Veterans Home of California - West Los Angeles

Allegation investigated: Wrongful eviction. Staff not providing a safe environment for resident.

On 06/14/23, Licensing Program Analyst (LPA), Perry Scott initiated a 10-day complaint investigation at the facility listed above. LPA Scott met with Supervising Registered Nurse, Julius Lozano and explained the purpose of today’s visit was to investigate the allegations listed above. On 06/14/23, the investigation consisted of the following: During today's visit LPA conducted a health & safety check of the facility. LPA conducted interviews with the staff (S1- S3), and residents (R1 & R2). LPA requested and obtained copies of the following documents: Resident and staff roster, eviction notice for R1, ID/Emergency information, admission agreement, code of conduct agreement, Interdisciplinary Team meeting note, and eviction procedures. The investigation revealed the following: Allegation # 1 Wrongful eviction. Report continued on LIC9099-C Unsubstantiated On 06/14/23, LPA interviewed S1-S3 about the allegation. It was alleged that R1 punched R2 while having a disagreement at the facility. All staff corroborate that indeed R1 punched R2. LPA conducted an interview with R1 and R2. R1 did not deny that R1 punched R2 in the face while having a disagreement. R2 confirmed that they were arguing and R1 got up and punched R2 in the face. Upon an investigation of the incident, the facility had an Interdisciplinary Treatment Team meeting to address the issue. The facility maintains in their Resident, Code of Conduct, entitled Abuse/Violence/Illegal Actions that “if the incident involves elder abuse, threats of violence or violence against another resident…the resident may be considered for immediate involuntary discharge from the home”. Accordingly, the facility issued R1 a thirty-day eviction notice that complied with Title 22 regulations. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the facility issued a Wrongful eviction. 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. Allegation #2: Staff not providing a safe environment for resident. On 06/14/23, LPA interviewed S1-S3 about the allegation. All staff reported that no one has ever come to them stating that the staff are not providing a safe environment for the resident. LPA interviewed R1 about the allegation and R1 stated that R2 had been harassing R1 but R1 did not tell anyone about it. LPA interviewed R2 and R2 stated that there haven’t been any problems with R1 in the past. Based on interviews and records reviewed there is insufficient evidence to support the allegation: Staff not providing a safe environment for resident. 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. No deficiencies were cited. An exit interview was conducted, and a hard copy of this report was provided to Deputy Administrator, Teresa Starks.the state’s words, verbatim · CDSS document, Sep 19, 2023 · control 11-AS-20230606142622

Allegation investigated: “Facility staff are harassing residents in care” “Facility staff did not have resident fill out a valid admissions agreement” “Facility staff are verbally abusing residents” “Facility does not have awake staff on night shift” “Facility staff are smoking marijuana while caring for residents”

On 08/23/2023, at 8:05 AM Licensing Program Analyst (LPA) David España met with Teresa Starks, Administrator and Julius Lozano, Supervising Registered Nurse to conduct a complaint investigation to address the allegations listed above. LPA España met with Teresa Starks, Julius Lozano and explained the purpose of this visit. The investigation consisted of the following: LPA España reviewed records and documents concerning the needs further investigation. LPA España reviewed the interviews of 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. Unsubstantiated The investigation revealed the following: Regarding the Allegation: “Facility staff are harassing residents in care.” LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. Staff 1-6 (S1-S-6) have provided statements confirming that the facility staff handled the residents appropriately and did not engage in any inappropriate behavior. LPA and LPM asked questions relevant to the nature of the complaint. LPA and LPM were unable to interview Resident 1 (R1) who was in the community. Resident 1 (R1) was contacted by LPA and LPM by telephone and approached R1’s room for interview two times for interview with no response. Resident 1-6 (R1-R6) displayed no aggressive conduct and provided interviews and provided answers to specific questions to the allegation above. R1-R6 provided context to claimed harassment, however, did not provide a specific connection to said harassment and associated staff to LPA and LPM. R2 reported that in the dining room there was a staff member (unknown staff) who has exhibited harassing behavior, by rushing out residents from the dining room area. R2 shared that he had a difficult situation at this time, contributing to his emotional state, discussed a specific resident at the facility (R2 did not name another resident, just referenced). However, S1-S6 has stated that staff members have not harassed any resident in care. S1-S6 denied any involvement in such actions, refuting the allegation. The investigation revealed the following: Regarding the Allegation: “Facility staff did not have resident fill out a valid admissions agreement.” LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. During record review of the timeline of events indicated in R1's 3-day eviction notice, LPA and LPM did not observe reasons indicating that R1 was engaging in a behavior which poses an immediate threat to the physical and mental health of himself or others at the facility. However, LPA and LPM did observe that R1 and R2 did fill out a valid admission agreement. Signed admissions agreement stated and showed signatures on all respected admissions agreement pages. LPA España and LPM Coronel interviewed 6 staff, and 6 out of 61 residents who stated everyone signs and agreed to the admission agreement here at the facility. The investigation revealed the following: Regarding the Allegation: “Facility staff are verbally abusing residents.” LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. All staff interviewed denied verbally abusing residents in care. 6 out of 61 residents interviewed revealed that no staff verbally abuse residents. There was no corroborating evidence to demonstrate verbal abuse from facility staff. S1-S6 denied any involvement in such actions, refuting the allegation. The investigation revealed the following: Regarding the Allegation: “Facility does not have awake staff on night shift.” LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. LPA España and LPM Coronel interviewed S5 and S6 who did not express a concern that staff are asleep on night shift. Per S5 and S6 staff are required to be awake at night per the facility management. S5 and S6 stated that there were two staff at night and per the facility protocol staff and are not a sleep in any shifts. LPA España and LPM Coronel interviewed 6 staff who stated that there are sufficient staff and that the staff schedule is updated weekly. S1-S6 denied any involvement in such actions, refuting the allegation. The investigation revealed the following: Regarding the Allegation: “Facility staff are smoking marijuana while caring for residents.” LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. LPA España and LPM Coronel interviewed 6 staff and 6 out of 61 residents who stated they have not heard or seen the above allegation happen at the facility. S1-S6 denied any involvement in such actions, refuting the allegation. The investigation consisted of the following: LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which included admission agreements and eviction notices. The residents’ records were observed and thoroughly reviewed. During the interviews and records review, S1-S6 and 6 out of 61 residents refuted the allegations. Additionally, the staff has reported all special incident reports to all relevant agencies before the complaint, adhering to proper protocols. S1-S6 stated that the staff is well-trained and competent to provide the necessary services to meet the resident’s needs. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegations 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 deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C were provided to the facility Administrator, Teresa Starks. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Aug 23, 2023 · control 11-AS-20230815144902

