Vista Corona Senior Living

Allegation investigated: Staff does not prevent residents from speaking inappropriately to each other.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to investigate and deliver findings for the allegation listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Blasia Lee-Lole. The investigation consisted of resident interviews, staff interviews, and document review. For allegation, Staff does not prevent residents from speaking inappropriately to each other: Interviews with residents and the staff revealed that on 9/22/2023 there was a verbal altercation between two (2) residents. When the incident occurred, the two (2) residents were outside of the facility with no witnesses present. The staff was made aware of the verbal altercation after the incident occurred. The staff completed an internal investigation and found that there were not enough facts to prove what was said to the residents. A document review of the internal investigation revealed that there were no witnesses to the verbal altercation. Unsubstantiated The staff spoke to both of residents involved about being respectful to each other. A notice of lease violation will be issued to both residents involved. The staff at the facility have been instructed to notify management if they observe any additional issues between the two (2) residents. Adult Protective Services (APS) came to the facility on 9/29/2023 to investigate the incident. The facility was not provided information regarding the outcome of APS’s visit. Overall, there was not enough evidence to collaborate the allegation listed above. Based on evidence obtained during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Blasia Lee-Lole, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 56-AS-20230925094954

Allegation investigated: Staff failed to treat resident with dignity and respect. Facility has mold.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to investigate and issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Administrator Blasia Lee-Lole. The visit today consisted of a facility tour, interviews with residents and staff, and document review. For allegation, Staff failed to treat resident with dignity and respect: During interviews with residents, the residents explained that the staff is very nice and treats them fairly. The residents stated that the staff does not yell at them or make inappropriate comments towards them. The residents feel like they are treated with dignity and respect. During interviews with staff, the staff denied yelling at the residents and denied making inappropriate comments towards the residents. Unsubstantiated The staff stated that the only time they would raise their voice to resident is when the resident has a hard time hearing and needs to be talked to in a louder tone. The staff stated that if a resident gets upset and yells at them, the staff doesn’t not respond in the same demeanor. The staff will try to calm the resident down in a pleasant manner and give the resident time and space if needed to work out any issues that arise. For allegation, Facility has mold: During document review, LPA reviewed statements and an estimate of repair work for a water pipe leak that started in basement of the facility in January of 2023. LPA also reviewed a statement for a leak that occurred in the underground parking lot on 7/5/2023. During the facility tour, LPA was shown areas in the basement and parking lot where the water leaks occurred. LPA was shown areas of the walls and the ceiling that still need to be repaired. The areas that need to be repaired are in the basement area near the salon and the break room, as well as the ceiling in underground parking lot. During interviews with staff, LPA discovered that multiple companies have come to repair the water leaks, but as more companies come out, more issues have been found during the process. LPA was informed that the facility currently is waiting on company approval of a construction estimate to repair the damages the water leaks created. Once the estimate is approved, the facility will repair the walls, ceilings, and all other areas affected by the water leaks. LPA was informed that the facility will notify state licensing when all the repairs are complete. Based on evidence obtained during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Blasia Lee-Lole, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jul 10, 2023 · control 56-AS-20230703113153

Allegation investigated: Questionable death. Staff did not seek timely medical attention for resident. Staff smokes marijuana inside facility.

On 05/31/2023 at 08:50 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Blasia Lee-Lole at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the Office Visit. The investigation consisted of file review, interviews with staff and residents as well as observation. The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates Questionable death. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Staffs interviews indicated that Resident #1 (R1) passed away while sleeping. LPA Brown reviewed R1’s death certificate that stated primary cause of death was heart condition. Interview with R1's family indicated that they did not suspect that the facility hastened the death of their family member and maintains that R1 died of natural causes. ***Continuation in LIC9099C *** Unsubstantiated The second allegation alleges that Staff did not seek timely medical attention for resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that staffs are seeking timely medical attention for residents and no incident happened at the facility that a staff did not seek timely medical attention for resident. Interview with R1's family indicated that staffs seek timely medical attention for residents. The third allegation indicates Staff smokes marijuana inside facility. Residents’ interviews indicated that they did not see a staff smoking marijuana inside the facility and they added that smoking inside the facility is not allowed, and no incident happened at the facility that a staff smoke marijuana inside the facility. Staffs’ interviews revealed no staff are smoking marijuana inside the facility and no incident happened at the facility that a staff was seen smoking marijuana. Based on interviews and records review, the allegation Questionable death (Allegation #1), Staff did not seek timely medical attention for resident (Allegation #2), Staff smokes marijuana inside facility (Allegation #3) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, where this report, (LIC9099) was discussed and provided to Executive Director Blasia Lee-Lole.the state’s words, verbatim · CDSS document, May 31, 2023 · control 56-AS-20220411153553

