Vista Del Mar Senior Living

Allegation investigated: Staff did not seek medical attention for resident in a timely manner . Staff did not keep resident's authorized person informed about incidents involving the resident.

On 12/19/24, at 11:57am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director, and Andrea Perez, Marketing Director. LPA explained the purpose of the visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10) from 12:00pm-02:00pm. The department received the following: Resident Roster (No Date) Staff Roster (Dated: 12/19/2024), ID/Emergency Information (No Date) Admission Agreement (Dated:12/29/2019), After Visit Summary (Dated: 12/14/2024), Service Plan (Dated: 01/16/2024) Resident Appraisal (Dated: 11/08/2024), Physicians Report (Dated: 03/14/2024), Unusual Incident/Injury Report (Dated: 12/19/24), Faxed Receipt of Incident Report (Dated: 12/19/2024), and Resident Incident Charting Notes (Dated: 12/14/2024) were obtained from the facility. Complaint Investigation Report Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1-Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the resident (R1) had a fall at the facility two days prior before (R1) was taken to the hospital for head trauma and dizziness; and no one sought medical attention for the resident. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not seek medical attention for resident in a timely manner. All staff (S1-S4) interviewed stated that the facility had no knowledge of a fall and that they informed the family member on 12/14/24 when it was discovered that R1 had dried blood on the left side of R1s face and shaved hair in spots on the left side of R1s head as well. Staff stated that they checked R1s room for evidence of a fall and did not notice anything out of the ordinary. Staff also stated that they checked R1s room, floors, pillows, bathroom, furniture, and clothing for blood stains and could not find any. S2 stated that they observed the dried blood on R1 and asked R1 if R1 was in pain, R1 said no. S2 then asked who shaved your head like that, did you or anyone else do that, R1 said R1 was not sure. S2 then stated that they alerted management and management called the family member the same day that it was noticed on 12/14/24, and the family came and took R1 to urgent care. Staff also stated that they had no reports that R1 had fallen and when asked if R1 had fallen, R1 said no. Staff (S3) stated that S3 saw R1 on 12/13/24 and R1 looked fine and had no issues. But that on 12/14/24 they noticed a problem. S1 stated that the resident had shavers in R1s room, S1 stated that they packed them up and gave them to R1s family member. The Department reviewed the Unusual Incident/Injury Report (Dated: 12/19/24) that was sent to the department noting that R1 was found with dry blood and part of the top of R1s left head shaved in spots. The department also reviewed the After Visit Summary (Dated: 12/14/2024) that noted R1 had dry blood on left forehead and was unclear of etiology. The report also stated that R1 had no acute intracranial abnormalities. R1 was evaluated and returned to the facility. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not seek medical attention for resident in a timely manner. The majority of the residents interviewed (9 of 10) stated that they have not had any problems with staff seeking medical attention when they need it. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not seek medical attention for resident in a timely manner. 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. Complaint Investigation Report Continued on LIC9099-C Allegation #2- Staff did not keep resident's authorized person informed about incidents involving the resident. The details of the complaint alleged that the staff did not inform the resident’s authorized person about the incident that occurred at the facility. On 12/19/24, from 12:00pm-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not keep resident's authorized person informed about incidents involving the resident. All staff (S1-S4) interviewed stated that the family member was notified on 12/14/24 when they noticed that the resident had dried blood and hair that was shaved in spots on the left side of R1s head. Staff (S4) stated that the family member was notified that day and that S4 sent the family member a picture of R1 that showed the dry blood and shaved hair. S4 also stated the family responded by coming to the facility on that same day and as a precaution took R1 to urgent care. All staff (S1-S4) corroborated that the family member was made aware of the incident with R1. The department reviewed the Resident Incident Charting Notes (Dated: 12/14/2024) that showed the incident was logged and the family was notified. The department also received an incident report (Dated: 12/19/24) that was sent to the Department of Social Services, Community Care Licensing Division, detailing the incident. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff did not keep resident's authorized person informed about incidents involving the resident. The majority of the residents (9 of 10) interviewed stated that the staff does inform their authorized person when they have incidents at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff did not keep resident's authorized person informed about incidents involving the 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 with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 11-AS-20241216102632

Allegation investigated: Staff do not assist resident with obtaining medical care. Staff do not allow resident to choose care provider. Staff did not safeguard resident's personal belongings.

On 12/26/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Suzette S. Johnson/ Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#9) and Resident’s interviews (R#1-R#14). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report or LIC 602A, (R#1-R#4) Client/Resident Personal Property and Valuables or LIC 621, (R#1)’s Doctor’s letter dated 12/9/24. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegations: Staff do not assist resident with obtaining medical care. The details of the complaint alleged that facility staff is not assisting (R#1) with their medical appointments. During the records review, LPA Iniguez reviewed (R#1)’s medical file; LPA observed that (R#1) has Kaiser as their medical provider. A letter dated 12/9/24 from (R#1)’s doctor states that (R#1) requested to manage their own medications and medical care; the doctor wrote that they could manage their medications and medical care. During an Interview with the Administrator (A#1), she stated that in the case of (R#1), they call Kaiser to have them pick them up, but we can always provide transportation for them if they need it. During interviews with residents (R#1-R#14), (8) out of (14) stated that the family takes them to their medical appointments, (1) out of (14) stated that they go on their own, (5) out of (14) state that the used the facility transportation and (1) out of (14) stated that their doctor comes at the facility to see them. In addition, (13) out of (14) residents stated that they feel the facility will assist them if they require transportation to their medical appointments. During interviews with facility staff (S#1-S#9), (9) out (9) stated that the facility provides and assists the residents in care with transportation. Evaluation Report continues LIC 9099-C Allegation: Staff do not allow resident to choose care provider. The details of the complaint alleged that facility administrator is forcing (R#1) to choose in-house doctor. During the records review, LPA Iniguez examined (R#1)’s medical file and noted that (R#1) is enrolled with Kaiser as their medical provider. A letter dated December 9, 2024, from (R#1)’s doctor confirms that (R#1) requested to manage their own medications and medical care and has an active membership on file. During an interview with the administrator (A#1), she stated that she had never forced (R#1) or other residents in care to change their primary care physicians to choose our in-house doctor. During interviews with residents (R#1-R#14), (13) out of (14) stated that the administrator has never forced them to change their primary care physician for an in-house doctor. During interviews with facility staff (S#1-S#9), (9) out (9) stated that they had never heard that the administrator was forcing the residents in care to change their doctors for the facility doctor. Evaluation Report continues LIC 9099-C Allegation: Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is not safeguarding (R#1)’s personal belongings. During the records review, LPA Iniguez reviewed (R#1)’s admission file. LPA observed that (R#1) declined to list their personal belongings on the Client/Resident Personal Property and Valuables or LIC 621 form, which is dated 3/14/2024 and signed by (R#1). In addition, LPA reviewed (R#2-R#4)’s admission files, and everyone has an LIC 621 form on file. During an Interview with the Administrator (A#1), she stated that the facility staff safeguard the personal belongings of (R#1) and the residents in care. The facility staff never takes anything from the resident’s room, including money. In addition, (A#1) stated that she had never heard about a resident sleeping in their wheelchair the whole night because their bed was broken. During interviews with residents (R#1-R#14), (13) out of (14) stated that they have an inventory list on file and that the facility staff is not taking their personal belongings, including money. In addition, (13) out of (14) residents stated that they had never heard of another resident sleeping in their wheelchair the whole night because their bed was broken. During interviews with staff (S#1-S#9), (9) out (9) stated that they do not take the personal belongings of (R#1) or other residents in care, including money. In addition, (9) out of (9) facility staff never heard about a resident sleeping in their wheelchair the whole night because their bed was broken. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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 the Complaint Report was given to Suzette S. Johnson / Executive Director.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 11-AS-20241219092922

Allegation investigated: Staff allowed resident in care to leave the facility without supervision.

On 12/20/24 at 8:36 am Licensing program analyst (LPA) Villegas conducted an unannounced initial complaint visit regarding the allegation above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of the visit was explained. The investigation consisted of the following: On 12/20/24 LPA obtain copies of the following: staff and resident rosters, resident sign in/sign out sheets for December 2024, and visitors log for the month of December 2024. On 12/20/24 LPA also obtain the following for R1: Admission agreement dated 09/13/24, emergency ID form, service plan dated 09/13/24, preplacement appraisal dated 09/13/24, and Physicians report dated 09/13/24. On 12/20/24 between 10am- 11am LPA conducted interviews with ED, staff #1-4 (S1-S4), responsible party. On 12/20/24 between 11am-12:30pm LPA conducted interviews with residents #2-3 (R2-R3), and between 12:30pm-12:45pm LPA conducted interview with R1. The investigation revealed the following: Substantiated Allegation: Staff allowed resident in care to leave the facility without supervision. It is being alleged that R1 left the facility unassisted and was later found wandering the streets. On 12/20/24 between 10am- 11am LPA conducted an interview with Executive Director(ED) Suzette Johnson. Per ED Johnson, she was told that R1 informed staff that R1s partner would be coming by to pick R1 up, and R1 proceeded to make their way into the community. Per ED, the facility has procedures in place for when a resident is requesting to go out into the community. The reception desk will check August health to determine if a resident is able to go out without supervision, if a resident is not allowed, the resident is redirected. On 12/20/24 between 10am- 11am LPA conducted interviews with staff 1-staff 4 (S1-S4) reading the allegation. Of those interviewed, 4 of 4 staff denied the allegation and reported there is always a staff member at the front desk to ensure that residents who cannot leave the facility unassisted do not make their way out into the community. Per S1, residents who cannot leave the facility unassisted have an asterisk next to their name in the computer. On 12/20/24, between 11am-12:30pm, LPA conducted interviews with residents #2-3 (R2-R3). Of those interviewed, 2 of 2 residents denied the allegation and reported being unable to leave the facility unassisted. On 12/20/24 between 12:30pm-12:24pm LPA conducted interview with R1 regarding the allegation. R1 stated during the interview they walked right out the front door of the facility, unassisted by staff. On 12/20/24 LPA reviewed incident report sent to CCLD on 12/13/24. On 12/20/24 LPA conducted a records review for R1 and observed the physicians report, dated 09/13/24, which indicates resident has wandering behaviors and is unable to leave the facility unassisted. On 12/20/24 LPA reviewed Needs and Services plan, dated 09/13/24, which indicates that R1 had a wander guard device. On 12/20/24 LPA reviewed facility resident sign out sheet. Per the sheet, R1 was signed out by their responsible party on 12/11/24 at 10 am. On 12/20/24 LPA conducted interview with Witness 1 (W1), responsible party for R1. Per W1, they arrived to the facility around 1pm when it was determined R1 was out in the community and R1 was found at around 3pm. Based on LPAs observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 11-AS-20241212123022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 3, 2025

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... this requirement was not met as R1 who has a dementia diagnosis was able to leave the facility unassisted which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Licensee and Executive Director will submit to the department a plan detailing what measures the facility is taking to ensure this dificiency does not reoccur moving forward. Licensee and Executive Director will ensure all residents are reassessed when a change in condition is observed.

Type of visit: Case Management - Deficiencies

12/10/24 LPA Villegas conducted case management deficiencies visit in order to issue a citation observed during complaint investigation, control number 11-AS-20241209092305. LPA met with Executive Director Suzette Johnson as the purpose of the visit was explained. The facility failed to report an incident that occurred on 11/30/24 where resident #1 (R1) sustained a fall at the facility. Based on observations LPA Villegas did observe documentation on nurse notes that R1 sustain a fall on 12/01/24. On 12/10/24 ED confirmed that incident occurred on 12/01/24 and confirmed an incident report was not submitted to CCLD within (7) days. The licensee is being cited with Title 22 Reporting Requirements 87211(a)(1)(B) Based on interviews, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8 by not reporting the incident to Community Care Licensing. Exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Dec 13, 2024

Reporting Requirements.Each licensee shall furnish to the licensing agency such reports as the Department may require...a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(B) Any serious injury ... occurring while the resident is under facility supervision. Based on records and interviews, the facility failed to submit a written report to ccld for R1's fall within (7) days. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: Licensee/Administrator shall read Title 22, Section 87211 “Reporting Requirements” and send a written statement to CCLD that they have read and understand this section and will report all resident's incidents in the future. Written statement must be submitted to LPA Villegas by 12/13/24.

Allegation investigated: Facility staff did not respond to resident's calls for assistance

On 12/05/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff held a subsequent complaint visit at the above-mentioned facility. CCLD was met by staff one Suzette Johnson, exective director (S1). The investigation consisted of the following: On 12/05/24 CCLD staff further interviewed four (4) residents (R11-R14) and two (2) staff (S4-S5). CCLD staff requested further records, including home health services visit notes for a resident. On 11/22/24 CCLD staff requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff. Resident seven (R7) was sleeping and denied CCLD staff's interview. The investigation revealed the following: Regarding the allegation "Facility staff did not respond to resident's calls for assistance", it has been alleged that staff do not respond to the call button. Report continues, see LIC9099C. Substantiated On 11/22/24, at 10:13AM, CCLD staff initiated an "emergency call" via pull cord, located in the restroom. CCLD staff interviewed a resident, within their room, and observed there was no response for at least 22 minutes. CCLD continued facility tour at 10:35AM, without CCLD observing any caretaker response. On 12/05/2024 CCLD staff tested five (5) additional pull cords located in residents' restrooms, four (4) of which were in working order. CCLD also tested the pull cord in the theatre room on the second (2nd) floor. CCLD did not observe a caretaker response. During the testing of the working pull cords, CCLD observed an average response time of 5 minutes. Interviews revealed that five (5) out of fourteen (14) residents and one (1) out of six (6) staff have agreed with the allegation. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see the attached LIC-9099D. An exit interview was held with Suzette Johnson, Executive Director (S1), and a copy of the appeal rights, one (1) deficiency cited, and this report have been provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 19, 2024

87303 Maintenance and Operation (a) The facility shall be...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 has not been met as evidenced by: Based on CCLD's observations, the licensee has failed to ensure the facility has been maintained in good repair which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: The licensee and CCLD staff have agreed that the facility will have their maintenance team inspect each room to ensure that resident's emergency pull cord are in working condition. All updates will be forwarded to CCLD staff at Mario.Leon@DSS.CA.GOV

Allegation investigated: Facility staff did not respond to resident's calls for assistance

On 12/05/24 The Department of Social Services, Community Care Licensing Division (CCLD) staff held a subsequent complaint visit at the above-mentioned facility. CCLD was met by staff one Suzette Johnson, exective director (S1). The investigation consisted of the following: On 12/05/24 CCLD staff further interviewed four (4) residents (R11-R14) and two (2) staff (S4-S5). CCLD staff requested further records, including home health services visit notes for a resident. On 11/22/24 CCLD staff requested staff and resident roster, three (3) resident admissions agreement (R1, R6, R7) and toured the facility and interviewed ten (10) out of two-hundred and thirty-eight (238) residents (R1-R10) and five (5) out of one-hundred and five (105) staff. Resident seven (R7) was sleeping and denied CCLD staff's interview. The investigation revealed the following: Regarding the allegation "Facility staff did not respond to resident's calls for assistance", it has been alleged that staff do not respond to the call button. Report continues, see LIC9099C. Substantiated On 11/22/24, at 10:13AM, CCLD staff initiated an "emergency call" via pull cord, located in the restroom. CCLD staff interviewed a resident, within their room, and observed there was no response for at least 22 minutes. CCLD continued facility tour at 10:35AM, without CCLD observing any caretaker response. On 12/05/2024 CCLD staff tested five (5) additional pull cords located in residents' restrooms, four (4) of which were in working order. CCLD also tested the pull cord in the theatre room on the second (2nd) floor. CCLD did not observe a caretaker response. During the testing of the working pull cords, CCLD observed an average response time of 5 minutes. Interviews revealed that five (5) out of fourteen (14) residents and one (1) out of six (6) staff have agreed with the allegation. Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see the attached LIC-9099D. An exit interview was held with Suzette Johnson, Executive Director (S1), and a copy of the appeal rights, one (1) deficiency cited, and this report have been provided.the state’s words, verbatim · CDSS document, Dec 5, 2024 · control 11-AS-20241119135616

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 19, 2024

87303 Maintenance and Operation (a) The facility shall be...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 has not been met as evidenced by: Based on CCLD's observations, the licensee has failed to ensure the facility has been maintained in good repair which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: The licensee and CCLD staff have agreed that the facility will have their maintenance team inspect each room to ensure that resident's emergency pull cord are in working condition. All updates will be forwarded to CCLD staff at Mario.Leon@DSS.CA.GOV

Allegation investigated: Staff do not ensure facility is free from pests. Staff does not ensure that facility is adequately cleaned.

On 11/22/24, at 09:00am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Suzette Johnson, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R10). The department received the following: Resident Roster (No Date) Staff Roster (Dated: 11/22/2024), Pest Control Invoice (Dated: 07/31/2024, 08/31/2024, 09/30/2024, & 10/31/2024), and Deep Cleaning Schedule (Dated: 07/24/2022) were obtained from the facility. The investigation revealed the following: Allegation #1-Staff do not ensure facility is free from pests. Complaint Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that the facility has roaches throughout the building and in the Spa Room. On 11/22/24, from 9:30am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff do not ensure facility is free from pests. All staff (S1-S4) interviewed stated that the facility has a pest control company (Terminix) that comes weekly and sprays, set traps, and tries to prevent any further infestations. During a record review, the department received and reviewed receipts from Terminix Pest Control company dated 07/31/2024, 08/31/2024, 09/30/2024, & 10/31/2024. The Department observed that Terminix has weekly visits to the facility to provide services for any current pests as well as ensure the facility remains pest free by doing preventative services. The department toured the kitchen, Spa Room, bathrooms, dining areas, activity rooms, and resident bedrooms and did not observe any roaches or other pests at the time of the visit. The department interviewed residents (R1-R10) about the allegation and 8 of 10 residents that were interviewed denied the allegation that Staff do not ensure facility is free from pests. The majority of the residents interviewed (8 of 10) stated that they have not seen any pests in the facility for quite a while. They further state that they believe the facility is doing what it can to keep it free from pests by having pest control come out weekly. Based on interviews, observation, and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure facility is free from pests. 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 does not ensure that facility is adequately cleaned. The details of the complaint alleged that the staff does not ensure that the facility is adequately cleaned. On 11/22/24, from 9:30am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that the Staff does not ensure that facility is adequately cleaned. All staff (S1-S4) interviewed stated that the facility is cleaned daily by maintenance, the janitorial staff, house keepers, and caregivers. S1 stated that the Spa Room, kitchen, bathrooms, dining areas, common rooms, and bedrooms are cleaned daily. Additionally, S1 stated that a deep cleaning of those areas is done weekly. The department toured those areas and observed them to be clean, sanitary, and in compliance with Title 22 regulations. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed denied the allegation that Staff does not ensure that facility is adequately cleaned. The majority of the residents (9 of 10) interviewed stated that the staff does ensure the facility is cleaned and sanitary. Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegation that the Staff does not ensure that facility is adequately cleaned. 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 with Suzette Johnson, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 11-AS-20241120082650

Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure the facility is clean and sanitary. Staff do not ensure resident has hot water.