Allegation investigated: Illegal Eviction

On 08/22/2023, at 9:05 AM Licensing Program Analyst (LPA) David España and Licensing Program Manager (LPM) Ulysses Coronel met with Teresa Starks, Administrator and Julius Lozano, Supervising Registered Nurse to conduct a complaint investigation to address the allegations listed above. LPA España and LPM Coronel met with Teresa Starks, Julius Lozano and explained the purpose of this visit. The investigation consisted of the following: LPA España and LPM Coronel conducted a tour of the facility grounds. LPA España and LPM Coronel interviewed 6 staff, 6 out of 61 residents, and reviewed the following documents: client roster, staff roster, residents R1 and R2's records which includes admission agreements and eviction notices. The investigation revealed the following: Regarding the allegation: "Illegal Eviction" During record review of the timeline of events indicated in R1's 3-day eviction notice, LPA and LPM did not observe reasons indicating that R1 was engaging in a behavior which poses an immidiate threat to the physical and mental health of himself or others at the facility. Substantiated During record review of resident R2's 60-day eviction notice LPA and LPM did not observe exact statements "as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Based on LPA’s observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations, Tittle 22 are being cited please see LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Administrator Teresa Starks whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, Aug 22, 2023 · control 11-AS-20230815144902

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(b) · Plan of correction due date: Aug 24, 2023

Eviction Procedures. The licensee may, upon ... prior written approval from the licensing..., evict the resident upon three (3) day...notice to quit. The licensing...may grant approval...upon finding of good cause. ... facility. This requirement was met by: Based on record reviews the licensee failed to indicate good cause that R1 was engaging in a behavior which poses an immidiate threat to the physical and mental health of R1 or others at the facility, this poses a potential health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: The licensee shall dismiss the eviction notice to resident R1, in writing, and submit a copy of the dismissal by the POC due date of 08/24/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(D) · Plan of correction due date: Aug 24, 2023

The... statement...: "In order to evict a resident ... facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If...hearing." This requirement was met by: Based on record reviews the licensee failed to indicate exact statements as specified in Health and Safety Code Section 1569.683(a)(4):, this poses a potential health & safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2023

Plan of correction: The licensee shall dismiss the eviction notice to resident R2, in writing, and submit a copy of the dismissal by the POC due date of 08/24/2023.