Allegation investigated: Staff yell at resident in care. Staff does not provide adequate food service to resident. Staff does not ensure facility has adequate food supplies. Facility has mold.

Licensing Program Analyst (LPA) Victoria Chitgian conducted an unannounced visit to the facility to investigate and deliver findings for the above allegations. LPA met with Executive Director Blasia Lee-Lole and explained the purpose of today’s visit. Investigation consisted of interviews with pertinent parties, observations and records review. The first allegation indicates Staff yell at resident in care. During interviews conducted with staff, LPA discovered there have not been any reported complaints regarding staff making inappropriate comments to residents. The staff all stated that the interactions with the residents are positive and respectful. The only reason a staff might raise their voice during a conversation with a resident is to ensure the resident can hear them. The second allegation indicates Staff does not provide adequate food service to resident. Based on observations, LPA witnessed the dining room during lunchtime, between 11:30am-2:00pm. Food service provided was observed to ensure enough time was allocated to consume the meal. Interviews with staff and clients indicate that residents are allowed plentiful time to consume their meals. Unsubstantiated Residents receiving food tray service in their rooms are served first. Interviews with residents and staff also indicated that they are not rushed, nor are rushing anyone out of the dining room. The third allegation indicates Staff does not ensure facility has adequate food supplies. Based on interviews and observations, the dining room has a new head chef since March 2023. Per Interviews with residents and staff, there have been improvements in the food quantities, quality and taste. LPA observed the kitchen refrigerators to be fully stocked with proteins, starches, fruits, vegetables and non-perishables in large quantities. Interview with staff indicate they have options for all the diet-needs of the residents, including sugar-free deserts, low-sodium options, and heart-healthy varieties. Interviews also indicate food is purchased bi-weekly. The fourth allegation indicates Facility has mold. Based on records review, LPA received copies of pertinent documents and photographs of past work orders for air conditioner damage, resulting in mold. Facility addressed the mold by hiring a contractor. Start date on record indicated 3/9/2023, completed on 3/14/2023. LPA observed the physical location of the past damage and noted it to be corrected. During review of records and interview with administrator, LPA discovered the facility does not have a resident by the name indicated on the LIC 802. Resident 1 has not, and does not live at the facility, nor is associated to the facility as stated. Based on the information obtained, LPA has determined the allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report (LIC 9099) provided to Executive Director Blasia Lee-Lole.the state’s words, verbatim · CDSS document, May 19, 2023 · control 56-AS-20230515165039