On 11/22/24 Licensing program analyst (LPA) Villegas conducted a subsequent complaint visit to deliver findings. LPA met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/20/24 between 9:30am-11:30am LPA conducted interviews with residents #1-7 (R1-R7), and between 11:30am-12:15pm LPA conducted interviews with staff #1-4 (S1-S4). On 11/20/24 LPA conducted a tour of the inside and outside of the facility and conducted water temperature checks in (4) bedrooms. On 11/20/24 LPA obtained copies of the following documents: staff and resident rosters, Terminex invoices for the months of September and October 2024, deep cleaning schedule, housekeeping schedule for the months of August-November 2024, and the water temperature log for the months of January 2024 -November 2024. On 11/20/24 LPA obtain copies of documents pertinent to the complaint for R1. On 11/22/24 LPA conducted interviews between 9am-11:30am with staff #5 (S5), and residents #8-10 (R8-R10). Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure the facility is free from pests It is being alleged that there is a mice, rats, and roach problem at the facility. On 11/20/24 between 11:30 am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above and reported bedrooms are sprayed by Terminex pest control when pest are reported by residents. 4 of 4 staff also reported rooms are being monitored for pest when cleaning is being conducted. On 11/20/24 between 9:30 am-11:30am LPA conducted interviews with residents R1-R7, 3 of 7 residents interviewed denied the allegation above, 1 of 7 residents refused interview, 3 of 7 residents interviewed confirmed the allegation and reported traps are placed and the bedroom gets sprayed when reported. On 11/22/24 at 9am LPA conducted interview with (S5),1 of 5 staff interviewed denied the allegation above and reported pest control visits the facility regularly to spray. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/20/24 while touring the inside and outside of the facility, LPA did not observed any pest activity. On 11/22/24 LPA conducted a a review of Terminex service reports and observed that the facility is being treated weekly. Allegation: Staff do not ensure the facility is clean and sanitary. It is being alleged that the facility is dirty and that the staff don't clean the rooms nor the bathrooms well. On 11/20/24 between 11:30 am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above and reported bedrooms along with the rest of the facility are cleaned daily and bedrooms are deep cleaned 1 time per week. Per 4 of 4 staff, some bedrooms require cleaning 2-3 times a week. On 11/20/24 between 9:30 am-11:30am LPA conducted interviews with residents R1-R7, 5 of 7 residents interviewed denied the allegation above, 1 of 7 residents refused interview, and 1 of 7 residents interviewed confirmed the allegation above, and stated the bedroom is cleaned once a week. On 11/22/24 at 9am LPA conducted interview with (S5),1 of 5 staff interviewed denied the allegation above and reported bedrooms and all common areas are cleaned daily and bedrooms are deep cleaned 1 time per week. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/21/24 while conducting tour of the facility LPA observed both floors being cleaned by the staff; trash was being removed and housekeepers were moping the floors. On 11/22/24 LPA reviewed the housekeeping schedule and observed that rooms are cleaned daily and deep cleaned once a week. Allegation: Staff do not ensure resident has hot water It is being alleged that R1's bathroom sink has no hot water and get's lukewarm at best. On 11/20/24 between 11:30am-12:15pm LPA conducted interviews with S1-S4, 4 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed stated residents have asked for the water temperature to be higher however it was explained that the facility has to be incompliance with water temperatures and hotter water temperatures may be harmful to other residents. On 11/20/24 between 9:30am-11:30am LPA conducted interviews with residents R1-R7, 5 of 7 residents denied the allegation above, 1 of 7 residents refused the interview, 1 of 7 residents confirmed the allegation and reported the water temperature was turned down, the water temperature is too low and not to the residents liking. On 11/20/24 LPA checked the water temperatures of 4 random rooms and the following was observed: room # 135 water temp 111.7 F, room # 137 water temp 113.6F, room # 293 water temp is 114.2 and room 227 water temp is 116.2. On 11/22/24 at 9am LPA conducted interview with S5, 1 of 5 staff interviewed denied the allegation above. On 11/22/24 between 9:15am- 11:30am LPA conducted interviews with R8-R10 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 11/22/24 LPA conducted review of the water temperature log for the months of January 2024 -November 2024, LPA observed that water temperatures are checked regularly to ensure compliance. 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 with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 11-AS-20241115123831

Allegation investigated: Staff is serving food that is not of good quality. Foods are not properly labeled.

On 10/24/24 at 9:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegation above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/17/24 LPA Villegas conducted an initial complaint visit regarding the allegation above. On 10/17/24 LPA obtained copies of the following: Staff and resident rosters, menus for September- October 2024, alternative menu, and sanitation inspection of kitchen dated 09/21/24, documentation of food temperatures for September-October 2024 as well as copies of pertinent documents for resident #1 (R1). On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and between 10:00am- 11:30 am LPA conducted interviews with ED and staff #1-5 (S1-S5). LPA toured facility kitchen and observed dining room during lunch seating(s). On 10/24/2024 Between 9:30am- 11:45am LPA conducted interviews with residents #2-10 (R2-R10), and once again observed dining room during lunch seating(s). Unsubstantiated The investigation revealed the following: Allegation: Staff is serving food that is not of good quality. It is alleged that facility is not serving food of good quality. On 10/17/24 between 10:00am- 11:30 am LPA conducted interview with ED regarding the allegation above, ED denied the allegation above and reported there are monthly meetings held to hear the needs of the residents. On 10/17/24 between 10:00am- 11:30am LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above and reported residents have not complained of the food quality. On 10/17/2024 LPA toured the inside of the facility, during the tour LPA observed the kitchen, dining area and the facility’s food supply. LPA observed residents eating in the dining area and LPA did not observe food not of good quality being served. On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and on 10/24/2024 between 9:30am- 11:45am LPA conducted interviews with R2-R10. 8 of 10 residents interviewed denied the allegation above and reported having no concerns regrading the quality of food being served, 2 of 10 resident interviewed stated the food can be better. On 10/24/24 LPA observed residents having lunch in the dining area and did not observe food not of good quality being served. Allegation: Foods are not properly labeled It is being alleged that drinks served are not labeled sugar or sugar free. On 10/17/24 between 10:00am- 11:30 am LPA conducted interview with ED regarding the allegation above, ED denied the allegation above and reported kitchen manager oversees the labeling in the kitchen. On 10/17/24 between 10:00am- 11:30am LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. On 10/17/24 LPA conducted a tour of the facility kitchen as well as observed lunch seatings, LPA observed sugar free items to be separated and labeled in the pantry. LPA also observed the juice which was placed in a beverage pitcher to be labeled as regular/sugar and or sugar free. On 10/17/24 from 9:30am-10 am LPA conducted interview with R1, and on 10/24/2024 between 9:30am- 11:45am LPA conducted interviews with R2-R10. 5 of 10 residents interviewed denied the allegation above, 2 of 10 residents interviewed were unsure of labeling, 2 of 10 residents interviewed reported drinks are sometimes labeled, and 1 of 10 residents interviewed confirmed the allegation and reported juices are not labeled when served. 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 with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 11-AS-20241008133500

Allegation investigated: Staff do not answer resident's calls for assistance Staff do not ensure facility is free from pests Staff do not maintain facility in good repair.

On 10/23/24, Licensing Program Analysts (LPA), Wendy Gibbs and Perry Scott, conducted an unannounced complaint visit. During the visit the Department met with Executive Director, Suzette Johnson, and the purpose of today’s visit was explained. During today’s visit the Department conducted a facility inspection, interviewed Staff S1-S8, interviewed Residents R1-R11, and received documents pertinent to the investigation. The following documents were received and reviewed Resident Roster, Staff Roster, pest control receipts from Terminix, and Work Orders. The investigation revealed the following: Unsubstantiated Allegation: Staff do not answer resident’s calls for assistance. The complaint allegation alleges that the facility staff do not always answer calls for help or assistance. During the facility inspection, the Department tested resident call buttons in rooms 111, 205, 242, and 316. The Department timed how long it took for a caregiver to answer the call for assistance and the following times were recorded 6 minutes, 5 minutes, 6 minutes, and 8 minutes. During interviews with Staff S1 – S8, were asked how long it takes to respond to a resident’s call for assistance, eight (8) out of eight (8) stated they respond to residents calls for assistance in less than 10 minutes. During interviews with Residents R1-R11, were asked how long it takes staff to respond to their calls for assistance, seven (7) out of eleven (11) stated the staff come right away when called. Additionally, Residents R1-R11 were asked if there was a time they called for assistance and staff did not respond or come, four (4) out of eleven (11) stated there has been a time when they called for assistance and staff did not come to assist. Additionally, Residents R1, R3, R4, and R6, were asked what time of day the incident occurred, four (4) out of four (4) stated it happened during the evening and nights. Allegation: Staff do not ensure facility is free from pests. The complaint allegation alleges roaches were observed in the dining room and residents’ bed has bed bugs. During the facility inspection, the Department did not observe insects or any traces of insects. The facility and rooms inspected were observed clean and sanitary. During Record review, the Department received and reviewed receipts from Terminix pest control company dated 07/03/24 through 09/25/24. The Department observed Terminix has come out weekly to provide services. During interviews with Staff S1-S8, were asked if they have recently observed any insects or pests inside the facility, six (6) out of eight (8) stated they have not seen any insects inside the facility. Two (2) out of eight (8) stated they see cockroaches off and on but not since June. Additionally, Staff were asked if there is a pest control company that comes and provides services, eight (8) out of eight (8) stated Terminix comes out on a weekly basis to provide services. During interviews with Residents R1- R11, were asked if they have recently observed any insects or pests inside the facility, five (5) out of eleven (11) stated they have observed cockroaches inside the facility. Additionally, they stated if they see them inside the facility is on it and takes care of it quickly. Additionally, Residents R1-R11, were asked if there is a company that comes out to treat for the cockroaches, eleven (11) out of eleven (11), stated there is a company that comes out regularly. Allegation: Staff do not maintain facility in good repair. The complaint allegation alleges that their air conditioning and refrigerator in their room is not working properly. During the facility inspection, the Department observed the facility to be in good repair. The Department checked residents air conditioning and refrigerator in rooms visited and observed them to be working. During record review, the Department received and reviewed work orders from 09/14/24 through 10/23/24. During interviews with Staff S1 – S8, were asked what the process and procedure is if a resident reports something not working in their room is, eight (8) out of eight (8) stated once an issue is reported a work order is created, maintenance goes right away to check on the issue and they decide what is needed for a repair and once parts are ordered and received the issue is fixed. If the issue can be fixed right away, they fix it then. During interviews with Residents R1- R11, were asked if there was anything in the facility or in their room that is not working properly, ten (10) out of eleven (eleven) stated everything in their room is working properly and if something needs fixed, they come right away to fix it. During an interview with R1, they stated their refrigerator keeps freezing up and needs defrosted then sometimes takes a while to get cold. During the facility inspection, the Department observed R1’s refrigerator was working properly. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 23, 2024 · control 11-AS-20241015140936

Allegation investigated: Staff neglect resulted in the death of residents Staff did not prevent a resident from causing self harm

This report serves as an amendment to the 9/12/2024 report . The complaint findings reflected on the report dated 9/12/2024 remain the same and does not change. On todays date 11/26/24 LPA Day amended the 9/12/2024 report to soley include Administrators interview. On 9/12/2024 ThLicensing Program Analyst (LPA) Sparkle Day conducted a susbsequent visit to the facility regarding the above allegations. The investigation consisted of the following: LPA reviewed Death Reports of all Deaths in the facility from 3/2024 to 6/2024. R#1 passed away 3/15/2024 R#2 passed away 3/15/2024 R#3 passed away 3/15/2024 R#4 passed away 3/25/24 R#5 passed away 5/27/24 and R#6 passed away 5/29/24. LPA interviewed Staff #1 - Staff #2. LPA contacted (3) hospice Agencies: W#1 - Allied Hospice, W#2 Devine Hospice, W#3 Apprea Hospice and W#4, Conservator of R#6 Regarding Allegation: Staff Neglect resulted in the death of residents It was alledeged that staff neglect resulted in deaths of residents; During this visit LPA Day received the names of 6 residents who passed away from 3/2024 to 6/2024. Resident #1 (R#1) - Resident #5 (R#5) were all on Hospice during this time . During this visit LPA contacted the hospice agencgies and confirmed that the deaths of R#1 - R#5 was due to end stage illnesses. LPA contacted conservator for R#6 and confirmed that the cause of death was Unsubstantiated due to an end stage illness. All Hospice agencies contacted and conservator where unaware of any staff neglect. Based upon this information gathered LPA finds that 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 Regarding Allegation : Staff did not prevent a resident from causing self harm It was alleged that facility staff did not prevent a resident from causing self harm by cutting her wrist. During this visit LPA reviewed incident report of this incident dated 5/30/2024. LPA interviewed Staff #1 and Staff #2 which are both Med room staff who observed R#7 on day of incident. Incident report and staff interviews were consistent with incident: R#7 brought scissors to the Medroom and asked the staff to keep her scissors for her. Staff #1 asked R#7 why did she want them to hold the scissors for her and R#7 stated It would be safer for her. Staff took the scissors. Staff insist that R#7 did not seem distressed and acted normal. Later R#7 sustained a self cut to her wrist. LPA Day interviewed Administrator Suzette Johnson who explained the facility procedures of when a resident presumes to be distress or unusual behavior, that resident is put on a hourly watch. After R#7 brought the scissors to the Medroom S#1 alerted Administrator and was put on an alert. However R#7 cut herself within minutes of leaving the Medroom. LPA reviewed Physician report and Needs and Service Plan of R#7 which did not indicate any history of suicidal tendencies nor a history of cutting herself. During this visit LPA was unable to interview R#7 due to she has moved and whereabouts are unknown. Based on the information gathered and the interviews conducted LPA Day finds that the Staff had no knowledge of R#7 intent to harm herself , therefore could not prevent it. There is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED An Exit interview was conducted with Suzette Johnson Administrator and Sidonia Cordis, Resident Care Director and a copy of this report was providedthe state’s words, verbatim · CDSS document, Sep 12, 2024 · control 11-AS-20240604125752

Type of visit: Required - 1 Year

On 09/11/24, Licensing Program Analyst's (LPA's) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Suzette Johnson as the purpose of today’s visit was explained. The facility is licensed to serve 300 non-ambulatory elderly adults 60 and over of which 10 may be bedridden, there is an approved hospice waiver for 50 residents. The facility has a dementia wing w/ delayed egress. Executive Director was provided with upcoming fees info and pin, fees due on 10/11/24. The facility has an active liability insurance with expiration date of 10/26/24. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms, 4 common bathrooms, multimedia rooms, commercial kitchen, activity room, large dining room, medication room, a large outside patio, laundry room, and administrative offices. LPA’s conducted a records review of 8 staff records, 10 resident records, and 10 medication administration records, records were maintained accordingly with no discrepancies. LPAs observed medications were centrally stored and properly locked. The last fire and disaster drill was conducted on 06/19/24, fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Landline and internet service was observed. During facility tour 10 Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, showers were free of mold/mildew, and there are sufficient toiletries accessible to residents. Water temperature properly measured between 105-120 F., there was a comfortable temperature maintained throughout the facility. LPAs conducted tour of commercial kitchen, LPAs observed an adequate supply of perishable and non-perishable food. Toxins and knifes were observed to be inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. Exit interview conducted with Executive Director Suzette Johnson, and copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2024

Allegation investigated: Staff does not ensure resident is allowed to leave the facility at anytime with visitors.

On 09/04/24 at 1:30 pm, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint to render findings. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/16/24 LPA obtained copies of staff and resident rosters, visitors/visitation policy, resident sign in and sign out sheet or July 2024 and August 2024, and the following documents for R1: Emergency ID form, Admission agreement date 12/10/21, physicians report, physicians orders, needs and service plan, pre-appraisal, copy of POA document(s), and copy of documentation reporting POA's request regarding visitations. On 08/16/24 between 12pm- 1:15pm LPA conducted interviews with ED, staff #1-4 (S1-S4), and conducted a tour of the facility, there were no health and safety concerns observed. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with residents #1-10 R1-R10. Substantiated The investigation revealed the following: Allegation: Staff does not ensure resident is allowed to leave the facility at any time with visitors. It is being alleged facility staff is not allowing R1 to leave the facility with visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported the facility is following POAs request regarding visitations outside the facility. ED continued to report that R1 has restrictions set in place by POA and that visitor(s) are aware of the restrictions. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that residents are allowed to go out of the facility with visitors unless there are restrictions in place per POA. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party informed LPA that R1 has restrictions for visitations outside of the facility due to financial abuse concerns. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1 regarding the allegation above, R1 reported it is not allowed for R1 to go out into the community with visitor although R1 would like too. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 6 of 9 residents interviewed denied the allegation above and reported bring able to leave the facility with visitors, 2 of 9 residents interviewed reported not being able to leave the facility unaccompanied, 1 of 9 residents interviewed reported choosing to stay in the facility. On 09/04/24 LPA conducted review of the California all-purpose certificate of acknowledgment dated April 29, 2021 part 1 which is titled: Appointing an agent to make health care decisions, which reads “In this document I appoint an agent. That agent will make health care decisions for me in the future, if and when I no longer have the mental capacity to make my own health care decisions.” On 09/04/24 LPA reviewed provider information notice PIN 21-48-ASC page 3 title “Residents’ Right to Visitors, Telephone Calls, and Personal Mail” which details what POA agents are limited to the powers granted in the POA document. On 09/04/24 LPA conducted a review of title 22’s personal rights. Based on records reviewed and interviews conducted facility staff violated R1 personal rights by allowing a POA that only has the authority to make health care on behalf of R1 to make decisions on R1 personal rights. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter 8 are being cited on the attached LIC 9099D. exit interview conducted with Executive Director Suzette Johnson, appeal rights explained, and a copy of this report was provided. Allegation: Staff did not ensure resident was allowed to have visitors It is being alleged that facility staff do not allow residents to have visitors. On 08/16/24 between 12pm- 1:15pm LPA interviewed with ED regarding the allegation above, ED denied the allegation above and reported that visitors are always welcomed during visitation hours. On 08/16/24 between 12pm- 1:15pm LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported visitors are allowed daily. On 08/16/24 LPA conducted interview with responsible party for R1, responsible party stated that there are no visitor restrictions for visits conducted inside the facility. On 08/22/24 LPA between 9:30am-11:45am conducted interviews with R1 regarding the allegation above, denied the allegation above and reported having visitors. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R2-R10 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above, 2 of 9 residents interviewed reported not having any visitors that come by the facility. 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 with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 11-AS-20240808083344

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 20, 2024

Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night... Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. The facility staff is following the instructions of a POA over healthcare regarding R1 right to leave the facility with visitors on outings. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Administrator will submit a plan on how the facility will ensure R1 Personal Rights are not violated. Facility will reach out to the ombudsman and or law enforcement if and elder abuse is suspected.

Allegation investigated: Staff do not ensure the facility is free from pests. Staff do not ensure resident’s room is adequately cleaned.