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

LPA David España conducted an unannounced case management visit to the above facility. During visit, LPA met with staff person(s) Teresa Starks, Denise Davenport and Julius Lozano and made a completed tour of facility which included: The facility is licensed for eighty-four (84) bedridden residents, of which eight (8) may be in hospice care. Currently, there are no hospice residents present during today’s visit. LPA addressed Decision and Order Notice Regarding Petition for Reinstatement (Gov Code section 11522) Notice of Time Limits for Reconsideration for Jesse Limon: CDSS No. 7923115006. LPA and Teresa Starks, Denise Davenport and Julius Lozano agreed that Jesse Limon would be disassociated to the facility by August 15, 2023. LPA noted that Teresa Starks, Denise Davenport and Julius Lozano were unaware of Jesse Limon as an employee at the facility (Jesse Limon / CDSS No. 7923115006 / Subject ID No. 7517383831). No deficiencies were cited during this visit. No advisory notes were issued, and no technical assistance was provided. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 14, 2023

Type of visit: Required - 1 Year

On Monday, August 14, 2023, at 8:49:53 am, Licensing Program Analyst (LPA) David España conducted an unannounced required annual visit. Upon arrival at the facility, LPA España conducted a risk assessment in the front lobby. LPA verified that the facility has an approved mitigation plan report. LPA conducted a telephone call to Ms. Teresa Starks, Acting Administrator for the Veteran’s Home of California, West Los Angeles effectively as of July 31, 2023. LPA met with Denise Davenport, Chief of Domiciliary and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. The facility is licensed for eighty-four (84) bedridden residents, of which eight (8) may be in hospice care. Currently, there are no hospice residents present during today’s visit. During the tour, LPA observed the facility’s infection control practices. PPE supplies are readily available to staff, and an additional supply of PPE is stored in the facility storage. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation is in the den, telephone room, resident’s bedroom or front patio area. LPA observed required postings throughout the facility. The facility has no memory care unit associated with the RCFE. Potentially dangerous items such as toxins are kept inaccessible to residents. Some rooms were visibly inspected. Beds and bedding supplies are sufficient, adequate lighting provided throughout the facility, storage for resident personal belongings was observed and adequate. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. Walk-in tubs were observed and clean. The water temperature measured within range of 105f-120f. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed more than a two-day supply of perishable and seven-day supply of non-perishable food. Knives and toxins were kept secure and away from residents. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. Fire extinguishers were observed fully charged throughout the facility. Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No deficiencies were cited during this visit. No advisory notes were issued, and no technical assistance was provided. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 14, 2023

Allegation investigated: Resident's have access to sharp objects.

On 05/25/23 Licensing Program Analyst (LPA) Perry Scott conducted a continuation complaint investigation for the allegation listed above, that was initially conducted on 11/01/2022 by LPA Troy Agard. LPA met with Teresa Starks, Deputy Administrator, and explained the purpose of this visit is to deliver findings. The investigation consisted of the following: On 11/01/2022 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE). The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, dining room, 4 dens and a kitchen. LPA interviewed staff, residents, a witness, and reviewed records. LPA Agard requested documents, which were received at the time of visit. The investigation revealed the following: Regarding allegation #1: Residents have access to sharp objects. It’s being alleged that a resident had access to and pulled a pair of scissors on another resident. LPA Agard attempted interviews with 8 out of 57 residents. 0 out of 7 were able to confirm the allegation. 1 resident was unavailable for an interview. R1 states, “I never saw that, I heard about it from people talking about it. That’s what I heard.” R2 states, “the facility doesn’t allow us to have access to sharp items.” Report continued on LIC9099-C Substantiated R3 states, “in the dining room we have butter knives but something like a pocketknife they take away from you once you move in or at least they did when I moved in.” R5 states, “I know we are not supposed to have sharp objects, so I don’t know about that.” R6 states, “nope don’t know anything about it.” R7 states, “I don’t know what you are talking about, and I don’t know anything about that allegation.” R8 was unavailable for an interview. During interviews with staff, LPA Agard interviewed 3 out of 20 staff and 1 witness. 4 out of 4 confirmed the allegation. S1 states, “I think that happened in the resident’s common area in front of the nursing station. R7 grabbed some scissors from the nurse’s station. There was a CNA present during that time and was able to secure it away from them. The scissors were a simple scissor used for cutting paper. It was not sharp.” S2 states, “The resident R7 pulled a scissor on R8. The two of them were arguing and R7 picked up the scissors. I wasn’t present so I’m going off the incident report. I believe there was a code of conduct given to R7. I didn’t witness where the scissors came from but at any given time the nursing station could have tape, scissors, pens, or a stapler which could all be used as a form of a weapon, but residents don’t have access to sharp objects.” S3 states, “this was during a time we were shut down due to Covid. R7 was eating in the common area and because that was not allowed at the time, I reminded them to put on a mask. R7 yelled at me and R8 heard them yelling and told them not to talk to me like that and to put on a mask. They both started getting into a verbal altercation. R7 was walking towards the nursing station, went behind the desk and grab the scissors out the desk draw. I grabbed the phone and started to call security. R7 started to gesture that he was going to stab R8 and that’s when the Certified Nursing Assistant (CNA), took the scissors out of R7’s hands. They were not even close to R8. The scissors were not sharp enough to be used as a weapon. The residents are not allowed to have anything sharp like that on the premises. During an interview with a witness, W1 states, R7 and R8 got into some form of a disagreement. R7 secured some scissors from the front desk and brandished them towards R8. It was reported as an incident to the California Highway Patrol (CHP), management, and Community Care Licensing. They had a disagreement, or something was said. R7 received a code of conduct from the facility. However, residents don’t typically have access to sharp items." Report continued on LIC9099-C During a record review, LPA Agard reviewed an incident report and a SOC 341 dated for 01/15/2022 that was sent to licensing self-reporting an incident that took place on 01/15/2022 involving R7’s role in the incident mentioned above. LPA reviewed a code of conduct violations report dated for 02/08/2022 that was issued to R7 for violating the facility rules of threatening other residents and or staff in response to the same incident. During a tour of the facility, LPA observed the alleged scissors that were used on the incident. LPA observed the scissors not to be sharp in shape and removed from nursing station. LPA did not observe any other sharp items to be accessible. Regarding the allegation… Residents have access to sharp objects, based on LPA’s observation, interviews conducted, and record review, the “preponderance of the evidence” standard has been met; therefore, this allegation is substantiated. Title 22 Division 6 Chapter 8 Article 8 is being cited (please see LIC9099D.) An exit interview was conducted and a copy of this report and appeal rights were given to Teresa Starks, Deputy Administrator.the state’s words, verbatim · CDSS document, May 25, 2023 · control 11-AS-20221025163930

