated that they will provide documentation of S1, S2 and S3's current first aid certificates to CCL by 8/18/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Aug 18, 2021

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health… Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff records which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2021

Plan of correction: Administrator stated that they will provide documentation of S4's health screening to CCL by 8/18/21.

Allegation investigated: Resident's personal rights were violated Resident was transported in an unsafe manner and/or vehicle

During today's visit Licensing Program Analysts (LPA's) JoAnn Rosales and KaSandra Lopez toured the facility with Administrator, reviewed random resident records, interviewed random staff and obtained copies of pertinent documents. Concerns were that resident #1 (R1)'s rights were violated as housekeeping staff threw away R1's AARP bulletins. Interview with staff (S1) starting at 10:53 am revealed that S2 removed R1's AARP magazines from their room and placed them on their housekeeping cart to throw out. Interview with S2 starting at 11:44 am revealed that they removed a newspaper and magazines from R1's room as they thought that R1 did not need them anymore and placed them on their housekeeping cart. Concerns were that R1 was transported in an unsafe manner and/or vehicle as R1 was transported in S1's personal vehicle for an appointment. Interview with Administrator at 5:12 pm revealed that they did not do a car safety inspection and only confirmed verbally that S1 had current car insurance prior to S1 transporting R1 to their appointment. Continued on 9099C Substantiated Interview with S1 revealed that they transported R1 in their personal vehicle to an appointment. S1 stated that the Administrator did not request a copy of their current automobile insurance information and they were not required to do any safety checks on the vehicle prior to transporting R1 to their appointment. Starting at 11:35 am LPA's observed S1's vehicle with working blinkers, hazards, brake lights, horn and headlights. LPA's observed a crack on the passenger side windshield. S1 stated that the crack on the windshield happened on 7/10/21. LPA's observed current automobile insurance information for S1's vehicle. Based on the information obtained during the course of the investigation the allegations are deemed substantiated at this time. Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator. lock from R1's bathroom door however, R1's responsible person stated that R1 would not have privacy so Licensee/representative placed the lock back on the bathroom door. Licensee/representative stated that the lock is a toggle lock and can be locked and unlocked from both sides of the door. During Interview with R1 at 12:19 pm R1 pointed out the lock on their bathroom door indicating that the door was locked. LPA's observed R1's bathroom door to be unlocked. R1 stated that sometimes the door is locked sometimes it is not locked. Interview with S2 and S3 starting at 11:56 am revealed that they were unaware of R1's bathroom door being locked and R1 not having access to the bathroom. Based on the information obtained during the course of the investigation the allegations are deemed unsubstantiated at this time. Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2021 · control 29-NP-20210709071914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.269(a)(30) · Plan of correction due date: Jul 23, 2021

1569.269 Enumerated rights; severability (a)(30) To keep, have access to, and use their own personal possessions, including toilet articles, and to keep and be allowed to spend their own money, unless limited by statute or regulation. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as staff removed R1’s personal items from their room which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Administrator stated that they will provide documentation of staff training regarding residents rights to CCL by 7/23/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: Jul 23, 2021

87312 Motor Vehicles Used in Transporting Residents. Only drivers licensed for the type of vehicle operated shall be permitted to transport residents. The rated seating capacity... Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as licensee did not verify that S1's vehicle was maintained in a safe operating condition prior to transporting R1 which posed a potential safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Administrator stated that they will no longer being using staff to transport residents in their private vehicles as they have a contract with a medical transport company.

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

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) JoAnn Rosales and KaSandra Lopez conducted an unannounced Case Management - Deficiencies inspection at the facility today due to a violation observed during the investigation of complaint control #29-NP-20210709071914. At 10:32 AM the LPAs observed the following items accessible to residents in an unlocked storage closet: Milk of Magnesia, Miralax, fleet enemas, poly grip, and toothpaste. The facility has residents residing in the facility with a diagnosis of dementia. The door was locked during the inspection. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted, todays reports and appeal rights were reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Jul 14, 2021

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication,...and toxic substances.... This requirement is not met as evidenced by: Based on observation, the licensee failed to comply with the citation above as there are residents with a dementia diagnosis and over the counter medications and hygiene supplies were being stored in an unlocked storage closet which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2021