On 08/22/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Executive Director (ED) Suzette Johnson as the purpose of today’s visit was explained. The investigation consisted of the following: On 08/16/24 LPA obtained copies of staff and resident rosters, house keeping schedule for August 2024, deep cleaning schedule and a copy of termix invoices for July 2024.On 08/16/24 LPA obtained copies of the following documents for R1: Emergency ID form, Admission agreement date 12/10/21, physicians report, physicians orders, needs and service plan, pre-appraisal, copy of POA document(s). On 08/16/24 LPA conducted interviews with ED, staff #1-4 (S1-S4), and conducted a tour of the facility, there were no health and safety concerns observed. On 08/22/24 between 9:30am-11:45am LPA conducted interviews with R1-R10, on 08/22/24 between 12pm-1:25pm LPA conducted interviews with S5-S6. On 08/22/24 LPA obtained copies of document(s) detailing what rooms have been treated for the month of June 2024-August 2024, terminix invoice for Unsubstantiated June 2024-July 2024, Terminix inspection report, and documentation detailing the dates and times R1's bedroom is cleaned. The investigation revealed the following: Allegation: Staff are not ensuring that facility is free of pests. It is being alleged that roaches have been observed underneath R1’s bed. On 08/16/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Vista Del Mar Senior Living has increased their contract with Terminix commercial who will now come out once a week to spray the facility and bedrooms that require treatment. On 08/16/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that the facility is cleaned daily, bedrooms are cleaned daily and bedrooms are deep cleaned once a week. 4 of 4 staff interviewed also reported Terminix sprays the facility weekly. On 08/16/24 LPA interviewed W1 via phone who confirmed Vista Del Mar Senior Living have increased their services to once a week from twice a month. On 08/22/24 LPA conducted interviews with S5-S6, 2 of 2 staff interviewed denied the allegation above and reported bedrooms are being cleaned daily and that Terminix is coming out weekly to spray the facility and bedrooms that require treatment. On 08/22/24 LPA interviewed R1-R10 regarding the allegation above, 6 of 10 residents interviewed denied the allegation above, 4 of 10 residents interviewed reported observing and reporting pest in the past and reported that staff provided treatment. On 08/22/24 LPA toured R1's bedroom and did not observe any health or safety concerns nor pest. Allegation: Staff are not ensuring resident's room is cleaned It is being alleged staff are not cleaning R1’s bedroom floor properly. On 08/16/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s bedroom is cleaned daily and deep cleaned once a week per cleaning schedule. On 08/16/24 LPA interviewed S1-S4 regarding the allegation above, 4 of 4 staff denied the allegation above and stated that resident bedrooms are cleaned every day which consist of trash being removed, beds are made, and floors are cleaned. On 08/22/24 LPA conducted interviews with S5-S6, 2 of 2 staff interviewed denied the allegation above and reported that rooms are being cleaned daily and deep cleaned once a week. On 08/22/24 LPA interviewed R1-R10 regarding the allegation above, 9 of 10 residents reported bedrooms are cleaned daily, 1 of 10 residents reported bedroom is cleaned twice a day. On 08/22/24 LPA toured R1's bedroom and did not observe any health or safety concerns, documentation detailing when the bedroom was cleaned was observed on the bedroom door. On 08/22/24 LPA reviewed admission agreement page 3 letter C which states facility will provide daily, light housekeeping services (bed making, trash removal, and general tidying) and deep clean weekly. If you, fail to do so, you understand that the facility may provide additional housekeeping services to your bedroom, and residents shall agree to pay for such services, as facility deem necessary. Facility will provide additional housekeeping services beyond the standard daily and weekly services for an additional fee, as described Appendix A. 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 with Executive Director Suzette Johnson, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024 · control 11-AS-20240813145825

Allegation investigated: Staff did not administer medication to resident.

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 07/25/2024.** On 07/25/2024 at 8:00 am Licensing Program Analyst (LPA), David España conducted a complaint Subsequent Visit to facility to gather information for the above allegation(s). There are currently 12 residents in memory care with Covid-19. LPA was granted access and allowed to enter the facility to conduct the inspection. LPA España was met by Suzette Johnson, Administrator and the purpose of today’s visit was explained. Investigation consisted of the following: On 07/24/2024 as part of the LPA España investigation, LPA requested and received copies the following documents for resident #1-#5 (R1-R5) and staff #1-#5 (S1-S5): staff roster, resident rosters and LPA requested to review the Medication Administration Records (MARs) to check when medications were given to residents, who gave them, and what doses were administered. COMPLAINT INVESTIGATION REPORT 9099C CONTINUED Unsubstantiated Investigation revealed the following: On July 25, 2024, LPA España conducted interviews regarding an allegation of staff did not administer medication to resident. The Executive Director (ED) denied the allegation, stating that staff administers medication correctly and communicates with the Licensed Vocational Nurse (LVN) to prevent errors. LPA España Interviews with Staff #1-#5 (S1-S5) also revealed unanimous denial of the allegation, with staff reporting that routine cycle medications are automatically delivered. LPA España conducted a medication review confirmed sufficient medication availability for residents. LPA España interviewed resident #1-#5 (R1-R5), of those 4 out of 5 denied the allegation, reporting timely receipt of medication; 1 resident refused to participate in the interview. Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Staff did not administer medication to 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(s) is Unsubstantiated. No deficiencies were cited during this visit. Exit interview conducted. A copy of the report was given to Suzette Johnson, Executive Director. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank. This page was intentionally left blank.the state’s words, verbatim · CDSS document, Jul 25, 2024 · control 11-AS-20240717094224

Allegation investigated: Staff did not prevent a resident from attacking another resident.

On 07/19/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit at this facility. LPA was greeted by the Executive Director Suzette Jonhson. LPA explained the purpose of this visit was to deliver findings for the allegation mentioned above. The investigation consisted of the following: A copy of the facility's roster for residents and staff, service records for resident #1 (R1's) Physician Report LIC 602A (dated: 06/07/24), College Medical Center Psychiatric Evaluation (dated: 04/21/24 and 05/24/24), Physical Examination/Progress Notes (dated: 05/25/24),Unusual Incident Report LIC 624 (dated: 07/15/24), Physician’s Orders Medications List (dated: 06/16/24), and (R2's) Preplacement Appraisal Information LIC 603A (dated: 04/24/24). Interviews with resident #1-#10 (R1-R11), Executive Director #1 (ED1) and staff #1-#4 (S1-S4). A tour of the faciltiy was conducted. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not prevent a resident from attacking another resident. The details of the complaint alleged resident #1 (R1) was attacked and the facility staff failed to prevent the physical assault. The complainant reported (R1) was physically assaulted by a another resident and sustained abrasions and lacerations on the front of the leg. The complainant did not provide further details on this matter. Investigation revealed resident #1 (R1) came from Ocean Ridge Post Acute a skilled nursing facility. According to resident #1 (R1’s) Identification and Emergency Information LIC 601 (dated: 06/07/24) was admitted to Vista Del Mar on 06/07/24. (R1’s) Physicians Report LIC 603A (dated: 06/07/24) is non-ambulatory and requires assistance services with medication, transferring, bathing, dressing, and grooming. On 07/18/24, between 09:30 am – 02:00 pm, the Department interviewed (5) out of (5) Executive Director #1(ED1) and staff #1-#4 (S1-S4) claimed this allegation was false. (A1 and S1-S2) claimed there was no physical assault that took place between resident #1 (R1) and resident #2 (R2). (S1-S2) reported that (R1) had an unwitnessed fall on 07/07/24 at 07:00 pm, (R1) sustained a minor skin tear on the leg and was assisted by a facility licensed vocational nurse/med-tech. (S1-S2) stated the skin tear was minor and did not require hospitalization. On 07/08/24 at 10:00 am, when being assisted by the care staff experienced combative behavior and delusional hallucinations and needed further medical evaluation according to the facility medical physician and was sent to College Medical Center on a (5150). (S3-S4) primary caregivers to (R1), explained that (R1) has displayed combative behavior when assisted with daily activity services. (S3-S4) stated (R1) had an intense fear of being touched and would respond by acting in inappropriate physical behavior with staff. (S2) reported when (R1) was admitted to Vista Del Mar from Ocean Ridge, (R1) already had multiple skin problems. (R1) is taking Eliquis, a blood thinner that can cause bruising and skin tears. According to (S2), both (R1) and (R2) require medical devices or mobility support as they are non-ambulatory. (R2) was diagnosed with Paralysis, which is a loss of muscle function in part of the body that would limit (R2's) ability to move, causing no physical assault on (R1). (S2) indicated that the facility's physician modified one of (R1's) prescribed medications to help improve (R1's) disorderly behavior on 06/21/24. (Evaluation Report continues LIC 9099-C) On 07/18/24, between 10:20 am 11:45 am, the Department interviewed (10) out of (10) residents (R2-R10) #2-#10 who denied having experienced physical assault while in care at this facility. (R2-R10) claimed not to have witnessed any physical altercations or assaults between residents. (R2-R10) praised the facility staff and mentioned they were responsive to their care and supervision. (R2) declared that (R2) had never engaged in physical contact with (R1). On 07/18/24, between 12:30 pm – 12:55 pm, the Department interviewed (1) out of (1) witnesses #1 (R1’s) family representative who verified that (R1) has a history of physical aggression on facility aids. (W1) confirmed that due to agitation or anxiety (R1) has a history of disruptive behaviors in individuals who assisted (R1) with daily activities. (W1) reported the facility notified (W1) of the unwitnessed fall with the minor skin tear on the leg along with the disorderly conduct and was sent for further evaluation at College Medical Center. On 05/16/24, between 10:00 am – 10:15 am, the Department interviewed resident #1 (R1). (R1) who is currently at College Medical Center and is being treated on (5250) was interviewed by telephone. (R1) was not able to carry a full conversation and was unable to provide statements. As a result of the Department reviewing (R1’s) Physician Report LIC 602A (dated: 06/07/24), College Medical Center Psychiatric Evaluation (dated: 04/21/24 and 05/24/24), Physical Examination/Progress Notes (dated: 05/25/24), and Unusual Incident Report LIC 624 (dated: 07/15/24) verified (R1’s) has been evaluated with some form of mental disorder. A review of (R1’s) Physician’s Orders Medications List (dated: 06/16/24), revealed (R1) is on (22) routine medications. Thirteen (13) out of twenty-two (22) prescribed medications have side effects that can cause unusual skin irritation, peeling, or bruising per the National Institute of Health (ref: NIH). (R2’s) Preplacement Appraisal Information LIC 603A (dated: 04/24/24) confirmed (R2’s) health condition and ambulatory status verified the statement stated by (S2). Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. 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. An exit interview is conducted with Suzette Johnson, and a copy of the report is provided.the state’s words, verbatim · CDSS document, Jul 19, 2024 · control 11-AS-20240712155653

Allegation investigated: Staff are not ensuring that facility is free of pests. Facility staff failed to meet residents needs. Staff are not safeguarding resident’s personal items. Staff made inappropriate comments to resident. Staff are not meeting resident’s laundry needs. Staff are not ensuring resident's room is cleaned.

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director (ED) Janie Acosta, as the purpose of the visit was explained. The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, laundry and room cleaning schedule, invoice for Terminix services for the months of April 2024 and May 2024, and conducted a tour of facility. On 06/05/24 LPA Villegas obtained the following for residents #1 (R1): facesheet (move in date: 04/25/2024), physicians report (signed 04/16/24), pre-appraisal (dated 04/25/24), needs and service plan (dated 05/07/24), admission agreement (signed: 04/25/2024) and MAR for April 2024-June 2024. On 06/05/24 LPA Villegas obtained the following for residents #2 (R2): facesheet (move in date: 07/19/22), physicians report (signed 11/16/23), pre-appraisal (signed 07/16/22), needs and service plan (signed on 08/14/23), admission agreement (signed 07/14/22), MAR for month of May 2024, physician’s orders for May 2024-June 2024. Unsubstantiated On 06/05/24 LPA Villegas conducted interviews between 9:30am- 12:30pm, with ED, and staff # 1-5 (S1-S5), LPA conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10). The investigation revealed the following: Allegation: Staff are not ensuring that facility is free of pests. It is being alleged that R1 has been complaining about roaches. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Vista Del Mar Senior Living has increased their contract with Terminix commercial who will now come out 3 times a month to spray the entire facility. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 4 of 5 staff interviewed denied the allegation above and reported that the facility is cleaned daily, and bedrooms are cleaned daily but are deep cleaned once a week. 1 of 5 staff interviewed reporting having no knowledge of the Terminix contract. On 06/05/24 LPA interviewed W1 via phone who confirmed facility is on the recommended treatment plan from Terminix pest control. W1 also reported Vista Del Mar Senior Living have increased their services to 3 times a month. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed reported that their rooms are cleaned daily and have not observed any pest in their bedrooms, 2 of 10 residents interviewed reported observing pest in their restroom and having the restroom sprayed right after, 2 or 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. Allegation: Facility staff failed to meet residents needs It is being alleged that facility staff are storing personal belongings under R1’s bed, and R1 is unable to obtain belongings when needed. On 06/05/24 LPA toured R1’s bedroom and did not observe any belongings to be stored underneath the bed. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that personal belongings are stored in different areas of the bedroom, depending on the resident’s preference. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported all residents have dresser, nightstand, and a shared closet where residents belonging can be stored and are accessible. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported their belongings are accessible as belongings are stored in their dresser(s), and closet. 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 LPA reviewed service plan and service plan does not specify a need for items to be stored in a particular area of the bedroom. Allegation: Staff are not safeguarding resident’s personal items It is being alleged that S2 took R1’s wheelchair and gave R1 a wheelchair that was not R1’s. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that wheelchairs are not provided by Vista Del Mar Senior Living as wheelchairs are provided by resident’s insurance. ED also stated that all wheelchairs are labeled with the name of the resident it belongs too. On 06/05/24 LPA interviewed S2 regarding the allegation above, S2 denied the allegation above. S2 stated that upon R1’s arrival to the facility R1 was in a wheelchair that was too low which did not allow R1 to move around the facility comfortably, S1 states she provided R1 with a lender wheelchair that was higher while R1 was able to obtain a new wheelchair. S2 continued to report that after R1 received R1’s new wheelchair S2 asked for the lender wheelchair back; however, R1 was under the impression S2 was attempting to take away the new wheelchair from R1. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported that their wheelchair or walker have not been misplaced, 2 of 10 residents reported not using a wheelchair or walker, and 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 while conducting interviews LPA observed wheelchairs to be labeled with resident names. Allegation: Staff made inappropriate comments to resident It is being alleged that facility staff made inappropriate comments to R1. On 06/05/24 LPA interviewed ED regarding the allegation above. ED denied the allegation above and reported that Ed has not been informed of any staff member speaking inappropriately to any resident in care. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported that staff treat them with respect, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. Allegation: Staff are not meeting resident’s laundry needs It is being alleged staff are not meeting R1’s laundry needs. On 06/05/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s personal laundry is washed once a week and linen is washed 1 once a week. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and stated that not all residents are provided with laundry services, however, residents who have laundry services included in their admission agreement are provided with laundry services once a week. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 3 of 10 residents interviewed denied the allegation above and reported that staff provide laundry services weekly, 4 of 10 residents interviewed reported ding laundry themselves, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/05/24 LPA reviewed R1’s admission agreement that states that R1’s laundry services are waived monthly as part of the assisted living waiver program. On 06/11/24 LPA reviewed laundry schedule for June 2024 that shows R1 will have laundry done on Saturday’s. On 6/11/24 LPA reviewed admission agreement page 3 letter B that states facility will launder towels and linens once a week, if a resident would like towels and linens to be laundered more frequently, facility will do so for an extra charge, as set forth in Appendix A. Allegation: Staff are not ensuring resident's room is cleaned It is being alleged staff are not cleaning R1’s bedroom. On 06/05/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above and reported that R1’s bedroom is cleaned daily and deep cleaned once a week per cleaning schedule. On 06/05/24 LPA interviewed S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and stated that resident bedrooms are cleaned every day. On 06/05/24 LPA interviewed R1-R10 regarding the allegation above, 7 of 10 residents interviewed denied the allegation above and reported that bedrooms are cleaned daily and deep cleaned once a week, 2 of 10 residents did not want to be interviewed. On 06/05/24 LPA was unable to conduct interview with R1 as R1 did not want to be interviewed. On 06/11/24 LPA reviewed admission agreement page 3 letter C which states facility will provide daily, light housekeeping services (bed making, trash removal, and general tidying) and deep clean weekly. If you, fail to do so, you understand that the facility may provide additional housekeeping services to your bedroom, and residents shall agree to pay for such services, as facility deem necessary. Facility will provide additional housekeeping services beyond the standard daily and weekly services for an additional fee, as described Appendix A. 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 with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240529134240

Allegation investigated: Staff did ensure universal precautions were taken.

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director Janie Acosta, as the purpose of the visit was explained. The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, kitchen menu for April 2024-June 2024, in-services for March 2024, April 2024 and May 2024, and serve safe food handling certifications for all kitchen staff. LPA Villegas conducted a tour of facility kitchen and dining room to observe cleaning procedures. LPA Villegas obtained the following for residents #1-3 (R1-R3); facesheet, physicians report, pre-appraisal, needs and service plan, admission agreement and MAR for the last two months. LPA also conducted interviews between 9:30am- 12:30pm, with ED, and staff # 1-6 (S1-S6), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#2-10 (R2-R10). On 06/13/24 at 10:10 am LPA Villegas interviewed Resident #1 (R1). The investigation revealed the following: Allegation: Staff did ensure universal precautions were taken Unsubstantiated It is being alleged that R1 became ill due to the food served at Vista Del Mar Senior Living. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated all kitchen staff is trained on and are implementing all universal precautions. ED continued to report that the food service director provides initial training as well as enrolls new staff in reliase training for ServSafe certification. On 06/05/24 LPA Villegas obtained copies and verified that all kitchen staff have active ServSafe and food handler certification. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S6 regarding the above allegation, 4 of 6 staff denied the allegation above and reported that all meals are fresh, there are no leftovers, temperatures are conducted daily, and that food quality checks are conducted daily. 2 of 6 staff reported not having any knowledge of the kitchen protocols. On 06/05/24 LPA Villegas toured facility kitchen with S1, LPA observed kitchen staff wash off dishes and utensils prior to placing them into the dish washer that provides sanitation. LPA Villegas observed all food stored in pantry to be dated and observed the refrigerator and freezer to have appropriate temperatures. LPA Villegas toured dinning room following lunch service and observed staff sanitizing all tables and chairs. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 2 of 10 residents interviewed refused to be interviewed, 7 of 10 residents interviewed denied the allegation above. The 7 of 10 residents interviewed stated they have not been sick due to the food provided at Vista Del Mar Senior Living. On 06/13/24 at 10:10 am LPA Villegas interviewed R1 regrading the allegation above, per R1 R1 went to the E.R. twice in May 2024 and was provided with Anti- Nausea, anti-diarrhea, and cepacol medication, and reports R1 has requested a no Mayonnaise diet moving forward. Based on observation, interviews, and records reviewed there is not enough evidence to support the allegation above. 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 with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240530104557

Allegation investigated: Staff did not seek medical attention for resident. Facilty staff failed to meet residents needs.

On 06/13/24 Licensing program analyst (LPA) Villegas conducted a subsequential complaint visit to render findings regarding the allegation(s) above. LPA met with Executive Director Janie Acosta, as the purpose of the visit was explained. The investigation consisted of the following: On 06/05/24 LPA Villegas obtained a copy of the following documents: staff and resident rosters, a list of all residents that require blood pressure checks (date: June 1st, 2024-June 5th, 2024), a list of residents that require blood glucose checks (updated 05/31/24). LPA obtained the following for resident #1 (R1) face-sheet (move in date: 03/14/24), physicians report (signed 03/12/24), pre-appraisal (signed 03/12/24), needs and service plan (signed on 03/20/24), admission agreement (signed 03/14/24), and MAR for months of April 2024-May 2024. LPA Villegas obtained the following resident #2 (R2) face-sheet (move in date: 07/19/22), physicians report (signed 11/16/23), pre-appraisal (signed 07/16/22), needs and service plan (signed on 08/14/23), admission agreement (signed 07/14/22), MAR for month of May 2024, and physician’s orders for May 2024-June 2024. On 06/05/24 LPA Villegas also conducted interviews between 9:30am- 12:30pm, with ED, Unsubstantiated and staff # 1-5 (S1-S5), LPA conducted a medication review for Residents #1-2 (R1-R2), LPA Villegas conducted interviews between 12:30pm-2:30pm with R#1-10 (R1-R10). The investigation revealed the following: Allegation: Staff did not seek medical attention for resident. The details of the complaint allegation alleged that facility staff failed to obtain R1’s medication prescribed by Kaiser psychiatrist. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that med room staff were unable to administer R1’s medication as R1 is obtaining medication from Kaiser pharmacy and Kaiser pharmacy had not delivered the medication when requested by R1. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that when an outside pharmacy is used medication refills are ordered 7 days prior to the medication running out. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 8 of 10 residents denied the allegation above and reported receiving medication daily and have not run out of meds. 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA Villegas conducted (2) medication reviews and did not observe any discrepancies. Allegation: Facility staff failed to meet resident’s needs. It is being alleged that the facilities med room staff failed to monitor R1’s blood pressure. On 06/05/24 LPA Villegas interviewed ED regarding the allegation above, ED denied the allegation above and stated that R1 does not have a doctor’s order for blood pressure checks. On 06/05/24 between 9:30am- 12:30pm, LPA Villegas interviewed S1-S5 regarding the above allegation, 5 of 5 staff denied the allegation above and stated that R1 does not have an order for blood pressure checks, however med room staff have been conducting blood pressure checks when it is requested by R1. On 06/05/24 between 12:30pm-2:30pm LPA Villegas interviewed R1-R10 regarding the allegation above, 5 of 10 residents interviewed denied the allegation above and reported med room staff conducted blood pressure checks daily, 3 of 10 residents interviewed reported not requiring blood pressure checks, 2 of 10 residents did not wish to be interviewed. On 06/05/24 LPA reviewed R1’s MAR for the months of April 2024 and May 2024 and did not observe a doctor’s orders for blood pressure checks. Based on interviews and records reviewed there is not enough evidence to support the allegation above. 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 with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240530110920

Allegation investigated: Staff did not provide resident an admission agreement. Staff did not pick resident up after a medical appointment. Staff prohibit resident form eating in their room.