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 1, 2022

Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights… (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews and records reviewed by LPA Agard, Licensee failed to ensure sharp objects were locked at all times. This violation possess a Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, May 25, 2023

Plan of correction: Licensee shall ensure that all sharp objects are always stored in a locked area in accessible to clients. Licensee immediately removed the sharp object from the resident and placed it in a locked cabinet. Deficiency Cleared at the time of visit.

Allegation investigated: Facility staff are not providing a safe environment for residents in care. Facility staff are insufficient to meet the needs of the residents. Facility staff are not communicating properly with residents. Facility staff are not properly trained to assist residents.

On 05/25/23 Licensing Program Analyst (LPA) Perry Scott conducted a continuation complaint investigation for the allegations listed above, that was initially conducted on 11/01/2022 by LPA Troy Agard. LPA met with Teresa Starks, Deputy Administrator, and explained the purpose of this visit is to deliver findings. The investigation consisted of the following: On 11/01/2022 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE). The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, dining room, 4 dens and a kitchen. LPA interviewed staff, residents, a witness, and reviewed records. LPA Agard requested documents, which were received at the time of visit. The investigation revealed the following: Regarding allegation #1: Facility staff are not providing a safe environment for residents in care. Report continued on LIC9099-C Unsubstantiated On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are not providing a safe environment for residents in care. S1-S3 and W1 stated that none of the residents has ever come to them stating they did not feel safe in the facility. LPA interviewed R1-R8 about the allegation and 5 of 8 denied the allegation. Based on interviews there is insufficient evidence to support the allegation: Facility staff are not providing a safe environment for residents in care. 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. Allegation # 2: Facility staff are insufficient to meet the needs of the residents. On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are insufficient to meet the needs of the residents. S1-S3 and W1 all report that there are sufficient staff to meet the needs of the facility. LPA Agard interviewed R1-R8 about the allegation and 5 of 8 denied the allegation. Most of the residents don’t see a problem with staffing. Based on interviews there is insufficient evidence to support the allegation: that Facility staff are insufficient to meet the needs of the residents. 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 allegations are Unsubstantiated. Report continued on LIC9099-C Allegation #3: Facility staff are not communicating properly with residents. On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are not communicating properly with residents. Staff state that they have an open-door policy where residents can come to the door and express any issues they may have. In addition, they can file a grievance with the social worker, who then logs in the grievance, and tracks the outcome. W1, also states that there is an open-door policy for the residents as well as the grievance process. LPA interviewed R1-R8 about the allegation and 5 of 8 denied the allegation. Most of the residents don’t have an issue with the staff and communication. Based on interviews there is insufficient evidence to support the allegation: that Facility staff are not communicating properly with residents. 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 allegations are Unsubstantiated. Report continued on LIC9099-C Allegation # 4: Facility staff are not properly trained to assist residents. On 11/01/22, LPA Agard interviewed S1-S3, and W1. S1-S3 and W1 denied the allegation that Facility staff are not properly trained to assist residents. S1-S3 and W1 state that they receive ongoing in-service training monthly as well as training through Relias. During a record review, LPA reviewed the staff scheduled for October and November of 2022. LPA did not identify any patterns of the facility having insufficient staffing. LPA did not identify any safety concerns, lack of communication with residents or staff not being properly trained based on residents’ interviews. Report continued on LIC9099-C Based on interviews there is insufficient evidence to support the allegation: that Facility staff are not properly trained to assist residents. 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 allegations are Unsubstantiated. No deficiencies were cited during this visit. An exit interview was conducted with Teresa Starks, Deputy Administrator, and a copy of the complaint report was provided.the state’s words, verbatim · CDSS document, May 25, 2023 · control 11-AS-20221101132438

Allegation investigated: Facility dining rooms are not thoroughly being cleaned in between services.