Allegation investigated: Licensee neglect resulted in resident sustaining injuries while in care.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to conclude and issue findings for the investigation that was initiated on 12/13/2022. LPA stated the purpose of the visit and was granted entry and met with Administrator Blasia Lee-Lole. The investigation was conducted by an IB Investigator which included a review of Resident R1’s facility records and medical records, interview with a medical social worker (MSW), interviews with four (4) facility staff (S1, S2, S3, S4), an interview with R1, and an interview with R1’s family member(R1FM). For allegation, Licensee neglect resulted in resident sustaining injuries while in care: It was alleged that on 12/3/2022 R1 fell due to neglect and sustained injuries. Unsubstantiated During interview with R1, when asked about R1 injuries, R1 pointed to their face near their eyebrow. R1 stated that they could not remember how they sustained injuries and they could not remember the names any of the staff at the facility. During interview with R1FM, R1FM stated that R1 could not remember details of how they sustained their injuries. R1FM stated that R1 has a condition that causes them to lose their balance. R1FM did not have any concerns of abuse or neglect from the facility. During interview conducted with the MSW, the MSW stated that R1 was unclear how they sustained the injuries and R1 was not sure why they were at the hospital. During interview staff S1, S1 stated that R1 had been found on their bedroom floor by S3. R1 appeared to be tangled in their wheelchair. S1 stated that R1 was not moved by staff due to unknown injuries and 911 was called immediately. During interview with staff S2, S2 stated that R1 had difficulty walking, was a fall risk, and had therapy twice a week to help with daily living, balance, and mobility. S2 stated the facility would give R1 visual and verbal reminders of how to transitions to and from their wheelchair. During interview with Staff S3, it was discovered that S3 was the staff that found R1 the day of the fall. R1 was found during a medication check. S3 found R1 on their bedroom floor near the restroom. S3 immediately called for backup from S1. R1 was not moved due to unknown injuries and 911 was called immediately. S3 stated that due to R1’s risk of fall, R1 was checked on every two (2) hours. R1 was very independent and would often decline help from S3. During interview with S4, it was discovered that R1 had fallen prior this current incident. S4 stated that R1 had a condition that made it difficult for R1 to walk. R1 was defined as a fall risk, due to this the staff would assist R1 with wheelchair transfers and would provide assistance with their walker. The day R1 fell, 911 was called immediately due to R1 injuries. During record review, it was discovered that R1 was taken to the hospital and treated for the injuries sustained due to the fall. Overall, during the investigation, there was not substantial evidence to collaborate the allegation. Based on evidence obtained, the IB Investigator deemed the allegation listed above UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Blasia Lee-Lole, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Mar 8, 2023 · control 56-AS-20221206143918