On 06/13/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an initial 10-day visit regarding the complaint allegations above. LPA met with Resident Care Director Sidonis Cordis in the purpose of today’s visit was explained. later was joined by Executive Director Janie Acosta. The investigation consisted of the following: On 06/13/2024, LPA interviewed the Resident Care Director, staff #1-5 (S1-S5), Resident #1-5 (R1-R5). LPA obtained copies of the following: staff and resident roster, as well as the following documents for R1, R2, R3, R4 and R5, face sheet, admission agreement, pre-placement appraisal, physicians report, needs and service plan. Unsubstantiated Allegation 1- Staff did not provide resident an Admission Agreement. It is being alleged that staff did not provide resident with an admission agreement since R1 moved to the facility on 05/31/24. On 06/13/24 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility provides its clients with a copy of their admission agreement. If the client would like to have a copy of their admission agreement, they would only come to the office, and ask the staff, to make them a copy, from their client file. Sometimes client may ask for other items on their file, as they may need some for banking, social security, and medical. The staff in the office are available to assist the clients with whatever paperwork they need. LPA obtained a copy of the admission agreement for R1 upon reviewing the admission agreement, LPA discovered that the resident R1 signed the admission agreement on 05/31/24. LPA interview 5 residents (R1-R5) 4 out of 5 stated that the facility did let them sign the admission agreement and they told them if they need a copy they could come and get it in the office. LPA interviewed R1, client R1 stated that R1 don’t have any knowledge ever signing the form, but the admission agreement for resident R1 had the resident signature on it. Based on the records review and interviews there is insufficient evidence to support the allegation. 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 found to be unsubstantiated. Allegation 2 - Staff did not pick up resident up after a medical appointment. It is being alleged that staff did not pick up resident after a medical appointment. Interviews were conducted with staff 1-2 (S1-S2), and residents 1-5 (R1-R5). LPA asked all residents, “Do you receive help with transportation when you need it?”, 4 out of 5 residents stated, “Yes”, Administrator does assist in transportation needs. LPA noted that Resident Care Director RCD stated that the facility offers to take residents to the appointments if requested and if they have issues with their schedule pick up. LPA interviewed five residents 4 out of 5 residents stated that they must schedule their medical appointment pick-up and drop-off in advance. The RCD noted that the insurance had already set up an arrangement for dialysis patients before they even move in. On 06/13/2024, during the review of the admission agreement in the section on transportation, stated that, “the facility would provide transportation to the nearest appropriate health facilities for medical and dental appointments, local destinations, banking, shopping, religious activities, and social services agencies.” There was no mention of transportation for dialysis patients. On 06/04/2024, ED stated that the facility staff helped some residents get to their medical appointment since their transportation's were running late, understanding that the residents, regular transportation BS and Access would bring them back to the facility if it were after 5:00 PM. Based on records review, interviews there is insufficient evidence to support the allegation. 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 found to be unsubstantiated. Allegation 3 - Staff prohibit resident from eating in their room. It is alleged that staff prohibit resident from eating in their room resulting of resident missing several meals. During the interviews with five residents (R1-R5) 5 out of 5 stated that they never had any problem eating inside their room unless the rooms are being repair or the caregiver is mopping the floor. Resident also stated that the facility allows them to come down and get their food and go back to their room and eat it. LPA interviews five staff (S1-S5) 5 out of 5 all stated that some residents want to eat outside or in their room to watch TV, this is their choice they have rights we have to obey them. During the facility tour, LPA observed the residents eating breakfast inside their rooms. LPA asked Executive Director ED about staff prohibit residents from eating breakfast inside their rooms. ED stated that we cannot control what the resident brings inside their room let alone their breakfast, lunch, and dinner. She also stated we encourage the resident to come to the dining room to eat with other residents is to help them interact with one an another. Based on the interviews and observation LPA could not to find evidence to support the allegation. 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, therefore the allegation is found to be unsubstantiated. No deficiencies cited. exit interview conducted a copy of the report was provide to Executive Director Janie Acostathe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 11-AS-20240606114646

Allegation investigated: Staff did not allow resident to use a doctor of their choice Staff did not provide resident medication as prescribed Staff do not treat resident with dignity or respect Staff do not respond in a timely manner to resident's call for assistance

Licensing Program Analyst (LPA) Sparkle Day conducted an “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,Administrator and the purpose of the visit was discussed. The investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1) file, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs from March 2024 to May 2024 and Face sheet . LPA interviewed the following: Staff# 1-S6 and Resident #1-6. The investigation revealed the following: Allegation: STAFF DID NOT ALLOW RESIDENT TO USE A DOCTOR OF THEIR CHOICE It is alleged that facility staff did not allow resident to choose her own doctor. Unsubstantiated On 6/5/24 at around 10:00am LPA interviewed S1 - S6 regarding the allegation. 6 out of 6 staff deny the allegations and stated when resident #1 came to the facility an in- house doctor was assigned to the resident, however Resident #1(R1) changed her doctor to a doctor of her choice which is a Kaiser physician On 6/5/24 at around 11:30 am LPA interviewed R1-R6. 5 of 6 residents informed LPA that they can choose the doctor that they like . On 6/5/24 at around 12:40pm . LPA interviewed R#1 who informed LPA that she changed her doctor when first came to Vista Del Mar. She changed from a In House doctor of the facility to a Kaiser physician. R#1 still has that Kaiser physician. LPA observed file, medication and appointments from Kaiser for R#1. Based upon this investigation, LPA finds that 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 Regarding Allegation - STAFF DID NOT PROVIDE RESIDENT MEDICATION AS PRESCRIBED It is alleged that facility staff do not dispense medications correct dosage as prescribed. On 6/5/24 at around 11:30am LPA interviewed the S1 - S5 regarding the allegation. 5 out of 5 staff deny the allegation Staff state the medication is given as listed on the Mars. LPA interviewed R1 who informed LPA of the following: The medication Clorazepam should be given 2 times a day. The medication Sulfurate should be given 5 times daily and the medication Miralax should be given morning and night. On 6/5/2024 during this visit LPA reviewed the Mars of Resident #1 (R1) from March 2024 , when R#1 was admitted (March 2024) to present June 2024 LPA found that the medication dosage is the same and has not changed since the admission of R#1. LPA interviewed R2-R6 all residents deny the allegation and states that their medication is given to them timely and as prescribed.. Based upon this investigation, LPA finds that 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 Regarding the Allegation - STAFF DO NOT TREAT RESIDENT WITH DIGNITY OR RESPECT It is alleged that staff do not treat resident with dignity or respect due to the staff do not allow residents to make jokes or use sarcasm . On 6/5/24 at around 1:15 pm LPA interviewed R#1 - R#7 . 6 of 7 residents were consistent in their statements that the facility staff treat them with dignity and respect without question. R#1 informed LPA that due to she said some curse words and staff seemed offended because staff put their hands to their mouth like they had never heard cures words she was not treated with dignity or respect. Based upon this investigation, LPA finds that 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 Regarding the Allegation: STAFF DO NOT RESPOND IN A TIMELY MANNER TO RESIDENTS CALL FOR ASSISTANCE It is alleged that on 6/3/24 residents push their call button and staff did not come. On 6/5/2024 LPA interviewed Staff #4-5 who were on duty 6/3/24. 2 of 2 staff denied the allegation. LPA reviewed the call list of 6/3/24 and 6/4/24 and observed that All buttons pushed between 6/3/24 and 6/4/2024 were answered timely. LPA observed that the call that took the longest time was 12 mins. A button was pushed at 6:09am and the call is reported as complete at 6:21am, meaning they answered and took care of the problem in that time. On 6/5/2024 LPA interviewed 6 residents. 5 of 6 residents were consistent in their statements that the staff respond timely to their calls. Staff state their goal is 10 mins. Based upon this investigation, LPA finds that 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 . A copy of this report was left with the Administrator Janie Acostathe state’s words, verbatim · CDSS document, Jun 5, 2024 · control 11-AS-20240604111353

Allegation investigated: Questionable death. Resident fell while in care. Resident was left on floor for an extended period of time. Staff did not seek medical attention to resident. Staff mishandled resident's medications. Staff do not answer facility phone.

On 5/24/24, Licensing Program Analyst LPA Alfonso Iniguez conducted a subsequent complaint visit to deliver findings for the complaint assigned to LPA Calderon on 7/29/22. LPA Iniguez met with Janie Acosta/Executive Director and explained the purpose of the visit. During this investigation, LPA Calderon interviewed Resident (R1-R14), Administrator (A1), staff (S1-S5). These interviews were conducted on 05/05/2023 and 07/20/2023. On 07/20/2023 LPA Calderon obtained and reviewed the following: Needs and Service Plan (dated 06/08/2022), Pre-Placement Appraisal (dated 05/15/2022), Physicians Report (dated 03/29/2022), complaint form (dated 07/26/2022), Incident report (dated 07/16/2022 and 07/25/2022), Regal Specialty Pharmacy (dated 05/04/2022), Monterey wellness center (dated 05/11/2022) for R1. On 10/25/2022, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Ryan Philippe was assigned to this case. Investigator Philippe provided an IB report after concluding IB’s investigation which revealed the following: Evaluation Report continues LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation 1: Questionable death. This complaint alleged that (R1) death was questionable. On 10/25/2022, LPA Calderon reviewed the department's Investigation Branch (IB) Investigator Ryan Philippe's report. The investigator's report stated that interviews were conducted with witnesses and staff members. On 07/26/2022 at approximately 10:00 hours, In-Home support services (IHSS) staff stated that R1 was alive in the morning. That following afternoon, at approximately 12:45 hours, IHSS staff entered (R1)'s room and discovered (R1) sitting on the toilet with their pants down, "sitting sideways," (IHHS) staff managed to get (R1) upright. (IHSS) staff screamed for help, and facility staff responded immediately. Staff members began life preventative measures (CPR) and called 911. When 911 arrived, they took over the life-preventative measures for (R1). In the (R1)’s personal folder were orders of "Do Not Resuscitate" (DNR) dated 03/01/2022 signed by (R1) and R1's conservator as a witness." 911 stopped, and (R1) was pronounced dead at the scene. Long Beach Police Department (PD) DR#: 220036549 Officer J. Clark's #11410 observed R1's body and found no "bruising, injury, or other signs of foul play." (R1) had died of natural causes, according to (R1)'s conservator. Evaluation Report continues LIC 9099-C Allegation 2: Resident fell while in care. The complaint alleged that (R1) fell while in care. On 10/25/2022, LPA Calderon reviewed the department's Investigation Branch (IB) Investigator Ryan Philippe's report. The investigator's report stated that (R1), a resident in the assisted living of Vista Del Mar Senior Living, had an unwitnessed fall in (R1)'s room. Night shift staff asked (R1) how they got on the floor, and (R1) replied: "I fell on my buttock trying to get my dessert on the vanity." Staff assessed (R1) and found no visible signs of injuries. The internal incident report noted, "Please keep monitoring." Since (R1) was a resident in assisted living and did not need assistance with ADLs or mobility. LPA Calderon interview with Administrator: (A1). (A1) stated that residents fall due to age and health and that (R1) has fallen in the past. In addition, (A1) stated that facility staff helped (R1) and provided medical aid when they needed. LPA Calderon interviewed staff (S1-S5), (5) out of (5) stated that (R1) lives in the assisted living section of the facility and does fall due to age and health issues. LPA Calderon interviewed residents (R2-R14), (6) out of (13) stated that they have never fallen. Also, (4) out of (13) stated that they had fallen in the past, and facility staff were always quick to aid. LPA Calderon could not interview (R1), they had passed away. LPA Calderon reviewed the incident report (dated 07/25/2022), which stated that facility staff promptly found (R1) on the floor in their room. (R1), who had lost balance, was not injured, and got off the floor alone. Evaluation Report continues LIC 9099-C Allegation 3: Resident was left on the floor for an extended period. This complaint alleged that staff left (R1) on the floor for an extended period. LPA Calderon interviewed Administrator: (A1). A1 stated that facility staff did not leave any resident on the ground for an extended period unless there was a medical need not to move the resident. Also, (A1) stated that (R1) did fall to the floor in their room and was found by staff within 10 minutes of the fall. In addition, (A1) stated that facility staff checked on all residents per shift, and no resident in care had been left on the floor for an extended period. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that (R1) was checked regularly and was found on the floor on 7/25/2022. In addition, (5) out of (5) facility staff stated that 5 to 10 minutes went by until a staff found (R1) on the floor. Also, (5) out of (5) facility staff stated that no resident has been left on the floor for more than 5 minutes. LPA Calderon interviewed residents (R2-R6, R10, and R13), (13) out of (14) stated that they had fallen in the past, and on average, it takes 5 to 10 minutes for staff to help unless residents get off the floor on their own. LPA Calderon could not interview (R1), they had passed away. LPA Calderon reviewed the incident report (dated 07/25/2022). The report states that facility staff found (R1) on the floor in their room. (R1) lost balance and was not injured. (R1) got off the floor by themselves. In addition, LPA Calderon reviewed the preplacement appraisal (dated 05/15/2022); (R1) had health issues, was non-ambulatory, and needed assistance getting in and out of bed. Moreover, LPA Calderon reviewed (R1)’s needs and services plan (date 06/08/2022). (R1) had health issues and ambulated with a walker. Evaluation Report continues LIC 9099-C Allegation 4: Staff did not seek medical attention from residents. This complaint alleged that staff did not seek medical attention for (R1). LPA Calderon conducted an interview with Administrator (A1). (A1) stated that all facility staff had the authorization to call 911 if needed. Also, (A1) stated that facility staff are trained to call the RN or LVN for residents' medical needs and, if needed, to call 911. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that staff had called 911 in the past when a resident was not responding to urgent care provided. Also, (5) out of (5) facility staff stated that the facility offers additional training on calling 911, RN, or LVN. In addition, (5) out of (5) facility staff stated that (R1) was provided with the best care possible. LPA Calderon interviewed residents (R2-R14), and (13) out of (14) stated that the facility staff provides medical care to any resident who needs it. Also, (13) out of (13) residents stated that facility staff has called 911 for residents and facility staff acts quickly on residents' medical needs. LPA Calderon could not interview (R1), they had passed away. Evaluation Report continues LIC 9099-C Allegation 5: Staff mishandled residents’ medications. This complaint alleged that staff mishandled (R1) medications. LPA Calderon interviewed with Administrator (A1). (A1) stated that no medication errors had happened, but if they happen, corrections are addressed with additional staff training if a mistake is made. In addition, (A1) stated that the facility has new electronic Medication Administration Records (MARs). With these latest (MARs), facility staff could avoid making more mistakes on (R1) or other resident's medications. In addition, (A1) stated that all facility staff handling medications are provided with the necessary training. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that no medication errors were made, and in case they happened, facility staff addressed them and corrected the issue. In addition, (5) out of (5) facility staff stated that if an error is made, the error is reported to the RN or LVN, and the resident’s family is also informed. Also, (5) out of (5) facility staff stated that training is provided to all who handle residents’ medications. Moreover, (5) out of (5) facility staff stated that no errors were found regarding (R1) medications. Furthermore, (5) out of (5) facility staff stated that the new (MARs) are being used, and it is hard for any error to happen. LPA Calderon interviewed residents (R2-R14). (13) out of (14) stated that no medication errors have occurred with their medications. Also, (13) out of (13) residents stated that if a medication error is made, facility staff corrects the error. LPA Calderon could not interview (R1), they had passed away. LPA Calderon reviewed the Monterey Healthcare medication summary report (dated 05/11/2022) and observed (7) medications ordered by phone for (R1). Also, LPA Calderon reviewed the authorization from Regal Specialty Pharmacy (dated 05/04/2022) given to (R1)’s family to order their medications. LPA Calderon did not find discrepancies in (R1)’s medications. Evaluation Report continues LIC 9099-C Allegation 6: Staff do not answer facility phones. This complaint alleged that staff do not answer the facility call button when (R1) pushes the button. LPA Calderon interviewed with Administrator: (A1). (A1) stated that, on average, facility staff answers the call button within 10 to 15 minutes. In addition, (A1) stated that facility staff are trained to answer the call if they are near the resident’s room and push the call button. Also, (A1) stated that if a resident pushes the call button, the closest staff member will answer the call within 10 to 15 minutes. LPA Calderon interviewed facility staff (S1-S5), (5) out of (5) stated that when a resident pushes the call button, it takes, on average, 10 to 15 minutes for them to respond to the call.LPA Calderon interviewed residents (R2-R14), (13) out of (14) stated that when they push the call button, it takes 10 to 15 minutes for facility staff to answer the call. Also, (13) out of (13) residents stated that facility staff promptly answer the call button. In addition, (13) out of (13) residents stated that they have no problems with the services provided by facility staff. LPA Calderon could not interview (R1), they had passed away. During this investigation, LPA did not find sufficient evidence to support the above allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Janie Acosta /Executive Director..the state’s words, verbatim · CDSS document, May 24, 2024 · control 11-AS-20220729081919

Type of visit: Case Management - Other

On 5/ 24/ 2024, Licensing Program Analyst-LPA Alfonso Iniguez conducted a Case Management visit during a subsequent complaint visit. LPA Iniguez meet with Janie Acosta/Executive Director and explained the purpose of the visit. LPA Iniguez cleared Plan of Correction (POC) from complaint 11-AS-20220718085319. Executive Director sent proof of correction to LPA before POC due date. A copy of Letter of Deficiency Citations Cleared was given to Janie Acosta/Executive Director. LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Janie Acosta/Executive Director.the state’s words, verbatim · CDSS document, May 24, 2024

Allegation investigated: Resident sustained multiple pressure injuries while in care

This is an amendment of the report dated 05/22/2024. On 5/22/24, the Community Care Licensing Department (CCLD) conducted a subsequent unannounced complaint visit to deliver the complaint investigation findings. Upon arrival, CCLD staff was greeted by the administrator Janie Acosta, and the purpose of his visit was explained. CCLD staff and administrator conducted a health and safety check of facility. The investigation consisted of the following. On 07/19/2022 CCLD initiated a complaint investigation and toured the facility including all common areas, kitchen, dining room. Copies of the following records were requested: Staff and Resident Roster, SIR reports for current complaint, physician report, needs and service plan, home health care plan Kindred Paramount Hospital medical records, College Medical Center of Long Beach medical records, doctors’ orders for R1. On 07/21/2022, the Department interviewed staff and residents. On 05/22/2022 the Department conducted a subsequent complaint investigation and delivered the initial complaint investigation findings. On 06/02/2024 the Department conducted a review of the complaint investigation. Unsubstantiated The investigation revealed the following. Regarding the allegation “Resident sustained multiple pressure injuries while in care.” It is being alleged that resident R1 developed stage 3 and/or stage 4 Pressure Injuries while in care. The Department reviewed R1’s records, home health records and hospital records,and records indicate that R1 did not develop a stage 3 or 4 pressure injuries while in care and during R1’s hospitalization on 06/29/2022. Home Health Records indicate that R1 was being provided wound care for an unrelated injury between 04/22/2022 and 06/27/2022. Hospital Medical Records indicates that during R1’s hospitalization on 06/29/2022 the hospital wound care nurse assessed that R1 had a wound indicative of a stage 2 pressure injury, there was no documented evidence that R1 had a stage 3 or 4 pressure injury prior to R1’s admission at College Medical Center. Hospital Medical records also indicates that R1 was discharged from College Medical Center and admitted to Kindred Paramount Hospital on 07/14/2024. On 07/15/2024 Kindred Paramount Hospital staff diagnosed R1 with multiple unstageable injuries on R1’s back. Interviews revealed the following: R1’s unrelated wounds were healed and R1 was cleared by home health before R1 was sent to College Medical Center. 7 out of 7 staff indicate that R1 did not have a pressure injury prior to being admitted to the hospital. Staff denied the allegation and reiterated that they would have seen R1’s lower back area several times per day. Staff indicated that a home health nurse was treating wounds on the front of R1 upper thigh and R1 skin area. S3 performed diaper changes on R1, and this involved repositioning R1, cleaning and drying R1. S3 did not see any skin breakdown for R1. Based on interviews and record reviews, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation “Resident sustained multiple pressure injuries while in care”, is found to be UNSUBSTANTIATED. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2024 · control 11-AS-20220718085319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: May 23, 2024

87615(a)(1)Persons who require health services for or have a health condition including, but not limited to...Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by: Based on records review and interviews conducted the facility retained resident 1 despite being informed by the home health agency that the resident had pressure injury. This poses a health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee/Administrator will ensure to comply and review Title 22 Regulations, Section 87615 (a)(1) Prohibited Health Condition and create a plan of correction (POC) to ensure to stay in constant communication with medical professionals and if the resident’s medical condition elevates, meaning they require a higher level of care, Licensee/Administrator will ensure the resident is relocated to a skilled- nursing facility(SNF) or hospital and the relocation will take place immediately. Licensee/Administrator agreed to submit a verification of completion to CCLD/ El Segundo ASC office no later than 5/23/24.