On 4/24/23 at 9:30 am, Licensing Program Analyst (LPA) Perry Scott conducted a complaint visit to the above facility. LPA was met by Julian Manalo, Administrator, and the purpose of the visit was explained. The investigation consisted of the following: On 4/24/23, LPA interviewed the administrator, Julian Manalo, staff 1 (S1) and S2-S4, and residents R1-R5. Additionally, LPA obtained copies of resident/staff rosters. The investigation revealed the following: Allegation- Facility dining rooms are not thoroughly being cleaned in between services Report continued on LIC9099-C Substantiated There was a complaint filed against the facility that alleged that housekeeping was not doing a good job in keeping the dining area, carpeting, and seating clean in between breakfast, lunch, and dinner. LPA interviewed administrator, S1 about the allegation. S1 stated that he believes the allegation is untrue and that the housekeeping staff is doing a great job at cleaning the dining area and has no issues with their performance. The LPA asked S1 if staffing could be an issue in response to the complaint, S1 denied that staffing was an issue and stated that they are adequately staffed at the facility. On 04/24/23, LPA interviewed S2-S4 about the allegation that the facility dining rooms are not thoroughly being cleaned in between services and 2 of 3 confirmed that there is a staffing issue. They stated that they are in the process of hiring a new person but maintains that they are doing their best with the staff they currently have. It was acknowledged that housekeeping was available from 6am-2pm. And that the following days crew would be responsible for cleaning the dining area for the dinner service for the previous day. On 04/24/23, LPA interviewed R1-R5 and 5 out of 5 all corroborated that the facilities dining rooms are not thoroughly being cleaned in between services. They all contend that it has been an ongoing issue for the past few years and that they have just learned to adapt to it not being as clean as it should be. Based on interviews conducted, the preponderance of evidence standard has been met. The administrator failed to keep the dining area, carpeting, and seating areas clean and sanitary throughout the entire day. Therefore, the above allegation: Facility dining rooms are not thoroughly being cleaned in between services is found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. An exit interview was conducted. Plans of corrections were developed and a copy of this report and appeal rights were given to Teresa Starks, Deputy Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2023 · control 11-AS-20230418140750

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 2, 2023

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 has not been met as evidenced by: Based on interviews conducted, the licensee did not comply with the section cited above. The licensee did not ensure that the dining area, carpeting, and seating were cleaned in between services (e.g., breakfast, lunch, & dinner). This violation poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 24, 2023

Plan of correction: The administrator will ensure that the dining room, carpeting, and seating areas are thoroughly cleaned after each meal period. The Administrator will provide the LPA with documentation by email, that the issue has been discussed with the housekeeping supervisors, and a plan has been put in place to address these issues by the POC due date on 05/02/23.

Allegation investigated: Illegal Eviction

On 2/03/23 at 9:30 am, Licensing Program Analysts (LPA) Perry Scott, Lizeth Villegas, and Licensing Program Manager (LPM) Janae Hammond conducted a complaint visit to the above facility. LPAs and LPM was met by Julian Manalo, Administrator, and the purpose of the visit was explained. The investigation consisted of the following: On 2/03/23 at 10:00am, LPA interviewed the administrator, Julian Manalo, staff 1 (S1) and Staff 2-4 and residents 1-6. LPA obtained copies of resident/staff rosters, a copy of residents # 1 file which included (admission agreement, face sheet, code of conduct, eviction notice, and supporting documents). The investigation revealed the following: Allegation 1 Illegal Eviction Continued on LIC9099-C Substantiated LPA interviewed administrator, Julian Manalo about the allegation. He stated that he issued an eviction notice to R1 for code of conduct violation for elder abuse under SOC 341 as well as other code of conduct violations. On 02/03/23 at 10:40am, LPA interviewed S2-S4 about the allegations and 3 of 3 confirmed that R1 was issued an eviction notice for code of conduct violations. On 02/03/23 at 11:00am-01:00pm, LPAs interviewed R2-R6, and 4 out of 5 all corroborated that R1 was issued an eviction notice. Based on interviews and record review the administrator failed to serve R1 with an eviction notice in accordance with tittle 22 regulations. Review of the eviction notice dated 12/30/22, revealed the following items were not included in the eviction notice: The eviction notice was missing resources and referrals for R1, and a statement regarding if R1 stays at the facility an unlawful retainer shall be filed. Also, a written copy of the eviction notice was not issued to Community Care Licensing within 5-days. Therefore the allegation is substantiated. Deficiencies cited under California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted and a copy of the report was given to the administrator, Julian Manalo. LPAs interviewed S1-S4 and 4 out of 4 denied the allegation that the staff retaliated against the resident while in care. LPA interviewed R1-R6 and 1 out of 6 confirmed that they were retaliated against. And 5 of 6 denied the allegation. LPA reviewed facility records and did not find evidence that the resident was retaliated against. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of the report was given to the administrator, Julian Manalo.the state’s words, verbatim · CDSS document, Feb 3, 2023 · control 11-AS-20230124090434