Allegation investigated: Staff did not seek medical attention for resident timely. Staff do not address residents change in condition. Staff do not respond to residents call pendant. Staff do not assist resident with incontinence needs timely. Staff do not assist resident with bathing. Staff do not remove discarded foods from resident's room timely. Staff did not ensure facility was free from insects.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Health Services Director Alexis Brown. During today’s visit, LPA toured the facility, conducted interviews with staff, conducted interviews with residents, and reviewed facility documents. For allegation, Staff did not seek medical attention for resident timely: During interviews conducted with staff, LPA discovered that when a resident needs medical attention the care staff immediately calls for a medical technician staff. If further medical evaluation is necessary, the facility staff immediately calls 911 for medical attention. Unsubstantiated During interviews conducted with residents, LPA discovered that the residents found that the facility is quick to respond to their medical attention needs. There were no concerns with the facility not being responsive to their medical needs. During document review, LPA reviewed the facilities recent reports to State Licensing and found that the facility is reporting that medical attention was sought out in a timely manner. For allegation, Staff do not address residents change in condition. During interviews conducted with staff, if a resident has a change in condition, the change is immediately reported to the Health Services Director and the Resident Care Coordinator. The Health Services Director and the Resident Care Coordinator immediately updates the residents file and care plan with the change in condition to ensure the proper care starts right away. For allegation, Staff do not respond to residents call pendant: During interviews conducted with staff, LPA discovered that the care staff does respond to resident’s call pendants. The amount of time it takes for a care staff to respond to a resident pendant call averages five (5) to fifteen (15) minutes. The response time depends on how many residents require care at the same time. During interviews conducted with residents, LPA discovered that most of the residents reported that care staff responds to their pendant calls immediately. Other residents reported that the care staff responds to their pendant calls within fifteen (15) minutes. During document review, LPA discovered the majority of the resident pendant calls were responded to within fifteen (15) minutes. There were some instances of a longer response time, but during review staff noted that the longer response times were not actually response times, but extra time to reset a residents call pendant when they do not reset on their own. For allegation, Staff do not assist resident with incontinence needs timely: During interviews conducted with staff, LPA was informed that the facility has a “Residents on Care Schedule”. The schedule notates which residents need incontinence care. LPA discovered that staff assist the residents with incontinence needs every one (1) to two (2) hours throughout the morning, day, and evening shifts. If a resident needs more assistance than the one (1) to two (2) hour checks, the resident can press their call pendant to receive more assistance. The residents are sleeping during NOC shift (night shift), during this time the resident’s incontinence needs are met on a as needed basis by resident pendant calls. During interviews conducted with residents, LPA discovered that the residents do not have any issues or concerns about the staff not assisting them with their incontinence needs in a timely manner. LPA did not encounter a resident that had complaints of being left in a soiled diaper for an extended period to time. During document review, LPA reviewed the facilities “Residents on Care Schedule”. The schedule notates which residents need incontinence care. The facility uses this document to ensure the residents on the list are checked on the appropriate number of times throughout the day/night. For allegation, Staff do not assist resident with bathing: During interviews conducted with staff, LPA was informed that the facility has a “Residents on Care Schedule”. The schedule notates which residents need bathing assistance. In addition, the staff follows a shower schedule that notates what days each resident is assisted with bathing. If a resident refuses bathing, a shower refusal slip is filed out and signed by the resident notating the reason for not accepting bathing assistance. LPA was informed that prior to filing out a shower refusal slip the resident speaks to two (2) care staff to verify the resident is sure they want to refuse bathing assistance. It is the residents personal right to refuse a shower if they do not want one. The facility will document the refusal and attempt to bathe the resident on their next scheduled shower. During interviews conducted with residents, LPA discovered that the residents do not have any issues or concerns about the staff not assisting them with bathing. LPA did not encounter a resident that had complaints of not being provided bathing assistance. During document review, LPA reviewed the facilities “Residents on Care Schedule”. The schedule notates which residents need shower assistance. LPA also reviewed the facility shower schedule and an example of a shower refusal slip. For allegation, Staff do not remove discarded foods from resident’s room timely: During interviews conducted with staff, LPA discovered that the food brought into the resident’s rooms is discarded within one (1) to four (4) hours of a resident receiving a meal. This gives the resident time to eat their meal and decide if they want to save part of the meal for later. The portion of the meal that needs to be discarded is either removed by kitchen staff when they bring the next meal of the day or when care staff is doing resident room checks. There is never time when residents’ food is not discarded from the resident’s rooms. During interviews conducted with residents, LPA discovered that the resident’s did not have any concerns or issues with food being removed from their rooms. For allegation, Staff did not ensure facility was free from insects: During interviews conducted with staff, LPA discovered that Western Exterminator Company treats the facility for pests and insects on a monthly basis. If a resident has pests in their room, the facility ensures that the resident’s room is treated until the issue is resolved. LPA was not informed of any areas within the facility where insects or pests were present. During interviews conducted with residents, LPA was not informed of any areas within the facility where there were insects and pests present. During document review, LPA reviewed Western Exterminator invoices for December 2022 and January 2023. LPA discovered that the facility is ensuring the facility is free of pests and insects by having monthly pest control treatment completed. During facility tour, LPA toured the main areas, hallways, offices, resident bedrooms, the dining area, and the kitchen. During the tour, LPA did not observe any insects or pests. Based on evidence obtained during today’s visit, the seven (7) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Health Services Director Alexis Brown, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Feb 22, 2023 · control 56-AS-20230217143828

Allegation investigated: Facility staff made inappropriate comments to resident.

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to investigate and deliver findings for the above complaint allegation. LPA met with Health Services Director Alexis Brown and explained the reason for the visit. During today’s visit, LPA toured the facility, conducted interviews with staff, and conducted interviews with residents. For allegation, Facility staff made inappropriate comments to resident: During interviews conducted with staff, LPA discovered there have not been any reported complaints regarding staff making inappropriate comments to residents. The staff all stated that the interactions with the residents are positive and respectful. The only reason a staff might raise their voice during a conversation with a resident is to ensure the resident can hear them. Unsubstantiated The staff’s tone of voice is never raised in a mean or hostile way. If a resident is upset and or yelling at staff, the staff listens to the resident’s concerns, responds in a calm demeanor, and assists them in finding a resolution. During interviews with residents, LPA discovered that the residents had positive remarks about the interactions with staff. The residents did not have situations where they were spoken to inappropriately or been yelled at by the staff. The residents stated that sometimes staff will raise their voice but only so residents that have a hard time hearing can hear the staff. Based on the evidence gathered during today’s investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided Health Services Director Alexis Brown, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Feb 16, 2023 · control 56-AS-20230215100819

Allegation investigated: Staff do not properly maintain the facility.