Allegation investigated: Staff did not ensure prescribed medical equipment was provided to resident in care.

On 5/15/24 at 1:15 pm, Licensing Program Analyst (LPA) Sparkle Day conducted the initial Complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,(Resident care Director) who assisted with the visit. Todays investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1)- (R#10) files, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs and Face sheet . LPA interviewed the following: Staff #1-S#4 and witness #1(W-1.). LPA attempted to interview Resident #1 (R1) but R1 refused to be interviewed. The investigation revealed the following: Allegation: STAFF DID NOT ENSURE PRESCRIBED MEDICAL EQUIPMENT WAS PROVIDED TO RESIDENT IN CARE Unsubstantiated It is alleged that facility staff has orders to get resident #1 a medical bed, but has not done so. On 5/15/24 at around 1:45pm LPA interviewed (S1-(S3) regarding the allegation, 3 of 3 staff interviewed denied the allegation and stated resident #1 did not come to the facility with an order for a hospital bed. On 5/15/24 LPA interviewed witness #1 (W1), 1 of 1 witnesses interviewed denied the allegation that there was no hospital bed prescription for a resident #1. On 5/15/24, LPA conducted a file review of Resident #1 filed and did not observed any prescription for a hospital bed dated priori to R1 admission to the facility. On 5/15/24, LPA was unable to interview R1 since R1 refused to be interviewed. Based upon this investigation, LPA finds that 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 An exit interview was conducted and a copy of this report was left with the Executive Directorthe state’s words, verbatim · CDSS document, May 15, 2024 · control 11-AS-20240508145728

Allegation investigated: Staff did not assist resident with obtaining prescribed medication Staff did not administer resident's medication as prescribed

On 5/15/24 at 10:24 am, Licensing Program Analyst (LPA) Sparkle Day conducted the initial10 day Complaint visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1,(Resident care Director), S#2(Health Services Director) and S#3(Executive Director) who assisted with the visit. Todays investigation consisted of the following: LPA Day obtained copies of the facility's roster for residents and staff. LPA reviewed (R#1) - (R#10) files, including Physicians Report , Admission Agreement , Appraisal/Needs and Service Plan, MARs and Face sheet . LPA interviewed the following: R1- R8, Staff 1-S7 and witness #1(W-1). The investigation revealed the following: Allegation: STAFF DID NOT ASSIST RESIDENT WITH OBTAINING PRESCRIBED MEDICATION t is alleged that facility staff did not order a medication for resident and facility staff refused to pick up the medication. Unsubstantiated On 5/15/24 at around 10:40am LPA interviewed the Executive Director and Health Services Director regarding the allegation, Executive Director and Health Services Director denied the allegations and stated when resident #1 came to the facility an in- house doctor was assigned to the resident so that so that the previous medication that was being given to resident 1 could continue. Health Services Director explained due to medication being considered a controlled substance it could not follow resident #1 from last placement. The exact date is not known but shortly after Resident #1 switched health care to Kaiser without the knowledge of any of Vista Del Mar staff until they were requesting the medication. Staff were told that resident 1 was not a patient of theirs and would not be refilling the medication. Staff were not able to get medication from their pharmacy. Staff 3 (Health Director ) then called Kaiser for medication and was told, due to medication being a control substance the resident would have to be seen before medication refilled. On 5/15/24 between 11:45am - 1:00pm LPA interviewed 9 of 10 residents who were consistent in their statements that the facility staff has assisted with obtaining their medications regularly without failure. On 5/15/23, LPA interviewed Staff 1-S7 regarding the allegation. 7 of 7 staff interviewed denied the allegation. LPA conducted a file review and information obtained wad consistent with Facility staff interviews. Based upon this investigation, LPA finds that 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 Regarding Allegation - STAFF DID NOT ADMINISTER RESIDENT'S MEDICATION AS PRESCRIBED It is alleged that facility staff do not dispense medication on a timely basis. This medication is supposed to be dispensed one hour before meals and it’s dispensed during or after meals. On 5/15/24 at around 11:30am LPA interviewed the Med Tech Supervisor(S4) regarding the allegation ,S4 denied the allegation and stated resident 1 has a medication that is to be given an hour before dinner, however although staff is there to give it on time, there are times when the medication is refused by resident 1 and the Mars is the receipt of the days refused. On 5/15/24 around 11:45 am LPA interviewed 6 of 6 staff regarding the allegation. 6 of 6 staff denied the allegation. On 5/15/24 during this visit LPA Day observed The MARs of Resident 1 were resident #1 refused timely medication seven (7) times. Based upon this investigation, LPA finds that 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 An exit interview was conducted a copy of this report was left with the Executive Director.the state’s words, verbatim · CDSS document, May 15, 2024 · control 11-AS-20240507095441

Allegation investigated: Facility is in disrepair. Staff did not administer resident's medication as prescribed. Staff do not treat residents with respect. Staff do not assist residents in a timely manner. Staff cannot communicate effectively with residents due to language barrier.

On 04/11/2024 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to Vista Del Mar Senior Living to deliver the investigation findings for the allegations listed above. LPA Calderon met with Administrator Janie Acosta (A1) and the purpose of the visit was explained. During this investigation, LPA Calderon interviewed Residents (R1-R10), Administrator (A1), staff (S1-S6). These interviews were conducted on 04/10/2024. On 04/10/2024 LPA Calderon obtained copies of the following: Staff training from Regal Specialty Pharmacy (date 01/19/2023), Email from DBA Glass Land (date 03/14/2024) for door replacement, Invoice from DBA Glass Land (date 04/10/2024) for door replacement, Relias training for staff (date 02/25/2023), In-service training (date 03/06/2024 and 03/13/2024) for entering resident rooms and answering call buttons. LPA Calderon toured the facility grounds with A1 and entered rooms 263, 292, 304, 306, 315 and 316. The investigation revealed the following: Unsubstantiated Allegation 1: Facility is in disrepair. This complaint alleged that facility front door is damaged. LPA Calderon conducted an interview with A1. A1 states that a resident struck the front door to the facility with a wheelchair damaging the front door. A1 states that there was no safety issues and staff boarded up the door for safety issues. A1 states that staff and guests to use the front door damaged and A1 ordered a new door and glass. A1 states that the front door was damaged for 3 weeks and repaired on 04/10/2024. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that the front door was damaged by a resident wheelchair and was not a safety issue for residents. 6 out of 6 staff state that the front door was damaged for 3 weeks and repaired on 04/10/2024. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 residents state that the front door has been damaged for 3 weeks and was not a safety issue. 9 out of 10 residents state that staff maintain the facility and the facility is not in disrepair. On 04/10/2024 LPA Calderon reviewed email from DBA Glass Land (date 03/14/2024). Emailed noted that staff was given a quote for $10,000 dollars to replace the front door. LPA Calderon reviewed quote from DBA Glass Land (date 04/10/2024) for glass replacement. LPA Calderon and A1 toured the facility. LPA Calderon noted that staff and vendor were working on the facility front door. LPA Calderon toured the facility common area, and the facility was not in disrepair. LPA Calderon inspected room 263, 292, 304,306, 315 and 316 and there were no issues with the residents’ rooms. Allegation 2: Staff did not administer residents’ medication as prescribed. This complaint alleged that staff did not advise resident about medications taken. LPA Calderon conducted an interview with A1. A1 states that staff are trained to advise residents regarding the medications given. A1 states that staff must advise residents regarding medications given. LPA Calderon conducted an interview with staff (S1-S6). S3 and S5 (Med tecks) state that they always advise resident the name of the medications they are giving to the residents. S3 and S5 state that staff are given training on how to give medications to residents in care, LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 residents state that the Med-tecks always advise them of the medications they are taking. 9 out of 10 residents state that they know the name of the medications they are taking and what the pills look like prior to taking the medications. Reviewed training from Relias Company and Regal specialty pharmacy regarding medication management medication review. Allegation 3: Staff do not treat residents with respect. This complaint alleged that staff do not knock on resident room door prior to entering. LPA Calderon conducted an interview with A1. A1 states that all staff are given training on how to enter a resident’s room. A1 states that staff are trained to knock 4 times and to advise the resident why they are coming inside the room. A1 states that R1 shares the room with another resident and may have been confused as to why the staff entered the room. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that they always knock on resident’s front door prior to entering and 6 out of 6 staff state that staff always advise residents why they are entering the room. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 resident states that staff always knock on the front door prior to entering and 9 out of 10 residents state that staff always treat them with respect. LPA Calderon reviewed In-Service training (date 3/6/2024 and 03/13/2024). Training provided to all staff on being respectful and the proper way to enter a resident room. LPA Calderon toured the facility with Administrator and staff. Staff knocked on front doors to 263, 292, 304, 306, 315 and 316. Staff knocked and advised why they were entering the resident room. Allegation 4: Staff do not assist residents in a timely manner. This complaint alleged that staff do not answer call button when pressed by residents. LPA Calderon conducted an interview with A1. A1 states that staff are given training on what to do if a resident pushes the call button for help. A1 states that staff do answer call buttons every day and on average it takes 5 to 10 minutes to answer the call. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state that they are given training on what to do if a resident pushes the call button for help. 6 out of 6 staff state that normally it takes staff 5 to 10 minutes to answer a resident call button for help. LPA Calderon conducted an interview with residents (R1-R10). 9 out of 10 resident states that when they push the call button for help it takes staff 5 to 10 minutes to respond to their call for help. LPA Calderon reviewed In-service training (date 03/06/2024 and 03/13/2024) regarding how to respond to a resident call for help. LPA Calderon toured the facility with A1. LPA Calderon entered rooms 263, 292, 304, 306, 315 and 316. LPA Calderon pushed the room call button and average response from staff was 2 to 6 minutes. Allegation 5: Staff cannot communicate effectively with residents due to language barrier. This complaint alleged that staff do not speak to resident in English. LPA Calderon conducted an interview with A1. A1 states that all A1 staff first language is not English. A1 states that all A1 staff can communicate in English and if not can find a staff member that can communicate with the residents. A1 states that if a staff member can not find a way to communicate with residents, they may not have a job. A1 states that it is normal for staff to speak to each other in a language other than English. LPA Calderon conducted an interview with staff (S1-S6). 6 out of 6 staff state they have no issues communicating in English and 6 out of 6 staff state that they have no issues speaking to residents in care. LPA Calderon noted 1 out of 6 staff that LPA Calderon spoke to the staff member in Spanish, but the staff did understand English and spoke some English. LPA Calderon conducted an interview with residents (R1-R10). 8 out of 10 resident state to have no communications issues with staff and can speak to staff in English. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility is in disrepair”. “Staff did not administer resident's medication as prescribed”. “Staff do not treat residents with respect”. “Staff do not assist residents in a timely manner”. “Staff cannot communicate effectively with residents due to language barrier” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Janie Acosta (A1).the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 11-AS-20240404170613

Allegation investigated: Staff neglected resident resulting in dehydration.

On 04/09/24, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Janie Acosta, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). Resident Roster, Staff Roster, ID/Emergency Information, Physicians Report, Unusual Incident Report, & Needs and Service Plan for R1 were obtained from the facility. The investigation revealed the following: Allegation #1- Staff neglected resident resulting in dehydration. Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that the facility was not monitoring R1’s fluid intake causing R1 to be dehydrated. On 04/09/24, from 10:00am-01:00pm, LPA interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. R1 could not be interviewed because R1 was in the hospital, however LPA did interview R1’s family member. 5 of 5 staff denied the allegation that the Staff neglected resident resulting in dehydration. All staff (S1-S5) stated that they did not neglect R1 in any way. They stated that R1 would get fluids with each of R1’s three meals and that R1 had about six cases of water in R1’s room, that was not restricted in any way. S1-S5 stated that R1 was an independent resident and could eat and drink by R1’s self. They further stated that R1 would get monitored throughout the day and that R1 seemed to be doing okay, until one day R1 seemed to have confusion and was lethargic; 911 was called on 03/25/24 and R1 was admitted to the hospital. S3 stated that R1 was very independent and did not want to be bothered but whenever S3 would take R1’s food and drink, R1 would eat and drink and did not seem to have any issues. R1’s family member stated that R1 was dehydrated and was malnourished when R1 entered the hospital and was not sure if staff were monitoring R1’s food and water intake. LPA took a tour of R1’s room and observed that the resident had six cases of water and several bags of empty water bottles in R1’s room. LPA interviewed residents R1-R10 about the allegation that Staff neglected resident resulting in dehydration. 9 of 10 residents that were interviewed denied the allegation and stated that the staff gives them enough food and fluids throughout the day and that they are happy with their care and supervision provided by the staff. Based on interviews, there is insufficient evidence to support the allegation that the Staff neglected resident resulting in dehydration. 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 with Janie Acosta, Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 11-AS-20240403154839

Allegation investigated: Resident sustained multiple injuries while in care. Facility staff are not properly trained Facility vehicle is not in good repair

“This is an amendment of the Investigation Report (LIC9099) dated 04/04/2024, the purpose of this amendment is to provide additional information that this report supersedes the LIC9099 dated 05/03/2024.” On 04/04/2024 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to Vista Del Mar Senior Living to deliver the investigation findings for the allegations listed above. LPA Calderon met with Administrator Janie Acosta (A1) and the purpose of the visit was explained. During this investigation, LPA Calderon interviewed Residents (R2-R12), Administrator (A1), staff (S1-S5). These interviews were conducted on 12/13/2021 and 03/30/2023. On 12/13/2021 LPA Calderon obtained copies of the following: Needs and Service Plan (dated 09/03/2021), Pre-Placement Appraisal (03/18/2018), Physicians Report (02/02/2018), hospital records (dated 03/22/2021), Incident report (dated 03/21/2021) for R1. LPA obtained vehicle maintenance record (dated 10/14/2021), driver D1 driving records (dated 03/02/2021). Unsubstantiated The investigation revealed the following: Allegation 1: Resident sustained multiple injuries while in care. On 12/7/2023, the allegation “Resident sustained multiple injuries while in care” was assigned to Investigator Peter Zertuche with the Department of Social Services Investigation Branch. Investigator Zertuche provided an investigation report to the El Segundo Regional office on 01/25/2022. Investigator Zertuche’s report conclusion states, on 3/23/2021, R1 fell off R1’s wheelchair while being transported to R1 doctors' appointment. Interviews corroborated that R1 seatbelt was not properly secured during transport, which resulted in a fall when facility driver S5 “slammed” on the brakes at a yellow light. R1 attended the scheduled doctor appointment after the fall and a full examination was conducted. According to medical records, no serious injuries were found. A minor abrasion on the left knee was reported only. A follow-up doctor appointment for x-rays was scheduled for R1 on 3/25/2021, and no injuries were found on any part of R1’s body according to x-ray images reported in R1’s medical records. Investigator Zertuche conducted an interview with R1 who confirmed falling out of R1’s wheelchair during transit on 3/23/2021; however, R1 reported feeling “ok” and did not report that injuries were sustained as a result of the fall. Investigator Zertuche conducted an interview with S5, who confirmed not properly securing R1’s seatbelt and R1 fell out of R1’s wheelchair when S5 had to brake at a light on 3/23/2021. S5 observed R1 for injuries after R1’s fall and found R1 had a knee scrape and no other visible injuries. Based on interviews conducted, observations, and records reviewed, Investigator Zertuche was unable to find sufficient evidence to support “Resident sustained multiple injuries while in care”. Allegation 2: Facility staff are not properly trained This complaint alleged that staff are not trained in how to transport residents in the facility van. LPA Calderon conducted an interview with A1. A1 states that A1 facility drivers have been trained on how to properly transport residents in the facility van. A1 states that S3 is the facilities primary driver and when S3 is out, S5 is a back-up drive. LPA Calderon conducted an interview with S5, who states that S5 was provided training on how to properly transport residents in the facility van by management and the facility primary driver S3. S3 states S3 receives transportation safety training by an outside vendor. S3 then provides training to S5 the back-up driver. On 12/13/2021, LPA Calderon reviewed driving records and confirmed that S5 has a clean driving record and has been with the facility for over 10 years and no personnel issues on record. LPA Calderon conducted an interview with R2 -R13 for complaint. 12 out of 13 residents state that residents have been transported by facility staff in the company van and that all residents were secured with a seatbelt. Based on interviews conducted, observations, and records reviewed, LPA Calderon was unable to find sufficient evidence to support “Facility staff are not properly trained”. Allegation 3: Facility vehicle is not in good repair. This complaint alleged that the facility vehicle is not maintained by mechanic. LPA Calderon conducted an interview with A1 who states that all facilities vehicles are given maintenance by third party vendors and the breaks are checked to make sure they are in good working order and all other vehicle services are done monthly to make sure the facility vehicles are in good working order. LPA Calderon conducted an interview with S3 and S5. S3 and S5 state that the facility van has been serviced and had new brakes and tires prior to the accident. S3 and S5 state that the facility van was in working order and the incident did not happen due to vehicle failure. On 12/13/2021 LPA Calderon reviewed Jiffy Lube (10/14/2021) records for facility van and noted that the facility van has been serviced and was in good repair prior to the incident. 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: "Resident sustained multiple injuries while in care", "facility staff are not properly trained", and "faculty vehicle is not in good repair'' did or did not occur, are unsubstantiated. An exit interview was conducted with Administrator Janie Acosta (A1), and a hard copy providedthe state’s words, verbatim · CDSS document, Apr 4, 2024 · control 11-AS-20211207093606

Allegation investigated: Resident sustained a pressure injury while in care Staff left resident in soiled diaper for extended period of time Facility has roaches