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(B)(1)(D) · Plan of correction due date: Feb 5, 2023

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction...The notice to quit shall include the following information: Resources available to assist ...Referral services...the residential care facility for the elderly must file an unlawful detainer action. This requirement is not met as evidenced by: Based on interviews and record review the licensee failed to serve resident number one with an eviction notice in accordance with tittle 22 regulations. This poses a personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2023

Plan of correction: The licensee shall dismiss the eviction notice to resident number one, in writing, and submit a copy of the dismissal by the POC due date of 02/05/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 874224(f) · Plan of correction due date: Feb 6, 2023

A written report of any eviction shall be sent to the licensing agency within five (5) days. This rerqiurement is not met as evidenced by: Based on interviews and record review the licensee failed to provide a copy of the eviction notice for resident number to licensing within 5 days. This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2023

Plan of correction: The licensee shall review title 22 regulations for evictions and submit a statement to licensing acknowledging understanding of the regulations by POC due date of 02/06/23.

Type of visit: Required - 1 Year

On Wednesday, November 23, 2022 at 12:00pm, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Agard conducted a risk assessment in the front lobby. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for eighty-four (84) bedridden residents, of which eight (8) may be on hospice. Currently, there are no hospice residents present during today’s visit. LPA met with Keith Gaines, Resident Care Specialist and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional supply of PPE is stored in the facility storage. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation is in the den, telephone room, resident’s bedroom or front patio area. LPA observed staff, residents, and visitors maintain 6 feet physical distancing. All staff and visitors were observed wearing a face covering. LPA observed required postings throughout the facility. The facility has no memory care unit associated with the RCFE. Potentially dangerous items such as toxins are kept inaccessible to residents. Some rooms were visibly inspected. Beds in shared bedrooms are more than 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies are sufficient, adequate lighting provided throughout the facility, storage for resident personal belongings was observed and adequate. continued on 809C Furniture throughout are separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. Walk-in tubs were observed and clean. The water temperature measured within range. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed more than a two-day supply of perishable and seven-day supply of non-perishable food. Knives and toxins were kept secure and away from residents. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. Fire extinguishers were observed fully charged throughout the facility. Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No deficiencies were cited during this visit. No advisory notes were issued, and no technical assistance was provided. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 23, 2022

Type of visit: POC

On 11/23/2022 at 12:30pm Licensing Program Analyst (LPA) Agard conducted an unannounced Plan of Correction Inspection and met with Keith Gaines, Resident Care Specialist. During today’s visit LPA attempted to verify the plan of correction cited on 10/24/2022 had been corrected as agreed in the licensee’s Plan of Correction. During today’s visit, Administrator Julian Manalo, requested additional time to complete the plan of correction. Stating the corrections will be completed by December 9th, 2022. LPA Agard agreed to the extension and will follow up with Licensee as due date approaches. An exit interview was conducted, and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 23, 2022

Allegation investigated: Staff did not prevent a resident from making inappropriate comments towards other residents

On 10/24/2022 Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegation listed above. LPA met with Denise Davenport, Chief, Domiciliary Services, and explained the purpose of this visit is to gather information regarding the complaint allegation. On 10/24/2022 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE). The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, meditation room, dining room, 4 dens and a kitchen. LPA interviewed staff, residents, witnesses and reviewed records. LPA Agard requested the following documents, which were received at the time of visit: 1) a copy of the resident roster, 2) copy of the staff roster, 3) R3 and R4’s physician report, and 4) Any violation(s) of code of conduct for R3 and R4. On 10/24/2022 LPA delivered findings. Cont. on 9099C Substantiated The investigation revealed the following…Regarding the allegation: Staff did not prevent a resident from making inappropriate comments towards other residents. It’s being alleged a resident is constantly disturbing other residents and making inappropriate remarks. LPA interviewed 5 out of 59 residents in total. 4 out of 5 residents confirmed the allegation to be true. One resident was unavailable for an interview. R1 states, “the staff never say anything. They just sit there. They hear it and see it but don’t say anything. I don’t know if it’s their job or not. They don’t do anything.” R2 states, “I don’t think the staff are doing anything. I don’t think they can do much.” R3 states, “the staff don’t intervene when there is conflict.” R4 states, “that was one of the problems, you think the staff would pull a resident aside to figure out what’s going on. That never happened.” During interviews with staff and witnesses, LPA Agard interviewed 2 out of 20 staff and 2 witnesses. 4 out of 4 confirmed the allegation to be true. S1 states, “there are 2 residents that are challenging each other verbally. It has escalated to the point that our legal team is involved. We are waiting for guidance from legal on how to handle this situation because both residents are doing it to each other.” S2 states, “things happen in the common areas or parking lot and staff aren’t monitoring the parking lot. As far as during dining time, staff have failed to report R3. W1 states, “I have tried to intervene, but you really can’t because you will get verbally attacked by either resident.” W2 states, “the staff can’t really get involved.” LPA reviewed several code of conduct reports given to R3 and R4. Dates ranging from February 2021 to September 2022 and July 2021 to September 2022, respectively. Reports speak to residents violating the code of conduct in various capacities and causing disturbances to other residents. LPA Agard also reviewed several incident reports involving R3 and R4 over the past year and a half. Regarding the allegation: Staff did not prevent a resident from making inappropriate comments towards other residents. Based on the interviews and record reviews conducted the “preponderance of the evidence” standard has been met; therefore, this allegation is substantiated. Title 22 Division 6 Chapter 8 Article 8 is being cited (please see LIC9099D.) An exit interview was conducted and a copy of this report and appeal rights were given.the state’s words, verbatim · CDSS document, Oct 24, 2022 · control 11-AS-20221019121217