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegation. LPA met with Administrator Blasia Lee-Lole and explained the reason for the visit. During today’s visit, LPA toured the facility, conducted interviews with staff and residents, and reviewed, and was provided facility documents. For allegation, Staff do not properly maintain the facility: During document review, LPA discovered that the facility has three (3) maintenance staff on duty between the hours of 8:30 am and 5:00pm. The facility averages eight (8) housekeeping staff on duty between the hours of 7:30 am and 5:00 PM. Unsubstantiated During interviews conducted with staff, LPA discovered that the hallways are cleaned daily, and the residents’ bedrooms are cleaned once a week. If a resident has a needed for more than one cleaning a week, the housekeeping staff will complete extra cleanings to ensure the resident has a clean-living space. If a resident soils a chair, mattress or a furniture item, the maintenance staff will remove the soiled liquid, and clean the furniture with a shampooer to ensure the furniture is clean and free from odor. When there are no maintenance staff or housekeeping staff on duty, the caregivers will step in to help clean the facility. During interviews with residents, LPA discovered that there were no concerns with the smell of the facility. The residents stated they did not smell any foul odors. During LPA tour of the facility, LPA did not smell any foul odors. The facility was clean and had a fresh smell throughout. Based on the evidence gathered during today’s investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided Administrator Blasia Lee-Lole, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Feb 9, 2023 · control 56-AS-20230206152838

Allegation investigated: Resident was under the influence of drugs while in care.

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to conclude and issue findings for the investigation that was initiated on 08/18/2020. LPA stated the purpose of the visit and was granted entry and met with Administrator Blasia-Lee Lole. For allegation, Resident was under the influence of drugs while in care: The investigation was conducted by IB Investigator Brittany Hudec which included a review of Resident R1’s facility and medical records, interviews conducted with the R1’s family, interviews conducted with facility staff, and an interview conducted with R1. Based on interviews conducted, and information, and evidence obtained, the IB Investigator found that R1 was not under the influence of drugs while in care. R1 tested positive for Amphetamines and Cannabinoids at the hospital lab test on 8/3/2020. Unfounded During a second test at the hospital lab on 8/5/2020, R1 tested negative for Amphetamines and Cannabinoids. It was noted by the physician that if Amphetamines and Cannabinoids were in R1’s system on 8/3/2020 the Amphetamines and Cannabinoids would still be present on hospital lab test on 8/5/2020. It was found that there was either a mix up at the hospital lab and or a false positive was read on the initial lab result at the hospital due to this the investigation is deemed UNFOUNDED. A finding that the complaint is UNFOUNDED means that the allegation was without a reasonable basis. Therefore, the above allegation is dismissed. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Blasia-Lee Lole, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Jan 9, 2023 · control 18-AS-20200810113759

Allegation investigated: Staff does not properly prepare food for residents. Staff are not providing residents with food of good quality.

Licensing Program Analysts (LPAs) Ryan Gardner and Paola Guerrero conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegations. LPAs met with Health Services Director Alexis Brown and explained the reason for the visit. During today’s visit, LPAs toured the kitchen, interviewed staff members, and interviewed residents. For allegation, Staff does not properly prepare food for residents: LPAs interviewed nine (9) residents and five (5) staff. During interviews conducted with residents, LPAs found that seven (7) out nine (9) residents stated the food served at the facility is prepared properly. During interviews conducted with facility staff, LPAs found that five (5) out of five (5) staff stated the food at the facility was prepared properly. LPAs were not given information to collaborate the above allegation. Unsubstantiated For allegation, Staff are not providing residents with food of good quality: LPAs interviewed nine (9) residents and five (5) staff. During interviews conducted with residents, LPAs found that nine (9) out nine (9) residents stated the food served at the facility is good quality. During interviews conducted with facility staff, LPAs found that five (5) out of five (5) staff stated the food served at the facility is good quality. The residents are served breakfast, lunch, dinner, and snacks throughout the day. The residents are served protein, fruit, and vegetables. LPAs were provided a copy of the weekly menu showing the planned meal options. LPAs were not given information to collaborate the above allegation. Based on the information found and provided, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations listed are deemed unsubstantiated. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Health Services Director Alexis Brown, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Nov 1, 2022 · control 56-AS-20221026090316

Allegation investigated: Facility has pests.