On 05/04/2023 Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Janie Acosta with Vista Del Mar Senior Living and the purpose of the visit was explained. During this investigation, LPA Calderon interviewed Administrator (A1), residents (R1-R20), staff (S1-S7). These interviews were conducted on 01/25/2023. On 08/31/2021 LPA Calderon obtained copies of Staff and Resident rosters, Medication Administration Records (MAR) (08/17/2021), Needs and Service plan (01/20/2021), Physician Report (02/09/2021) for R1 and pest control invoices (June to August 2021) for facility. On 8/31/21, Community Care Licensing Investigation Branch (IB) confirmed participation in this investigation and Investigator Peter Zertuche was assigned to this case. On 10/07/2021 Investigator Zertuche provided an IB report after concluding IB’s investigation. The investigation revealed the following: Substantiated Allegation #1: Resident sustained a pressure injury while in care. This complaint alleges that R1 sustained a pressure injury while in care: the investigation revealed that Resident #1 formed a Stage III pressure injury on its coccyx beginning 08/23/21; and it quickly progressed to Stage IV by 09/02/21. Resident #1 had been receiving hospice care since 03/03/21 for an unrelated issue. Facility staff were instructed to reposition Resident #1 every two (2) hours due to the resident’s status of Bedridden. The wound worsened over the next week – while the resident continued to reside in the facility – with no new hospice care plan or wound training. The facility was directed to reposition Resident #1 every two (2) hours; but according to Witness #1 (Hospice Care Nurse), the reposition chart was not being followed; and, it had missing initials in spaces where the resident was supposed to be turned and its pressure injury was listed as Stage IV by 09/02/21. Resident #1’s health was in decline and the facility continued to retain Resident #1 with a prohibited health condition until its passing on 09/03/21. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Allegation #2: Facility has roaches. This complaint alleges that the facility has roaches. LPA Calderon conducted an interview with A1. A1 expresses that residents have advised that there are roaches in certain rooms. A1 expresses that staff sprays certain rooms, and that pest control is called, and pest control company sprays the building and rooms for roaches and other bugs. LPA Calderon conducted an interview with S2-S7. S5, S6 and S7 have seen roaches in the building but expressed that pest control comes monthly and sprays for roaches. LPA Calderon conducted an interview with R1-R20. R2, R7 and R10 have seen roaches in their room. Residents called staff and pest control came out and sprayed their rooms. R1 and R13 have seen roaches in the dining room while eating food. Pest control came out and when the dining room was closed sprayed the dining room area. R4 states that R4 noted seeing roaches in the patio area. On 01/25/2023 LPA Calderon reviewed pest control paperwork that stated that pest control company sprayed roaches in the facility. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION: Resident sustained a pressure injury while in care is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Allegation 3: Staff left resident in soiled diaper for extended period. This complaint alleges R1 diaper was not changed timely. LPA Calderon conducted an interview with A1. A1 expressed that R1’s incontinence care occurred 3 times per shift. A1 was unable to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. R1 was receiving hospice care for the pressure ulcer and pre-existing health condition; however, the facility failed to update the hospice care plan to reflect incontinence needs. LPA Calderon was unable to obtain documented incontinence care instructions and staff training for R1’s incontinence care. Based on interviews conducted and lack of records provided to support R1’s incontinence needs were met according to Hospice orders, LPA Calderon found sufficient evidence to support the above-mentioned allegation and finds this allegation “Substantiated”. Based on interviews, observations and supporting documents facility staff failed to ensure a physicians order/hospice care plan were in place to address R1 pressure injury by an appropriate skilled medical professional The preponderance of evidence standard has been met; therefore, the allegation of “resident sustained a pressure injury while in care” and “facility has roaches”, “Staff left resident in soiled diaper for extended period”, is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiency has been observed and citations issued (ref LIC9099D) A face-to-face meeting was conducted with Administrator Janie Acosta, and a hard copy was provided. Allegation #1: Staff did not administer the correct medication dosage to residents. This complaint alleges the facility failed to increase R1 medication dosage per a physician’s order. LPA Calderon conducted an interview with Janie Acosta (A1). A1 stated R1’s medications were administered per doctors’ orders. LPA Calderon obtained and reviewed R1’s Medication Administration Record (MAR) and found 7 out of 8 medications were not administered on 08/25/21 and 08/26/21. LPA Calderon was unable to find or obtain a record of a doctor’s order indicating a change in any of the medication dosages. LPA obtained and reviewed a PRN Authorization Letter dated 2/9/21 and signed by the Hospice Medical Director. The PRN Authorization Letter states Hydrocodone Bitartrate and Loperamide can be taken added to R1’s PRN’s. These medications were found in the PRN section on R1’s MAR. LPA Calderon conducted an interview with 3 Staff members who handle Resident medications. LPA Calderon conducted interviews with 6 staff members. LPA found 6 out of 6 staff members did not report medication dosage issues. LPA Calderon conducted an interview with 20 Residents. LPA Calderon found 3 out of 20 Residents stated having experienced issues with medication administered; however, corrections were made, and issues resolved by the facility. LPA Calderon found 17 out of 20 Residents have not experienced issues with medication administered. Based on records obtained and interviews conducted, LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”. Allegation #2: Staff leave food in residents’ room for extended period. This complaint alleges that staff leave food trays in R1’s room and this is contributing to a roach problem. LPA Calderon conducted an interview with A1 who expressed that R1 receives tray service for all meals as R1 is bedridden. A1 stated staff will retrieve the food tray 3 times per day from R1’s room. A1 stated that roaches have been present in the facility and pest control is employed for this reason. LPA Calderon conducted an interview with Staff S2-S7 and found 3 out of 6 staff expressed that some residents prefer to eat in their rooms and food trays are retrieved from the Resident rooms timely. S5-S7 expressed that S5-S7 follows up with dining staff to make sure food trays are picked up timely. LPA Calderon conducted interviews with Residents R2-R20 for complaint and found 19 out of 20 residents either received tray service and expressed tray pick-up occurred timely or eat meals in the facility dining room; therefore, they were unable to speak to the timeliness of tray retrieval by staff. , LPA Calderon was unable to find sufficient evidence to support the above-mentioned allegation and finds this allegation “Unsubstantiated”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations “staff did not administer the correct medication dosage to resident” “staff leave food in residents’ room for extended period” did or did not occur, therefore the allegations is UNSUBSTANTIATED. A face-to-face meeting was conducted with Administrator Janie Acosta A1, and a hard copy was provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 11-AS-20210831121113

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Mar 22, 2024

Prohibited Health Conditions (a) Persons who require health services or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by: Facility retained Resident #1 with a Stage IV pressure injury on its coccyx (a prohibited health condition) until the resident passed away on 09/03/21. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to care for resident with stage 3 and 4 pressure sores. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Licensee/Administrator agreed to comply and review Title 22 Regulation, Section 87466 ‘Prohibited Health Condition’ and create a plan of correction (POC) to ensure to stay in constant communication with the medical professional; and, if the resident's medical condition elevates - meaning they require a higher level of /21care, Licensee/Administrator will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immeLicensee/Administrator agreed to comply and review Title 22 Regulation, Section 87466 ‘Prohibited Health Condition’ and create a plan of correction (POC) to ensure to stay in constant communication with the medical professional; and, if the resident's medical condition elevates - meaning they require a higher level of /21care, Licensee/Administrator will ensure the resident is relocated to a skilled-nursing facility (SNF) or hospital; and, the relocation will take place immediately. Licensee/Administrator agreed to submit a verification of completion to CCLD/El Segundo ASC Office no later than 03/22/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 29, 2024

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair always… Based on records reviewed and interviews conducted, the licensee failed to control roaches inside the facility for residents in care. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The administrator will provide pest control reports for a 3-month period and log pest control reports to LPA Calderon by the due date of 03/29/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87612(a)(7) · Plan of correction due date: Mar 29, 2024

87612(a)(7) Restricted Health Conditions (a) The licensee may provide care for residents who have any of the following restricted health conditions, or who require any of the following health services: (7) Incontinence of bowel and/or bladder as specified in Section 87625. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to provide an incontinence care log to support dates and times incontinent care has been provided to R1. LPA found R1 was diagnosed with a stage 3 pressure ulcer on the coccyx on 8/23/21. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: The administrator will provide training to staff on how to document the incontinence log notes for residents in care by the due date of 03/29/2024.

Allegation investigated: Staff did not prevent a resident from assaulting another resident.

On 03/19/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/19/24 LPA interviewed ED, staff #1-5 (S1-S5), Resident #1-10 (R1-R10), and witness 1 (W1). LPA obtained copies of the following; staff and resident roster, as well as the following documents for R1 and R2; facesheet, admission agreement, preplacement appraisal, physicians report, needs and service plan, physicians orders and staff notes. The investigation revealed the following: Allegation- Staff did not prevent resident from physically assaulting another resident in care. It is being alleged that resident was assaulted by roommate while in care. On 03/19/24 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility is assessing Unsubstantiated residents, following up with psychiatrist, conduct room change, and continued monitoring of resident’s behaviors to ensure this type of situation does not occur. ED also reported this was the first incident involving R1 and R2 as there has been no history of aggression for neither resident while in care. On 03/19/24 LPA interviewed R1-R10, 8 of the 10 residents interviewed denied the allegation above and reported feeling safe and believe staff would assist if they were being assaulted. On 03/19/24 LPA interviewed R1 regarding the above allegation, R1 reported being pushed by R2 after a verbal confrontation over a remote control. On 03/19/24 LPA interviewed R2 regrading the above allegation, R2 denied the allegation above and reported R2 did not physically touch R1. R2 continued to report that both R2 and R1 were pulling on a remote control and when R2 let the remote control go R1 lost R1s balance and stumbled but R1 did not fall or obtain injury. On 03/19/24 LPA interviewed S1-S5 regarding the above allegation, 4 of 5 staff interviewed denied the above allegation. 4 of 5 staff reported residents are separated, residents are talked to, and residents are assessed and are offered activities. 1 of 5 staff interviewed reported witnessing the incident and was able to intervene, per staff residents were pulling the remote control back and forth from each other when staff asked R2 to stop, let the remote go, and let staff handle the situation. As R2 let the remote go it is being reported that R1 lost R1s balance and took a step back but did not fall nor obtained injury. On 03/19/24 LPA spoke to W1 regarding the allegation above, per W1 W1 was made aware of the incident and after receiving the information of incident W1 does not have any safety concerns regarding R1. On 03/19/24 LPA conducted a review of R1 and R2s file and did not observe any prior incidents involving R1 and R2. 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 with Executive director (ED) Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 11-AS-20240313095158

Allegation investigated: Staff is not preventing the spread of scabies Staff are not preventing resident from engaging in inappropriate behaviors

On 3/13/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted a subsequent unannounced complaint visit to the address listed above. LPA arrived at and spoke to Executive Director Janie Acosta and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 11/28/22 Pamela Bunker conducted an unnanounced visit and interviewed then Executive Director Reggie Jones. Due to insufficient information available at that time, a needs further investigation was done. On 2/29/24 LPA Felisa Shirley reviewed both Staff and Resident files and toured the facility. LPA requested and received copies of the following: ID and Emergency Information, Preplacement Appraisal Information, Admission Agreement, Appraisal/Needs and Services Plan, Physician’s Report, Incident reports, Assessments, and Response to Public Health notice. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff is not preventing the spread of scabies On 3/13/24 LPA Shirley reviewed resident’s files and incident reports. LPA observed 2 incident reports that were sent to CCLD for scabies. The first report indicated there to be one incident that occurred 6/9/22, reported 6/14/22. Assessment of all the residents in Memory care unit proved signs of possible scabies on a few other residents. The Physician was notified, the community was locked down and quarantined. All residents were treated for possible scabies. Family, POA and Public health were all notified. LPA observed the second report that indicated a scabies outbreak in Memory Care unit that occurred 3/28/23. Four residents were diagnosed and treated for scabies. Measures were put into place to help mitigate the spread and keep it contained. Families and public health were notified. LPA reviewed response from public health in which guidance on Outbreak Management was provided along with an attached Scabies Toolkit. On 2/29/24 LPA Shirley interviewed Staff 1 – Staff 10 (S1-S10). LPA asked, did residents in the Memory Care unit have scabies? Of those interviewed, 5 out of 10 answered yes. LPA asked residents, did you know about an outbreak of scabies. Of those interviewed, 10 out of 10 was not aware of an outbreak. Based on information gathered, the department did not find sufficient evidence to support allegation "Staff is not preventing the spread of scabies.” This facility was not negligent, residents were tested and public health was contacted as is protocol. 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: Staff are not preventing residents from engaging in inappropriate behaviors It was reported that a resident from the assisted living side of the facility digs in the trash and the dog disposal and takes things out the trash and touches things within the facility. On 3/13/24 LPA Shirley reviewed resident’s file, which included yearly Appraisal/Needs and services plans and assessments. Upon review of documents, LPA observed that R1 has had this behavior their whole life and that their behavior has been documented on several needs and services plans and also provided what precautions that the staff were taking. Resident was moved from the assisted living side and placed in the Memory Care Unit of this facility. Con'd on 9099-C On 2/29/24 LPA Shirley interviewed Staff 1 – Staff 10 (S1-S10). LPA asked, did a resident from the assisted living side dig in the trash every day which also contained a dog disposal in the trash can? Of those interviewed, 8 out of 10 answered yes. LPA asked residents, have you ever seen a resident that use to dig in the trash everyday? Of those interviewed, only 2 out of 10 remembered the incident and answered yes. Based on information gathered and interviews conducted, the department did not find sufficient evidence to support the allegation, staff are not preventing residents from engaging in inappropriate behaviors. 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. An exit interview was conducted and a copy of the LIC 9099 was provided to Executive Director Janie Acosta.the state’s words, verbatim · CDSS document, Mar 13, 2024 · control 11-AS-20221118101001

Allegation investigated: Facility staff are not dispensing medications as prescribed for resident. Facility staff are not providing meals for resident.

On 03/01/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained. The investigation consisted of the following: On 03/01/24 LPA obtained copies of staff and resident rosters, facility infection control plan, menu dated 10/30-12/03, a copy of assisted living isolation rooms, and the following documents for Resident #1 (R1); identification and emergency info. form, admission agreement, physicians report, needs and service paln, diet clarification request, and after visit summary. On 03/01/24 LPA interviewed Residents #1-09(R1-R09), Executive Director, staff #1- 7(S1-S7), and obtained copies of MAR for R10-R11. The investigation revealed the following: Allegation- Facility staff are not dispensing medications as prescribed for resident. Unsubstantiated It is being alleged that facility staff failed to dispense medication to residents while on quarantine for covid. On 03/01/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED, med techs administered medications in the room the residents were quarantined in while wearing full PPE. On 03/01/24 LPA interviewed S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above reporting med techs would administer medications in the quarantine room while wearing PPE. S1-S7 reported quarantine residents were checked on every two hours, however, residents were asked to use their call button when they needed any assistance. On 03/01/24 LPA interviewed R1-R9 regarding the allegation above, 8 of the 9 residents interviewed denied the allegation above stating medication was administered daily. 1 of the 9 residents interviewed reported never having covid. On 03/01/24 LPA conducted review of MAR for R10-R11 and did not observe any discrepancies. Allegation: Facility staff are not providing meals for resident. It is being alleged that the facility failed to provide residents with dinner while on quarantine for covid. On 03/01/24 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED, when a resident test positive for covid the resident is placed on the kitchens meal tray lists and kitchen staff will deliver the meal to residents door and caregivers will then provide the meal directly to the residents on quarantine. On 03/01/24 LPA interviewed S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above reporting that kitchen staff will bring residents tray to room door and the caregivers in full PPE will provide the tray directly to the residents. If a covid positive resident requires assistance with feeding, caregiver will assist in full PPE and discard PPE once feeding is completed. On 03/01/24 LPA interviewed R1-R9 regarding the allegation above, 8 of the 9 residents interviewed denied the allegation above stating 3 meals a day were provided in their quarentine bedrooms. 1 of the 9 residents interviewed reported never having covid or was placed in quarantine, however reports receiving 3 meals everyday. On 03/01/24 LPA reviewed facility menu and observed a variety of meals listed, LPA also observed lunch pass and observed residents being accommodated with different food options upon request. 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 with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 11-AS-20221123130647

Allegation investigated: Facility staff fails to change resident's diaper. Facility staff fails to re-position bedridden resident. Facility staff fails to provide resident with basic services.

On 02/01/24 at 09:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Resident care director (CD) Sidona Cordis as the purpose of today’s visit was explained. The investigation consisted of the following: On 02/01/24 LPA interviewed CD, staff #1-9 (S1-S9), residents #1-10 (R1-R10), and obtained the following copies of the staff and resident roster, and a document listing residents that require toileting assistance and residents who are on hospice. LPA obtained the following for R1 and R2; Face sheet, Emergency I.D., admission agreement, physicians report, physicians order, needs and service plan, preplacement appraisal. A copy of R1's repositioning log was provided as well as a copy of the daily room service log. The investigation revealed the following: Allegation: Facility staff fails to change resident's diaper. Unsubstantiated It is being alleged facility staff fails to change resident's diaper. On 02/01/24 LPA interviewed CD regarding the above allegation, CD denied the allegation stating residents are checked on and changed every 2 hours. CD added a change can occur before the 2 hour mark if a resident has an accident. On 02/01/24 LPA interviewed S1-S9 regarding the above allegation, 9 of 9 staff interviewed denied the allegation above reporting that residents are changed every 2 hours or as needed depending on the residents needs. Per 9 of 9 staff there is a changing log for hospice residents. On 02/01/24 LPA interviewed R1-R10 regarding the above allegation, 7 of 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed reported they do not use diapers, and 1 of 10 residents interviewed did not provide an answer. On 02/01/24 LPA reviewed incontinent/changing log for R1 and did not observe any discrepancies. Allegation- Facility staff fails to re-position bedridden resident. It is being alleged that staff fails to re-position bedridden residents. On 02/01/24 LPA interviewed CD regarding the above allegation, CD denied the allegation stating bedridden residents are checked on and repositioned every 2 hours after they are changed. On 02/01/24 LPA interviewed S1-S9 regarding the above allegation, 9 of 9 staff interviewed denied the allegation above reporting that residents are repositioned every 2 hours and it is documented on a form located in the residents room. 9 of 9 staff continued to report that caregivers reposition residents and can obtain assistance from LVN when needed. On 02/01/24 LPA interviewed R1-R10 regarding the above allegation, 10 of 10 residents interviewed denied the allegation above reporting that staff are checking on resident often and their needs are being met. On 02/01/24 LPA reviewed repositioning log for R1 and did not observe any discrepancies. Allegation: Facility staff fails to provide resident with basic services. It is being alleged facility staff fails to provide resident with basic services when residents are asking for water. On 02/01/24 LPA interviewed CD regarding the above allegation, CD denied the allegation reporting that staff are constantly in residents room making sure residents have what they need. CD continued to report there is a list of bedridden residents which caregivers use to ensure residents have what they need. On 02/01/24 LPA interviewed S1-S9 regarding the above allegation, 9 of 9 staff interviewed denied the allegation above reporting that residents will use their pendants to request food/water and the caregivers will provide the items. On 02/01/24 LPA interviewed R1-R10 regarding the above allegation, 10 of 10 residents interviewed denied the allegation above reporting that staff are providing food/water when needed. 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 allegations are Unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 11-AS-20240122170207

Allegation investigated: Staff did not prevent resident from physically assaulting another resident in care.