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 23, 2022

87468.1 Personal Rights of Residents in All Facilities. To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence by: Based on interviews and record review, R3 and R4 have continued to caused disturbances within the facility. It is unclear what immediate actions are being implemented went these occurrences occur. It is also unclear what the facility is doing in the moment to deescalate the disturbance and inappropriate remarks. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2022

Plan of correction: Administrator will develop a conflict resolution plan to mitigate the disturbances being caused to other residents by R3 and R4. Administrator will share this plan with staff and train them on how to deescalate conflict between residents. Completion of plan and training is due to LPA via email or fax by POC due date.

Allegation investigated: Failure to provide timely medical attention .

On 09/27/2022 Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegation listed above. LPA met with Denise Davenport, Chief, Domiciliary Services, and explained the purpose of this visit is to gather information regarding the complaint allegation. On 09/27/2022 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE). The RCFE facility consists of 2 floors, including 34 double rooms and 16 single rooms, a total of 50 bathrooms, a bathing room, barbershop, activity room, meditation room, dining room, 4 dens and a kitchen. LPA interviewed staff, residents, and reviewed records. LPA Agard requested the following documents, which were received at the time of visit: 1) a copy of the resident roster, 2) copy of the staff roster, and 3) R1’s physician report. On 09/27/2022, LPA delivered findings. Cont. on 9099C Unsubstantiated The investigation revealed the following…Regarding the allegation: Failure to provide timely medical attention. It’s being alleged that a resident was refused timely medical attention when they asked a staff to call for emergency services. LPA interviewed 5 out of 56 residents in total. 3 out of 5 denied the allegation to be true. R3 states, “without a question they would get me medical attention if I needed. I’ve seen it happened. My roommate has significant things going on and they are always getting them medical attention quickly.” R4 states, “I have my own car so I can go and drive right over to building 500. If I tell the nurse, I have to wait for the ambulance, they have to take your vitals and then they take you to the hospital.” R5 states, “it happened twice, and they were prompt.” R1 states, “S3 refused to call 911 after I told them I had a medical emergency.” R2 states, “sometimes I can’t get medical assistance right away because they are so busy.” During interviews with staff, LPA Agard interviewed 2 out of 22 and attempted 1 additional interview: 2 out of 3 staff interviewed denied the allegation to be true. S1 states, “S3 followed the proper protocol, they called someone to assess the resident, the night supervisor, and notified the doctor. The supervisor came in with the nurse, but the resident was already upset and mad.” S2 states, “R1 has a history of being impatient. We were just trying to go to the proper channels. We didn’t refuse them medical treatment. We were just doing things that we were trained to do.” S3 was unavailable for an interview. During an interview with a witness they state, “R1 basically needs to go to the emergency room when that event happens. I think the missing part is the first part of our conversation that they might have missed. They need to be evaluated first. We need to evaluate the urgency and the emergency of the situation.” LPA Agard reviewed the following records: a staff roster which was not dated. The staff interviewed matches with the roster. A resident roster dated September 2022. All residents match with the roster. R1 refused to provide facility or LPA with discharge paperwork. Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. 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.the state’s words, verbatim · CDSS document, Sep 27, 2022 · control 11-AS-20220919160220

Allegation investigated: Staff cut residents hair/beard with residents consent. Staff does not maintain residents hygiene. Bathroom door is in disrepair. Facility failed to safeguard resident’s property.

Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Keith Gaines, Resident Care Specialist. The purpose of this visit was explained. LPA Agard conducted an interview with Keith Gaines, Resident Care Specialist of the Residential Care Facility for the Elderly (RCFE). Upon record review and interview, the following was determined: Resident Care Specialist stated, R1 is not a resident of the RCFE. The investigation consisted of the following: During today’s visit, LPA reviewed facility resident roster and found that R1 is not a resident at the RCFE. LPA confirmed that R1 is currently residing in the adjacent building which is the Skilled Nursing Facility (SNF). LPA obtained a copy of the roster from the SNF and from the RCFE. In a review of the staff roster, it was determined the Nursing Supervisor is not a match with the Nursing Supervisor for the RCFE. Continued on 9099 Unfounded Community Care Licensing has investigated the complaint alleging: 1) Staff cut residents hair/beard without resident’s consent. 2) Staff does not maintain resident’s hygiene. 3) Bathroom door is in disrepair. 4) Facility failed to safeguard resident’s property. We have found this complaint to be unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies were observed/cited during today's visit. An exit interview was conducted, and a hard copy was provided.the state’s words, verbatim · CDSS document, Mar 16, 2022 · control 11-AS-20220308140115

Allegation investigated: Illegal Eviction.

Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation for the allegation listed above. LPA met with Chief, Domiciliary Services, Denise Davenport and explained the purpose of this visit is to gather information regarding the complaint allegation. On 09/29/2021 LPA Agard toured the facility grounds for the main building of the Residential Care Facility for the Elderly (RCFE) and requested copies of the following: 1) a copy of the client roster, 2) Any Incident reports from the past 90 days, 3) Any eviction notifications. Requested documents were received at the time of visit. On 09/29/2021, LPA Agard delivered findings. Regarding the allegation: Illegal eviction. It’s being alleged that a client in care was illegally evicted, Continues on 9099C Unsubstantiated transferred to the skilled nursing facility (SNF) due to their inability to eat independently, and did not received their belongings. The investigation revealed the following: In the interview with R1 it was revealed that “everything has been resolved and there is no need for you (LPA) to visit the facility.” In an interview with Denise Davenport, Chief Domiciliary Services, it was revealed there have been no evictions within the past 90 days. She states R1 was moved to a SNF due to resident having a fall and the need for rehabilitation. Davenport states resident was never separated from their belongings, was on a “bed hold” and was scheduled to return to the RCFE once rehabilitation was completed. She states resident had access to their belongings for the duration of their stay within the SNF and would “come back and forth to bring things over.” She states while resident was in the care of the SNF it was discovered that the resident was displaying signs of having difficulties eating independently. Per record review, resident was evaluated on 06/08/2021, and monitored until they were cleared to return to the RCFE on 09/27/2021. During a record review, LPA observed a supporting incident report was submitted by the facility stating that the resident had a fall while in the community on 04/25/2021 which resulted in R1 dislocating and fracturing their right shoulder and the requirement for rehabilitation. Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. 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, and a copy of the report was given to Denise Davenport, Chief Domiciliary Servicesthe state’s words, verbatim · CDSS document, Sep 29, 2021 · control 11-AS-20210920162220

Type of visit: Required - 1 Year

On Monday, August 16th, 2021 at 11:12pm, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Agard conducted a risk assessment in the front lobby. LPA verified that the facility has an approved mitigation plan report. The facility is licensed for eighty-four (84) bedridden residents, of which eight (8) may be on hospice. Currently, there are no hospice residents present during today’s visit. LPA met with Chief, Domiciliary Services, Denise Davenport and they both toured the inside and outside grounds of the facility. LPA was properly screened for Covid-19 symptoms and temperature was checked. LPA was properly equipped with Fit tested N-95, gown, gloves and face shield. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log. PPE supplies are readily available to staff, and an additional supply of PPE is stored in the facility storage. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation prior to the most reason case was in the resident’s bedroom and front patio area. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility. LPA reviewed the facility’s surveillance testing records; unvaccinated staff are being tested twice per week and vaccinated staff, only during an outbreak or if requested. LPA observed two newly admitted residents. Which were both tested before admission. The facility has no memory care unit associated with the RCFE. Potentially dangerous items are kept Continued on 9099C inaccessible to residents. Some rooms were visibly inspected. Beds in shared bedrooms are more than 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies are sufficient, adequate lighting provided throughout the facility, storage for resident personal belongings was observed and adequate. Furniture throughout are separated, and 6 feet apart from each other. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew. Walk-in tubs were observed and clean. The water temperature measured within range. A comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed more than a two-day supply of perishable and seven-day supply of non-perishable food. Knives and toxins were kept secure and away from residents. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. Fire extinguishers were observed fully charged throughout the facility. Outside grounds were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. No deficiencies were cited during this visit. No advisory notes were issued, and no technical assistance was provided. An exit interview was conducted, and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Aug 16, 2021