Licensing Program Analyst (LPA) Ryan Gardner arrived at the facility unannounced to initiate and deliver findings for the above complaint allegation. LPA met with Administrator Blasia Lee-Lole and explained the reason for the visit. During today’s visit, LPA Gardner toured the facility, conducted interviews with residents, conducted interviews with staff, and reviewed facility documentation. For allegation, Facility has pests: The facility provided LPA with the housekeeping/laundry schedule for each resident. LPA discovered that the facility housekeeping staff cleans the resident’s bedrooms once a week. LPA was informed that the resident’s bedrooms will be cleaned more often by housekeeping staff if a resident needs additional cleaning. LPA discovered that the resident’s sheets and bedding are cleaned at minimum every two weeks and will be cleaned more often if needed. LPA Gardner entered eleven (11) of the twelve (12) resident’s bedrooms that were interviewed. Unsubstantiated LPA did not observe any pests in the residents bedrooms. LPA did not observe any pests in the main gathering areas within the facility. The facility has Western Exterminator Company treat the interior and the exterior of the facility for pests monthly. During documentation review it was discovered that on 8/30/22, R1’s bedroom was treated by Western Exterminator Company after complaints of pests in the bedroom. During documentation review and interview with staff and interview with R1 it was discovered that on 9/5/22, the Administrator purchased and treated R1’s bedroom with a bed bug/flee fogger. Based on information found and discovered, LPA found that 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 deemed UNSUBSTANTIATED. An exit interview was conducted, and this report was discussed and provided to Administrator Blasia Lee-Lole, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Sep 8, 2022 · control 56-AS-20220907155929

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Goldenberg made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. There are no positive cases of COVID-19 at this time at this location. During the inspection, LPA conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA also observed that all staff members were properly wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in infection control. The facility continues to monitor client regularly for any changes in condition. LPA inquired if facility employees have been fit tested for N95 masks and learned they have not. Technical assistance is being provided on how to obtain information for N95 fit testing. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with and a copy was provided to the facility representative.the state’s words, verbatim · CDSS document, Aug 31, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Amy Goldenberg is conducting this case management visit for the purpose of a health and safety check. LPA conducted a tour of the facility and grounds, assessing the physical plant, staffing, food supply, and general care of residents. Residents are present during this tour engaged in various activities of choice. Sufficient staff are present at the facility to provide care. LPA observed three (3) days supply of perishable and seven days (7) supply of non-perishable food. No imminent health and/or safety concerns identified at the time of this visit This report was reviewed with and a copy was provided to the facility representatives during the exit discussion.the state’s words, verbatim · CDSS document, Aug 23, 2022

Allegation investigated: Facility staff did not safeguard residents medication

Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to initiate and deliver the findings for the above complaint allegation. LPA met with Administrator, Blasia Lee-Lole and Health Services Director, Alexis Brown. The investigation consisted of relevant party interviews. In regard to the allegation, Facility staff did not safeguard resident’s medication, interviews with staff revealed resident medication for residents not on medication management is dropped off by the pharmacy and kept at the front desk for residents to pick up. Medication was not delivered to the residents and staff misplaced the medication. According to staff, the medication was found about a week later in the medication room, but it is unclear how it got there. Resident 1 reordered medications but did receive their misplaced medication about one week later. Based on interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 1) is being cited on the attached LIC9099D. An exit interview was conducted where this report was discussed and provided to Ms. Brown. Substantiatedthe state’s words, verbatim · CDSS document, Jun 2, 2022 · control 56-AS-20220524123756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(h)(2) · Plan of correction due date: Jun 3, 2022

Medication & Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This regulation was not met as evidence by, Staff did not take delivered medication directly to the resident or the medication room upon delivery and medication was misplaced. This poses an immediate health and safety risk to resdients in care.the state’s words, verbatim · CDSS document, Jun 2, 2022

Plan of correction: Licensee shall read the regulation in its entrirety, submit a statement of uinderstanding, create protocols to ensure medication remains locked up at all times and train staff on this regualtion and new protocols and submit the POC to CCL by the POC due date of 6/3/2022.