Plan of correction: Staff locked the door and secured the items during the inspection. Plan of correction is cleared.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPAs) JoAnn Rosales and KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility due to receiving information of an incident during the investigation of complaint control #29-NP-20210709071914. At 12:19 pm LPA Rosales was conducting an interview with resident #1 (R1) regarding the complaint investigation. During the interview, R1 stated about a week and a half or two ago three or four males of which some were African American grabbed R1 out of bed and threw them to their bedroom floor. R1 stated that they wanted to report this to law enforcement. Upon receiving this information, LPA Rosales notified the Administrator and requested that they call law enforcement. The LPA also requested the Administrator to complete an Incident Report and the Report of Suspected Dependent Elder Abuse form (SOC341) and cross report. At approximately 1:00 pm a review of R1's file was conducted and pertinent copies of records were obtained. During the inspection Law enforcement came to the facility and interviewed R1. At 2:07 pm the LPAs met with two law enforcement officers who stated that after interviewing R1 they would not be conducting any further investigation. LPA Rosales obtained the police report number from the investigation. Interviews with the Administrator revealed that they were not aware of this alleged incident reported by R1. The Administrator also stated that there is only one male staff working at the facility during the night shift and there are no African American staff or residents residing in the facility. At 2:27 pm the LPAs attempted to interview R2 who is the roommate of R1. Due to their medical condition, the LPAs were unable to conduct an interview with R2. At 2:31 pm the LPAs conducted an interview with R3 who resides in the room next to R1. R3 reported no issues or concerns of unwanted individuals coming into Continued on 809C their room or any reports of being abused. At 2:43 pm an interview conducted with R4 revealed no issues or no unwanted individuals coming into their room or any reports of being abused. At 2:53 pm an interview with R5 revealed no issues of concerns regarding how they are being treated at the facility. At 4:17 pm LPA Rosales conducted a telephone interview with staff #1 (S1) who works the overnight shift. S1 denied ever pulling any residents out of bed and throwing them on the ground. S1 stated that they are the only male staff who works at night. S1 reported no incidents of outside individuals coming into the facility and assaulting any residents. The facility is approved for delayed egress and secured perimeter of which individuals cannot enter the building or exit the building without staff unlocking the doors and granting entry/exiting. Based on the information obtained during the investigation there is insufficient evidence at this time to support R1 was physically abused at the facility. Exit interview was conducted, today's report was reviewed and emailed to the Administrator.the state’s words, verbatim · CDSS document, Jul 14, 2021

Type of visit: Office

A virtual Office Meeting was conducted to discuss concerns that were brought to our attention regarding the change in ownership from Treacy Villa #561703345. Present at today’s meeting were: Jill Nakata Regional Manager (RM), Kristin Heffernan Licensing Program Manager (LPM), JoAnn Rosales Licensing Program Analyst (LPA), Evangeline "Joy" Ward-Michayluk Administrator and Craig Michayluk Licensee/Representative. RM discussed staffing and communication with residents and their responsible persons and making sure that what is being communicated is cohesive. RM requested Administrator to submitted a current LIC500 Personnel Record. LPM discussed the visitation policy suggesting that they follow the Provider Information Notice (PIN) 21-17.2-ASC dated 5/14/21. Licensee/Representative agreed to follow the Provider Information Notices including revising their visitation policies. LPA to provide a copy of PIN 21-17.2-ASC to Administrator and Licensee/Representative. LPM discussed Health and Safety Code 1569.655 regarding any rates increases for residents. Licensee/Representative agreed to follow Health and Safety Code 1569.655 and provide residents and/or their responsible party a written 60 day notice. LPA to provide a copy of Health and Safety Code to Administrator and Licensee/Representative. LPM discussed changes in residents Pharmacies, Physical Therapists, Home Health, Hospice any other Providers. Licensee/Representative agreed to notify residents and their responsible persons prior to making any changes in residents Providers. LPM discussed the facility's transportation policy. Administrator stated that they have made arrangements with a 3rd party transportation company to provide transportation for residents. LPM discussed exceptions and waivers that will need to be submitted under the new license. Exit interview conducted, today's report was reviewed and emailed to the Administrator and Licensee/Representative.the state’s words, verbatim · CDSS document, Jul 8, 2021