On 02/01/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Resident care director Sidona Cordis as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/30/23 LPA interviewed Executive Director (ED), staff #1, and interviewed residents # 3-11 (R3-R11). LPA obtained copies of the following for R1 and R2, face sheet, emergency Identification form, service plan, physicians report, physicians orders and preplacement appraisal information. On 12/14/23 LPA interviewed resident #1 (R1), and staff #2-6 (S2-S6). The investigation revealed the following: Allegation- Staff did not prevent resident from physically assaulting another resident in care. Unsubstantiated It is being alleged that staff did not prevent resident from physically assaulting another resident in care. On 11/30/23 LPA interviewed (ED) regarding the above allegation, ED denied the above allegation stating that the facility is assessing residents, following up with psychiatrist and continued monitoring of resident’s behaviors to ensure this type of situation does not occur. ED also reported this was the first incident involving R1 and R2. On 11/30/23 LPA interviewed R3-R11 regarding the above allegation, 8 of 9 residents interviewed denied the above allegation reporting feeling safe at the facility. 1 of 9 residents interviewed reporting having a physical fight with roommate, however reports feeling safe at the facility as resident had a room change. On 12/14/23 LPA interviewed S2-S6 regarding the above allegation, 5 of 5 staff interviewed denied the above allegation. 5 of 5 staff reported residents are separated, residents are talked too, residents are assessed and are offered activities. On 12/14/23 LPA interviewed R1 regarding the above allegation, R1 denied the above allegation stating R1 could not remember the incident in question. LPA was unable to interview R2 as R2 is no longer a resident at this facility and there is no contact info on new location. 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 with Resident care director Sidona Cordis and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2024 · control 11-AS-20231127174916

Allegation investigated: Staff did not prevent a resident from hitting another resident in care. Staff did not prevent facility from becoming malodorous. Staff did not keep facility free of insects. Staff did not check resident's blood sugar.

On 01/02/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Executive Director (ED) Janie Acosta as the purpose of today’s visit was explained. The investigation consisted of the following: On 01/02/24 LPA interviewed Executive Director (ED),Resident #1-10 (R1-R10), and staff #1-5 (S1-S5). On 01/02/24 LPA obtained copies of the following; Staff and resident rosters, housekeeping and janitotial schedule for December 2023 and January 2024, copy of invoice from Terminix dated 12/04/23, 12/18/23, a copy of terminix's last service visit dated 12/26/23, and a copy of vital signs log. On 01/02/24 LPA obtained copies of the following for R#1; face sheet, emergency I.D. form, physician’s report, medication list, needs and service plan, and admission agreement. The investigation revealed the following: Allegation- Staff did not prevent a resident from hitting another resident in care. Unsubstantiated It is alleged that staff did not prevent a resident from hitting another resident in care. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above reporting that there were no recent reports made of a resident hitting another resident. Per ED, staff will de-escalate by separating residents, talking to residents and investigate what caused the incident. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 5 of 5 staff interviewed denied the allegation above stating they had no knowledge of a recent resident on resident incident. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 9 or 10 residents interviewed denied the allegation above and reported feeling safe at the facility. 1 of 10 residents interviewed admitted hitting a peer in the head, resident reported the incident occurred in their shared bedroom while no staff was present. Resident continued to report staff was later made aware of the incident and staff provided a room change, per resident this was the first time this has occurred. Allegation- Staff did not prevent facility from becoming malodorous. It is alleged that staff did not prevent facility from becoming malodorous. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above reporting that common areas are cleaned 3 times a day. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 2 of 5 staff interviewed denied the allegation above, 3 of 5 staff interviewed stated the facility may become malodorous at times due to residents having accidents in common areas, however housekeeping is really good about cleaning right away. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 10 of 10 residents interviewed denied the allegation above. Allegation-Staff did not keep facility free of insects. It is alleged that staff did not keep facility free of insects. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above. Per ED the facility has an ongoing pest control as a preventative measure for the facilities size. On 01/02/24 LPA Interviewed S1-S5 about the above allegation, 2 of 5 staff interviewed reported residents have reported insects. Per 2 of 5 staff interviewed, an inspection of the location will be done and it will be treated by terminix right away. 3 of 5 staff interviewed denied the above allegation, reporting no resident has reported any insects. On 01/02/24 LPA Interviewed R1-R10 about the above allegation, 4 of 10 reported seeing insects in the facility and reporting it, 6 of 10 residents interviewed denied the allegation above. On 01/02/24 LPA conducted tour of the facility and did not observe any insects. Allegation: Staff did not check resident's blood sugar. It is alleged that Staff did not check resident's blood sugar. On 01/02/24 LPA Villegas interviewed (ED) regarding the above allegation, ED denied the allegation above. Per ED, blood sugars are checked according to the Doctors orders, and can be checked from 2 times a day to 4 times a day. On 01/02/24 LPA interviewed S1-S5 regarding the above allegation, 2 of 5 staff interviewed do not assist with medication administration, 3 of the 5 staff interviewed denied the above allegation. Per 3 of 5 staff interviewed, blood sugars are checked and documented daily according to Doctors orders. On 01/02/24 LPA interviewed R1-R10 regarding the above allegation, 9 of 10 residents interviewed were unable to provide information in regards to allegation above, 1 of 10 residents interviewed reported conducting own sugar checks as assistance from staff is not needed. On 01/02/24 LPA reviewed resident vital signs log and did not observe any discrepancies or missed blood sugar checks. 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 allegations are Unsubstantiated. Exit interview conducted with Executive Director Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 2, 2024 · control 11-AS-20231226133527

Allegation investigated: Resident burned another resident with a cigarette.

On 12/14/23 at 9:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive director (ED) Janie Acosta and the purpose of today’s visit was explained. The investigation consisted of the following: On 11/30 /23 LPA interviewed Executive Director (ED), staff #1-8 (S1-S8), witness #1 (W1), and interviewed residents # 2-11 (R2-R11). LPA obtained copies of the following for R1 and R3, face sheet, emergency Identification form, service plan, physicians report, physicians orders and preplacement appraisal information. The investigation revealed the following: Allegation- Resident burned another resident with a cigarette. It is alleged Resident #1 had cigarette burns on the skin that were caused by another resident at the facility. On 11/30/23 LPA interviewed ED regarding the above allegation, ED denied the allegation above Unsubstantiated stating that no resident has disclosed being burned with a cigarette. Per ED, smoking is only allowed in the smoking patio which is located at the back of the facility building, ED continued to state that residents wear a pendant in case they need help and that staff conduct rounds to ensure safety. Per ED, staff will intervene, de-escalate, talk to residents involved, report to family, Primary Care Practitioner, and document if any such incident had occurred. 11/30/23, LPA interviewed S1—S8, 8 out of 8 staff interviewed denied the above allegation. 8 of 8 staff interviewed stated they did not have any knowledge of any resident being burned with a cigarette. On 11/30/23 LPA interviewed R2-R11 regarding the above allegations, 9 out of 11 residents interviewed denied the allegation. On 11/30/23 LPA interviewed W1 about the allegation above, W1 reported there were no burn marks observed during the body check conducted upon resident #1 admission to the new facility R1 is currently residing. On 11/30/23, LPA made an attempt to interview R1 via telephone due to R1 not currently residing at the facility. During the interview R1 was unable to answer LPA Villegas question due to communication barriers. As a part of the investigation LPA received photos of R1 with what appears to possibly be a burn mark. LPA was not able to verify when and where R1 sustained the burn marks as R1 is currently in a Skilled Nursing Facility. 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 with Executive director (ED) Janie Acosta, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 11-AS-20231120195648

Allegation investigated: Staff are not properly addressing scabies at facility.

On 11/17/23 at 9 am Licensing program analyst (LPA) Lizeth Villegas conducted an initial vist rageding the allegation above. LPA met with Resident Care Director Sidonia Cordis (D1) as the purpose of today’s visit was explained. During today's visit LPA obtained copies of the following: Staff and client rosters, and the facilities Prevention and contol of scabies in California healthcare settings. On 11/17/23 LPA interviewed Resident Care Director(D1), Staff # 1- 11(S1-S11), residents # 1- 10(R1-R10), and conducted a records review of to confirm facility has a scabies prevention and control plan. The investigation revealed the following: Allegation: Staff are not properly addressing scabies at facility. Unsubstantiated It is being alleged that staff are not properly addressing scabies at facility. On 11/17/23 LPA Villegas interviewed D1, who denied the allegation above. Per D1, there were 2 residents a few weeks ago but treatment has been completed and the public health department was notified. On 11/17/23 LPA Villegas interviewed R1-R10 regarding the allegation above, 10 of 10 residents interviewed denied the allegation above. On 11/17/23 LPA Villegas interviewed S1-S11 regarding the allegation above, 10 of the 11 staff interviewed denied the allegation above, 1 of the 11 staff interviewed corroborated the allegation and indicated that the facility failed to properly address scabies case. On 11/14/23 LPA reached out to Long Beach Department of Public Health and confirmed facility reported scabies and followed the recommended treatment plan. Although the allegation may have happened or is valid there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. Exit interview conducted with Resident Care Director Sidonia Cordis, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 17, 2023 · control 11-AS-20231114134358

Type of visit: Case Management - Deficiencies

On 11/17/23 LPA conducted a case management visit to issue citation observed during complaint investigation (Complaint control # 11-AS-20231114134358) as facility failed to report scabies case to community care licensing. Exit interview conducted with Resident Care Director Sidonia Cordis, appeals rights explained and a copy of this report was provided. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 809D.the state’s words, verbatim · CDSS document, Nov 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 24, 2023

87211 Reporting requirement Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any, and....the state’s words, verbatim · CDSS document, Nov 17, 2023

Plan of correction: Director to submit a plan to ensure Vista Del Mar Senior Living is in compliance with 87211 (a)(1) and submit plan outlining the steps that will be taken to ensure compliance of section cited. Director will also submit incident report for scabies cases by POC due date.

Type of visit: Required - 1 Year

On 10/13/23, Licensing Program Analyst's (LPA's) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director Janie Acosta as the purpose of today’s visit was explained. The facility is licensed to serve The facility is licensed to serve 300 elderly adults 60 and over non-ambulatory of which 10 may be bedridden, may retain 30 hospice residents and has a dementia Wing w/ delayed egress. Current census is 241. The facility is a 3-story structure located in a residential neighborhood and consists of the following: 278 bedrooms and 4 common bathrooms, multimedia rooms, commercial kitchen, large dining room, media room and a large common patio. LPA’s conducted a records review of 10 staff records, 10 resident records, and 10 medication Administration Records. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last fire and disaster drill was conducted on 09/08/23, fire extinguishers fully charged and observed throughout the facility, carbon monoxide detectors, smoke detectors and auditory signals are operational. Landline and internet service was observed. Liability insurance is current and active. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to residents. The water temperature properly measured between 105-120 F.. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Toxins and knifes were observed to be locked and inaccessible to residents. Exits/ Walkways around the facility were free of debris and hazards. During today’s visit the following discrepancy was cited on 809 D page. Exit interview conducted with Executive Director Janie Acosta, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 13, 2023

Allegation investigated: Facility staff failed to properly address pests control problem. Staff serve food of poor quality. Facility staff did not ensure eating utensils and dishes are sanitary and in good repair.

On 10/11/23 at 9 am Licensing program analyst (LPA) Lizeth Villegas conducted an initial complaint investigation visit regarding the above allegation(s). LPA met with Resident Care Director Sidonia Cordis (D1) as the purpose of today’s visit was explained. During today's visit LPA obtained copies of staff and resident rosters, Pest control invoices, menus for September and October, Dietician records, Food handlers’ certificates, In service for food handling, in services for sanitation and housekeeping schedule. LPA toured the kitchen, dining room area, and 5 resident bedrooms. On 10/11/23 LPA interviewed Resident Care Director(D1), Staff # 1-9 (S1-S9), residents # 1-1 (R1-R10) and witness #1 (w1) via phone interview. LPA was later joined by Director Janie Acosta. The investigation revealed the following: Allegation: Facility staff failed to properly address pests control problem. On 10/11/23 LPA interviewed S6 regarding the above allegation, per S6 facility has a contract with Terminix commercial who comes out 2 times a month to spray dining room, kitchen area, memory care Unsubstantiated kitchen, common areas, all offices, 10 bedrooms per visit and a flush is done quarterly in areas where food is prepped. LPA interviewed R1-R10, 5 out of 10 residents interviewed denied the allegation above, 5 out of 10 residents interviewed reported seeing roaches in their restroom. LPA interviewed S1-S10 who denied the allegation above. 10 out of 10 staff reported the facility and bedrooms are cleaned daily and bedrooms are deep cleaned once a week. On 10/11/23 LPA interviewed W1 via phone who confirmed facility is on the recommended treatment plan from Terminix pest control. LPA reviewed Terminix invoices and confirmed Terminix visits the facility 2 times a month. Allegation: Staff serve food of poor quality. On 10/11/23 LPA interviewed S2 regarding the above allegation, S2 reports that the facility has many vendors who are known for top quality food and the facility provides alternative meal options and accommodates special diets. S2 stated food supplies are checked for expiration dates and freshness upon delivery. S2 reported that food menu is reviewed by dietician once a month, kitchen is aware of modified diets, meetings are conducted sometimes once a month with residents and that there is a food board in the kitchen that helps kitchen staff identify what meal is for each resident. LPA interviewed R1-R10, 10 out of 10 residents interviewed denied the allegation above. LPA interviewed S1-S10 who denied the allegation above. LPA reviewed the facility menu and confirmed menu is checked monthly by dietician. While at the facility LPA observed food being served and did not observe any immediate concerns. LPA reviewed food handler certificates, menus and dietician records and did not observe any immediate concerns. Allegation: Facility is utilizing dishes that are hazardous to residents. On 10/11/23 LPA interviewed S2 regarding the above allegation, S2 reports that if any plate or utensils become broken, they are thrown out right away to ensure safety. Per S2 no resident has sustained injury due to plates or utensils. LPA interviewed S1 and S3-10 who denied the allegation above. LPA interviewed R1-R10, 9 out of 10 residents interviewed denied the allegation above, 1 out 10 residents reported that the serving plates are dirty. LPA toured the kitchen and dining room and did not observe any hazards utensils or immediate concerns. 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 with Janie Acosta and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 11-AS-20231002152933

Allegation investigated: Resident was sexually abused while in facilities care. Facility staff neglected resident resulting in unexplained bruising.

On 9/16/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit in order to render investigation findings. LPA met with (Andrea Perez, Marketing Director) and the purpose of the visit was explained. The investigation consisted of the following: On 3/24/23, LPA Jeremiah Randle conducted the initial visit. LPA Randle conducted a tour of the physical plant and obtained copies of the following records: Resident Roster delineating care to bedridden residents, Staff Roster of staff who use the Hoyer lift, Physicians reports of bedridden residents, emergency contact information for each bedridden resident, East/West video camera footage of hallway between rooms 112 and 123. On 3/24/23, the complaint investigation was referred to the California Department of Social Services Investigations Bureau for investigation. (Evaluation Report continues LIC 9099-C) Unsubstantiated The complaint was accepted for a full investigation and assigned to Special Investigator Douglas Real. As a part of the investigation Investigator Real obtain copies of Long Beach Police Department Police Report, Providence Little Company of Mary Hospital Records, True Carre Hospice Records and conducted interviews with Witness #1-3, Facility Administrator (A1), Staff #1-5 and Residents #1-3. THE INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Resident was sexually abused while in facilities care. Allegation #2: Facility staff neglected resident resulting in unexplained bruising. It is alleged R1 was sexually abused while in care due to unexplained bruising to R1 private areas. The complaint details alleged that a perpetrator may have enter R1 through the sliding glass door and assaulted R1. On 3/27/23 at 3:10pm, Investigator Real interviewed Janie Acosta (A1) regarding the allegation. A1 stated R1 has resided at the facility since 12/2022 and R1 health has continued to decline. A1 stated on 3/21/23 R1 Hospice Nurse came to the facility to bathe R1 and observe some bruising on R1. A1 stated all facility employees were unaware of R1 bruising and did not know how R1 sustained the bruising. A1 stated none of the staff have reported any incidents or falls involving R1. A1 indicated R1 is on blood thinners which could have contributed to the bruising. On 3/27/23, 5/10/23 and 6/19/23, Investigator Real interviewed Staff #1-5 (S1-S5), 5 out of 5 staff interview denied the allegation and stated they were unaware how R1 sustained bruising. 1 out of 5 staff interviewed stated staff observed the bruising on R1 at the same time R1 Hospice Nurse observed the bruising. The staff stated once staff observed the bruising staff checked R1 sliding glass door in room and observed it to be locked with a pen to prevent anyone outside the facility from opening it. On 5/10/23, Investigator Real interview Residents #1-3, 3 of the 3 residents interviewed denied the allegation. R1 was unable to recall any incidents nor expressed any concerns when R1 resided at Vista Del Mar Senior Living. Investigator interviewed Witness #1-3 regarding the allegations, 2 of the 3 witnesses interviewed were made aware of the bruising and expressed concerns of possible neglect at Vista Del Mar Senior Living. 1 of the 3 Witness denied finding any evidence to support the allegation of sexual abuse. (Evaluation Report continues LIC 9099-C) As a part of the investigation Investigator Real obtained and reviewed the Long Beach Police Department Police Report, Providence Little Company of Mary Hospital Records and True Care Hospice records. The review of the Long Beach Police Department revealed there is no evidence of a sexual assault and the investigation was concluded. The review of Providence Little Company of Mary Hospital records date 3/21/23 revealed R1 was seen in the Little Company of Mary emergency department on 3/21/2023 for unexplained bruising. A physical exam was done and identified bruising on R1 lower extremities, buttocks, and trunk. R1 was also noted as having diagnosed with chronic anticoagulation and has been on long-term anticoagulants as well as aspirin. Multiple x-rays as well as a CT scan found no fractures. Records noted no obvious defensive wounds were identified. It was noted the bruising appears to be in the region of the victim's hips, groin, and back and it was speculated the bruising may be due to tight fitting clothing, use of a Hoyer lift, or possibly a fall. The victim was noted as not being in acute distress. The records indicated a forensic medical (SART exam - sexual assault response team) exam was conducted. The review of True Care Hospice records revealed on 3/21/2023, a hospice nurse visited the R1 in the facility after a hospice aid found unexplained bruising. The hospice nurse observed traumatic bruising on the left arm, left hand, bilateral lower side abdomen, pubis area, right lateral mid abdomen, left under chest, right gluteal, posterior upper leg, right anterior upper leg, and right lateral lower leg. R1 was visited by a hospice nurse in the facility on 3/18/2023 and no bruises were observed at that time. R1 hospice medication list indicated R1 was receiving two anti-coagulants - 81 mg Aspirin once a day and 2.5 mg Eliquis twice a day. A review of R1 prescribed medications was reviewed and revealed R1 has a prescription for Eliquis “is used to prevent serious blood clots from forming due to a certain irregular heartbeat or after hip/knee replacement surgery with side effects included easy bruising (WEBMD). Based on interviews conducted, records reviewed and observations there is insufficient evidence to support the allegations. 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. An exit interview was conducted with Andrea Perez, and a copy of this report was provided. This report serves as an amendment to clarify finding. on line #3. It does not supersedes the complaint investigation findings reflected on report created 09/16/23.the state’s words, verbatim · CDSS document, Sep 16, 2023 · control 11-AS-20230321145555

Allegation investigated: Staff are not ensuring a safe and healthful environment by turning a resident timely. Facility is malodorous.