Allegation investigated: Facility is not meeting resident's dietary needs.

Licensing Program Analyst (LPA) Jennifer Semin arrived to the facility unannounced to initiate a complaint investigation into the above complaint allegations and deliver the findings. LPA met with Administrator, Blasia Lee-Lole and Business Office Manager (BOM) Rona Sanchez The investigation consisted of interviews and review of records. The allegation, Facility is not meeting resident's dietary needs. Staff stated that the kitchen can accommodate some special diets. Staff stated Resident 1 (R1) verbalized they needed a special diet but did not submit documentation from their physician to staff regarding a special diet. R1 stated they submitted documentation from their physician to the front desk. Resident 2-4 (R2-4) stated the kitchen accommodates for their special diet. Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to the administrator.. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 19, 2022 · control 56-AS-20220418113818

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 13, 2022

Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....This requirement was not met as evidence by, staff did not know the resident nor what room they were assigned to when escorting the resident to their room. This poses a health and safety risk to resdents in care.the state’s words, verbatim · CDSS document, Apr 19, 2022

Plan of correction: Licensss shall read the regulation in it's entirety, submit a statement of understanding and conduct staff training this regulation and submit it to CCL by the POC due date of 4/20/2022.

Allegation investigated: Staff do not change residents timely Staff do not answer resident call buttons timely Resident is not being bathed Resident developed a pressure injury while in care

Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Health Services Director, Alexis Brown. The investigation consisted of interviews and review of records. The first allegation, Staff do not change residents timely. Relevant party (RP) stated staff do not change Resident 1 (R1) “for hours”. Staff stated they change residents every 2 hours and as needed. Residents, requiring incontinent care, stated staff change them every 2 hours, assist them regularly and as needed. The second allegation, Staff do not answer resident call buttons timely. Relevant party (RP) stated call button wait time is almost 4 hours. Staff stated they have a response time within 15 minutes to call buttons. Residents interviewed stated staff respond quickly to their call buttons. LPA observed staff call button response time to be between 1-3 minutes. The third allegation, Resident is not being bathed. Relevant party (RP) stated staff are not bathing R1. Staff stated all residents requiring assistance with showering are bathed twice a week. Staff stated Unsubstantiated (R1) was scheduled to be showered twice a week but was showered at least once a week due to R1’s refusal. Residents interviewed stated staff assist them with showers twice a week. The fifth allegation, Resident developed a pressure injury while in care. Relevant party (RP) stated R1 developed a pressure injury on the side of their leg. Staff stated R1 did not have any pressure injuries. LPA observed R1's documents and they did not indicate R1 had a pressure injury. Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to Ms. Brown.the state’s words, verbatim · CDSS document, Apr 15, 2022 · control 18-AS-20220105112909

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 16, 2022

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning & that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician & the resident's responsible person, if any. This requirement was not met as evidenced by: Staff did not notify Resident 1's physician & the resident's responsible person once the rash was observed. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2022

Plan of correction: Licensss shall read the regulation in it's entirety, submit a statement of understanding and conduct staff training this regulation and submit it to CCL by the POC due date of 4/16/2022.

Allegation investigated: Resident not being administered medication as prescribed. Staff did not assist resident with feeding(s).

Licensing Program Analysts (LPAs) Jennifer Semin and Ryan Gardner arrived to the facility unannounced to initiate a complaint investigation into the above complaint allegations and deliver the findings. LPA met with Administrator, Blasia Lee-Lole and Business Office Manager (BOM) Rona Sanchez. The investigation consisted of interviews and review of records. The first allegation, Resident not being administered medication as prescribed. Staff stated all medication is given according to doctor’s order. Medication prescriptions are given between 8am-9am, 11am-12pm, 4pm-5pm, and 8pm-9pm unless a specific time is documented on the prescription orders. Resident interviewed stated all medication is given on time and according to their doctor’s order. The second allegation, Staff did not assist resident with feeding(s). Staff stated they do assist residents with feedings if needed. Staff stated there are currently no residents that require assistance with feedings. Residents interviewed stated they do not need assistance with feeding nor have they seen any resident requiring feeding assistance. Based upon interviews and information gathered, and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to the BOM. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 14, 2022 · control 56-AS-20220411153553

Allegation investigated: Facility staff are restricting visitation Facility staff stole residents belongings Facility staf are not asking permission to enter apartments Facility is in disrepair

Licensing Program Analys (LPA) Jennfier Semin conducted an unannounces visit to initiate a complaint investigation and deliver the findings for the above alegations. LPA met with Business Office Manager, Diana Gonzalez and spoke with Administrator Blasia Lee via telephone as she was in a meeting. The investigation consisted of observations and interviews. The first allegation, Facility staff are restricting visitation. All staff state visitors are allowed and permitted to visit in resident apartments if they are fully vaccinated or have a negative COVID test within 72 hours. Resident 2-7 (R2-R7) stated they are permitted to have visitors in their apartments. Resident 1 (R1) stated her vaccinated family member was denied entry to her apartment. R1 could not recall the date or time. The second allegation, Facility staff stole residents belongings. All staff stated they have never nor have they ever seen any staff steal the residents belongings. Housekeeping staff stated they do not take residents belongings. They stated they do throw away trash from residents rooms, not clothing or belongings.R2-7 stated they have never noticed any belongings missing. R1 stated several grocery bags containing papers were taken from her room. Housekeeping staff do not recall grocery bags full of papers in R1's room. Unsubstantiated The third allegation, Facility staff are not asking permission to enter apartments. All staff stated they always knock before entering resident apartments. They all stated for non-emergency calls they will wait for several minutes and knock repeatedly before entering to assist residents. R2-R7 stated staff always knock and generally wait for them to respond before entering their apartments. Care-giving staff stated they do not go into R1's apartment unless specifically asked by R1 as R1 does not usually require staff assistance. R1 stated staff just come in her apartment without knocking. The fourth allegation stated, Facility is in disrepair. All staff stated the facility is not in disrepair, anything that needs to be fixed or repaired is completed in a timely manner. R2-R7 stated they have not had any issues with anything being in disrepair or broken. R1 stated the toilet in her bathroom was running after being flushed. R1 stated maintenance has come up to check the toilet but they didn't do anything. LPA observed that the ruining water was normal tank refilling sounds. Maintenance Staff (MS) stated they have a work order to tighten the toilet seat in R1's bathroom. MS stated to there is nothing wrong with R1's toilet nor is there anything broken in R1's apartment. Based on interviews and observations and although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to Ms. Gonzalez.the state’s words, verbatim · CDSS document, Nov 8, 2021 · control 18-AS-20211103095201

Allegation investigated: Food Service is inadequate.

Licensing Program Analyst (LPA) Pauline Beschorner conducted an unannounced complaint visit in order to deliver findings for the above complaint allegation. LPA met with Executive Director Monique Del Junco. It was alleged the food served was not edible and had to be thrown out on multiple occasions. LPA interviewed residents and toured the kitchen. Interviews with residents revealed varying answers. Of the residents interviewed, 4 of 6 revealed the food service was adequate and the residents enjoy the food offered. Food is stored at appropriate temperatures and no food was observed past their expiration dates. Menus are posted to advise individuals of what is being served and an alternative is provided if they do not want to eat the meal being served. Residents tend to not tell the staff the food provided was inedible and did not request an alternative. Therefore, LPA is unable to corroborate that the food served was inedible and had to be thrown out. Although the above-mentioned allegation may have happened there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. Unsubstantiated An exit interview was conducted and a copy of this report was reviewed with and provided to Executive Director Monique Del Junco..the state’s words, verbatim · CDSS document, May 26, 2021 · control 18-AS-20201223164714