On 08/31/23 at 8:45am, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit to render investigation finding. LPA met with Executive Director Janie Acosta and the purpose of today’s visit was explained. The investigation consisted of the following: On 08/09/23 LPA interviewed Executive Director Janie Acosta (ED), staff #1-9 (S1-S9) and interviewed residents # 1-10 (R1-R10). LPA obtained copies of the following for R1's; complete file, Service plan, turning log (8/1/23-8/9/23), staff and resident rosters, cleaning logs, laundry schedule, copy of Group 7 log, a copy of in-service staff training for repositioning residents (6/2/23), copy of end of life-hospice in-service training (2/17/23). The investigation revealed the following: Allegation- Staff are not ensuring a safe and healthful environment by turning a resident timely. Unsubstantiated It is alleged the staff was to turn R1 at 2PM and at 4PM and the sign in sheet had not been signed off. On 08/09/23 LPA interviewed Executive Director Janie Acosta (ED), regarding the above allegation, ED denied the allegation above. Per ED, LVN’s and Caregivers are all trained in repositioning residents and residents are being turned every two hours. ED informed LPA that she does not recall how often R1 was to be repositioned. On 08/09/23 LPA interviewed R1-R10 regarding the above allegations, 10 out of 10 residents interviewed denied the allegation. On 08/09/23, LPA interviewed S1—S9, 9 out of 9 staff interviewed denied the above allegation. 6 of 9 staff interviewed reported that residents they are assigned to for the day are being turned every 2 hours. LPA conducted a review of R1 service plan dated 07/31/23 which indicates R1 is to be repositioned every 2 hours. LPA observed a repositioning log dated 08/01/23-08/09/23 and did not observe any missing signatures. LPA observed documented staff training records in repositioning residents on 06/02/2023 and hospice care dated 02/17/2023. Allegation: Facility is malodorous. It is alleged the first-floor hallway that is close to the dining room had a strong stench of feces because the staff have not cleaned the area. On 8/9/23, LPA interviewed the Executive Director regarding the allegation. According to the ED, the facility is cleaned daily by housekeeping and indicated there is a housekeeping schedule. The ED denied the allegation. On 8/9/23, LPA interviewed Staff #1-9 and 9 of the 9 staff interviewed denied the allegation. LPA interviewed Residents #1-10 and 10 of 10 residents interviewed denied the allegation. On 8/9/23, LPA conducted a tour of the facility physical plant and did not find the facility malodorous, and LPA did not observe any areas that required cleaning at the time of visit. LPA conducted a file review and observed the cleaning schedule and documented training for housekeeping staff. 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 with Executive Director Janie Acosta and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 31, 2023 · control 11-AS-20230731132017

Allegation investigated: Facility staff are not addressing bed bug infestation.

On 08/25/2023 Licensing Program Analyst (LPA), Antonine Richard conducted the 10 day complaint investigation visit regarding the allegation above. LPA spoke to Resident Care Director Cordis Sidonia regarding the above allegation. Later LPA was joined with Executive Director Acosta, Janie. The investigation consisted of the following: LPA Richard toured the facility grounds with Resident Care Director Sidonia and Executive Director Acosta. LPA toured the residents' bedrooms R301, R302, R303, R304, R321, and spoke to the residents regarding the allegations. LPA requested resident R1-R2 records. Residents roster, Staff roster. Service agreement, invoices and bed bug treatment from the last two months. In regards to the allegation Facility staff are not addressing bed bug infestation, based on records reviewed, observation, interviews conducted and information gathered there has not been a bed bugs infestation for over a year now in resident R1. LPA Richard, Resident Care Director Cordis, and resident R1, flipped the mattresses around, there were no bed bugs observed in resident R305 at the time of visit. Unsubstantiated Allegation: Facility staff are not addressing bed bug infestation. On 08/25/2023, LPA Richard Reviewed records received: On 08/21/2023, Pest control had sprayed resident room R303 and resident had to leave the room for 4 hours. LPA also conducted records reviews of R1-R2 record (Needs and service Plan, Pre-Placement Appraisal, and Physician's Report for Residential Care Facility For The Elderly.) (RCFE). and resident deep cleaning schedule. R1-R2 #303 is schedule for Thursday, August 31, 2023. LPA reviewed R1 emergency visit on 08/19/2023, the Nurse stated R1 visit reason: Bite or Sting, no mention of bed bug on the report. Based on LPA observations, interviews and records reviewed which were conducted. Although the allegation may have happened or valid the preponderance of evidence standard has not been met, therefore the above allegation is found to be Unsubstantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 . An exit interview was conducted and a copy of the report was provided to the Executive Director Acosta Janie.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 11-AS-20230823125050

Allegation investigated: Facility staff did not take residents to scheduled medical appointments.

The Investigation Consisted Of The Following On 7/06/2023, Licensing Program Analyst (LPA) Jeremiah Randle, conducted a complaint investigation visit to deliver complaint findings to the above-named facility for the allegation listed above. LPA was met by Janie Acosta Executive Director (S1). The LPA explained to (S1) the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (3) staff members, and interviewed (5) residents, resident R1 is deceased as of 12/17/22. The LPA also reviewed the following documents provided by Janie Acosta Executive Director (S1): Staff roster, Client roster, transportation schedule, Residence and Care Agreement, Incident Report from 12/22/22, Needs and Services Plan, and Physician Report for Resident R1. Unsubstantiated The Investigation Revealed The Following. Allegation: Facility staff did not take residents to scheduled medical appointments. PA interviewed three (3) staff members all denied the allegation. LPA reviewed facility documents that provide facility clients with transportation to doctor appointments, and back home to the facility. R1 was not entered as a resident that received transportation services from the facility. S1 informed the LPA, that the facility arranges client medical appointments, and provides clients transportation to and from the medical location if requested from the resident R1 had not requested services as R1 was independent. S1 also stated resident would have received transportation services even on short if required, however R1 never requested service R1 was independent. S1 stated that the facility has a facility van to transport clients to activities, and medical appointments. In addition, the facility staff will transport clients to other locations when necessary. Residential Care staff 3 of the 3 staff members interviewed, informed the LPA, that they transport clients to and from medical appointments when requested and R1 never requested services for transportation to medical appointments as R1 was independent and always used public transportation for various activities. In addition, 3 of 3 staff member, informed the LPA that R1 makes all self-medical appointments, also R1 has never been denied medical transportation services. LPA reviewed R1’s needs and services plan which indicates R1 was not designated as having a need for transportation services to medical appointments. LPA interviewed (5) residents all residents denied the allegation, Facility staff did not take residents to scheduled medical appointments, further residents stated the facility has not been the cause of missed medical appointments per residents’ statements. Findings Based on information gathered, the LPA did not find sufficient evidence to support allegation Facility staff did not take residents to scheduled medical appointments. Although the allegation 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 allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Janie Acosta Executive Director Executive Directorthe state’s words, verbatim · CDSS document, Jul 6, 2023 · control 11-AS-20221123145630

Allegation investigated: RESIDENT SUSTAINED MULTIPLE INJURIES WHILE IN CARE

On 05/03/2023 around 09:00 AM Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Janie Acosta and the purpose of the visit was explained. It is alleged that Facility staff are not properly trained. During this investigation, LPA Calderon interviewed R2-R12, A1, S1-S5. These interviews were conducted on 12/13/2021 and 03/30/2023. On 12/13/2021 LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medical Administration Records (MARS), Physicians Report, vehicle maintenance, driver 1 driving records. The investigation revealed the following: Unsubstantiated Allegation: Resident sustained multiple injuries while in care. It is stated on 12/07/2021 resident sustained multiple injury while in care. On 12/07/2021 LPA could not interview R1 for complaint as R1 has an attorney. Letter from attorney states that R1 was inside facility van and was injured when driver came to a stop and R1 flew out of wheelchair on the van floor. On 12/14/2021 LPA reviewed IB report which did not find that R1 was injured when van came to a stop. On 12/14/2021 LPA reviewed medical records from IB report, records did not find that R1 was injured from falling out of the wheelchair. Medical report suggests minor injuries to resident knees. On 12/13/2021 LPA interviewed S5 driver who stated that resident 1 did fall out of wheelchair when S5 came to a stop at a red light. S5 states that R1had very minor injuries to R1 knees and refused to be taken to hospital or for 911 to be called. S5 states that R1 asked driver to drive R1back to the facility. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) 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 and copy of the Complaint Report and Appeal Rights were provided to the Administrator. Allegation 2: Facility staff are not properly trained. On 12/13/2021 LPA Calderon interviewed A1 for complaint. James Bender A1 states that his facility driver has been trained in how to properly transport residents in the facility van. A1 states that his driver was sick and the maintenance staff who is the backup driver was tasked to drive R1. A1 states that S5 was trained in how to transport residents in care. A1 states that S5 does not have a commercial license and drives residents from time to time when the normal driver is not working or is on the road or is sick. On 12/13/2021 LPA Calderon interviewed S5 for complaint. S5 states that S5 was giving training on how to properly transport resident in the facility van. S5 states that he just forgot to secure R1 and wheelchair down prior to leaving and when he braked R1 fell to the van floor. On 12/13/2021 LPA Calderon interviewed S3 for complaint. S3 states that S3 was sick on the date of incident and that S3 had trained S5 on how to properly transport a resident in the facility van. On 12/13/2021 LPA Calderon reviewed records and confirmed that S5 has a clean driving record and has been with the facility for over 10 years with no issues noted for his employment record. On 12/13/2021 LPA Calderon interviewed R2 who states that R2 has been driven in the van many times and staff has always secured him in then van while sitting in a wheelchair. On 03/30/2023 LPA Calderon interviewed R3-R12 for complaint. S6, S8 and S9 are in wheelchair and state that staff has always secured their chair and person prior to leaving and have never been injured while in transport. All other resident interviewed state that they have been transport to doctors’ meetings and have never had any issues or injuries. Allegation 3: Facility vehicle is not in good repair It is alleged that facility vehicle is not in good repair. On 12/13/2021 LPA Calderon interviewed A1 for complaint. A1 states that all facilities vehicles are given maintenance by third party vendors and the breaks are checked to make sure they are in good working order and all other vehicle services are done monthly to make sure the facility vehicles are in good working order. On 12/13/2021 LPA Calderon interviewed S3 and S5 for complaint. S3 and S5 state that the facility van has been services and had new breaks and tires prior to the accident. S3 and S5 state that the facility van was in working order and the incident did not happen due to vehicle failure. On 12/13/2021 LPA Calderon reviewed maintains records for facility van and noted that the facility van has been serviced and was in good repair prior to the incident. 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. A exit interview was conducted with Administrator Janie Acosta, and a hard copy was provided.the state’s words, verbatim · CDSS document, May 3, 2023 · control 11-AS-20211207093606

Allegation investigated: Resident sustained pressure ulcers while in care Staff did not change residents soiled diaper in a timely manner Unlawful eviction

On 5/1/22023, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegation. LPA Brown met with the facility administrator Janie Aosta-Administrator the purpose of the visit was explained. The investigation consisted of the following: On 8/7/2020, Licensing Program Analyst (LPA’s) Martessa Brown and Janae Hammond conducted a 10-day complaint tele-visit and met the Administrator Brad Dehann. LPA requested the following documentations: Staff and Resident Roster, admission agreement, residents (R1’s) file: Emergency Identification, Physicians Report, Needs and Service, Incontinent care plan, Medication records for the last 6 months, hospital records, staff training records and recent incident reports. The complaint was referred to Community Care Licensing Investigations Branch and assigned to Special Investigator Denis Seng. Investigator interviewed 2 witnesses, Residents R1-R3, Administrator Brad Dehann and staff members S1-S5. Reviewed and obtained Resident R1’s Kaiser Medical records. The investigation revealed the following: Unsubstantiated Regarding the allegation #1: Resident sustained pressure ulcers while in care It was alleged that the Resident (R1) was diagnosed with stage IV pressure injuries on the left and right buttocks while living at the facility. On 6/25/2020 and 9/3/2020, investigator conducted interviews with administrator and staff members S1-S5 regarding R1’s pressure injuries. On 6/25/2020, S1-S5 stated resident was placed on incontinent care and was found with 2 small red sores on the lower left and right buttocks. Investigator reviewed the records and notes instructed staff to change R1 every 2 hours. On 9/3/2020, interview conducted with witness (W1) confirmed R1 to wear adult diapers on 6/25/2020. On 10/13/2020, Investigator conducted an interview with R1, and resident was unable to recall any details. Interviews conducted with S1-S5, confirmed with the Investigator R1 diapers was changed every 2 hours. Kaiser Medical records revealed on 6/27/2020, R1 had a stage 2 pressure injuries ulcer on the bilateral gluteus. On 7/9/2020 Kaiser noted a stage 3 pressure injuries on the left and right buttocks. Based on interviews and records review, R1 did not sustain a stage 3 or 4 pressure injuries while living at the facility. The above allegation is found to be unsubstantiated. Regarding Allegation: Staff did not change residents soiled diaper in a timely manner It was alleged that resident was sitting in diapers for an extended period. On 10/5/2020, LPA conducted interviews with Residents (R1-R6). During interviews conducted, 6 residents stated they have no concerns with their diapers being change. Residents stated staff will change them every 2-3 hours and will call staff if needed to be change earlier and staff will assist. LPA conducted interviews with the Brad Dehann- Administrator, Sidonia Cordis- Resident Care Director and staff members S1-S7 regarding the above allegation. Administrator, Resident Care Director and S1-S7, stated residents that are incontinent are change every 2-3 hours. LPA reviewed R1’s Changing Log and dates that stated R1 was changed every 2 hours and Regarding Allegation: Unlawful eviction It was alleged that resident was evicted unlawful. Interviews conducted with the Administrator, Resident Care Director and residents S1-S7. On 10/5/2020 Administrator stated Resident Care Director stated R1 had went to the hospital on 6/27/2020. Administrator and Resident Care Director stated resident was able to come back to the facility once R was released from the hospital. R1 was unable to return to facility due to needing higher level of care. Residents Interviews conducted with S1-S7, did not hear of any unlawful eviction with any residents. LPA reviewed records and R1 was in the hospital and transferred to a skill nursing facility on 7/15/23. Resident still had belongings in the facility with the anticipation of returning but resident was unable to return to the facility. Resident was not evicted from the facility. Continuation LIC 9099 is on the next page. Regarding the allegation #2: Staff mismanaging residents’ medication. It was alleged that staff wanted to increase the resident’s medication. On 6/22/2020, medical records revealed that doctor had order an increase in R1’s medication Seroquel (Quetiapine) from 25mg to 1.5 tablets 3 times a day and then reevaluate. Medication order was schedule to start 6/22/20-7/15/20. On 6/25/2020 and 9/23/2020, Investigator conducted interviews with Administrator and Staff members, S1-S5. Staff members stated R1’s behavior was aggressive and was hard to monitor resident in the facility. Staff stated R1 would leave isolation room instead of quarantine and would wander the facility and jeopardize other residents. Staff stated R1 would be redirected but will be combative. Staff stated was aware of medication increase and was directed to check resident every 2 hours. Interviews and documents revealed the following: On 6/16/2020, records showed that, R1 tested positive for Covid-19. On 6/16/2020, a meeting was held by telephone with administrator and witnesses (W1 and W2) to discuss R1’s care plan, due to behavior changes. During meeting conversation administrator, W1 and W2 have all agreed to increase R1’s medication. On 6/16/2020, medical record notes from physician were documented that W2 stated R1 is being combative and having a hard time in isolation. Administrator, W1 and W2, have agreed to increase medication. On 6/21/2020, it was noted that R1 would leave the isolation room and wander. On 6/21/20, incident took place that R1 left the isolation room through a sliding glass door on the balcony. R1 entered a neighboring resident's room and had wandered into the hallway. On 6/22/2020, staff was notified of changes to increase medication. LPA reviewed R1 medication records for the month of June 2020. Investigation revealed that on 6/25/20-6/26/20 the medication Quetiapine was on hold for 2 days and not given to R1. LPA did not see any directives to hold medication from R1. Based on records review and interviews, it was determined that R1’s medication was mismanaged, and the above allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) 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 with Administrator, and a hard copy was provided. Facility did not provide resident a refund It was alleged facility did not provide resident a refund. LPA conducted interview with (W1) stated the facility was to provide a refund due to R1 not living at the facility. Interview conducted with Administrator stated spoke to (W2) requested to have resident discharge from Vista Del Mar and not returning. LPA reviewed records and R1 belonging was moved out on 8/2/2020 and on 8/07/2020, refund was process. Exit interview conducted a copy of the report was provided.the state’s words, verbatim · CDSS document, May 1, 2023 · control 11-AS-20200805114021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468/1(a)(2) · Plan of correction due date: May 2, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)( To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: LPA reviewed R1 medication Mars and on 6/24/2020 and 6/25/2020 Medication Mars Quetiapine was on hold This posses an immediate health and safety issue.the state’s words, verbatim · CDSS document, May 1, 2023

Plan of correction: Administrator with review regulation and retrain staff on medication by POC due date 5/2/23.

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not safeguard resident's medications Facility staff did not give resident's medication as prescribed Facility elevator does not operate properly Facility elevator permit expired

On 04/26/2023 around 09:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA met with Administrator Janie Acosta and the purpose of the visit was explained. The investigation revealed the following: Allegation 1: Facility staff did not safeguard residents’ medications. It is alleged that facility staff did not safeguard residents’ medications. During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records. Unsubstantiated On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff lost or misplaced R1 medications. W1 states that R1 went with W1 to W1 home and staff did not provide medications for trip. W1 states that staff could not find or locate R1 medications and pills went missing or were lost. On 03/15/2023 LPA Calderon interviewed A1 for complain. A1 states that R1 medications were not lost, misplaced, or stolen. A1 states that all R1 pills were accounted for and W1 was given the right amount pills for the visit to W1 home. On 03/15/2023 LPA Calderon interviewed S2-S6 for complaint. S2-S6 was unaware of any medications being lost, stolen or misplaced. S2-S6 was not aware of any call or conversations with W1 or R1 regarding lost pills. On 04/26/2023 LPA Calderon interviewed R1-R7 for complaint. R1 states that R1 spent some time at W1 home and pills were missing from R1 bottle. R1 states that staff was able to account for all pills and was able to give W1 all medications R1 would need while away from the facility. R3, R5, R6, R7 state that they take their own medications and have a lock box. Residents state that staff keeps records of resident medications and no medications have been lost, misplaced, or stolen. On 03/15/2023 LPA Calderon reviewed the MAR for R1. MAR records suggest that all medication pills were accounted for, and staff safeguard residents’ medications. On 04/26/2023 LPA Calderon interviewed W2-W3 for complaint. W1-W2 have no knowledge of any of their family members medication that went missing, lost, or stolen. Allegation 2: Facility staff did not give residents medication as prescribed. During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records. It is alleged that facility staff did not give residents medication as prescribed. On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that staff could not give medications to R1 as R1 was not in the facility and at W1 home. W1 requested copies of R1 MAR and facility paperwork showed that staff had marked medications as given and prescribed. W1 states that this was not possible was R1 was at W1 home when supposed medication was being given to R1. On 03/15/2023 LPA Calderon interviewed A1 for complaint. A1 states that staff would not alter, or fake medication reports and that staff give all residents medications as prescribed by a doctor’s office. On 03/15/2023 LPA Calderon interviewed S2-S7 for complaint. S2 and S4 both had conversations with W1 and R1 regarding the prescribed medications and explained to W1 and R1 how the MAR was documented by staff and that there is no way to alter or change the medications that are given. S2-S5 state that they were not aware of any changes to R1 prescribed medications and that all medications were noted and documented when given. On 04/26/2023 LPA Calderon interviewed R1-R7 for complaint. R3, R5, R6 state that they self-medicate and the medication they take is prescribed and staff keeps records of every pill that residents take. On 04/26/2023 LPA Calderon interviewed W2-W3, both witness state that staff only give medications prescribed. On 03/15/2023 LPA Calderon reviewed the MAR for R1. R1 MAR review suggest that no medications were missing, and all pills were accounted for. Allegation 3: Facility elevator does not operate properly. During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records. It is alleged that facility elevator does not operate properly. On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that R1 and W1 were inside the elevator and the elevator stopped moving. W1 states that the elevator moved to the second floor and the doors opened. W1 states that they were stuck inside the elevator for a few minutes. On 03/15/2023 LPA Calderon interviewed A1 who states that elevator 1 has had service come to work on the mechanics and A1 was not aware that any person was stuck inside the elevator for a period. A1 states that if the elevator stops working the system moves the elevator to the closest floor and the doors open. If this does not work, then there is phone to call 911. On 03/15/2023 LPA Calderon interviewed S6 who states that the elevator company services the facility elevators monthly and S6 is not aware of any person being stuck inside the elevator for any period. On 04/26/2023 LPA Calderon interviewed R1-R7 for complaint. R2, R4, and R7 state that the elevator is slow and is down for service. Resident state that they have never been stuck inside the elevator. R1, R3, R5 and R6 state that they have never been stuck inside the elevator. On 04/26/2023 LPA Calderon interviewed W2-W3 for complaint. W2-W3 state that the main elevator work every time and they have never been stuck inside the elevator. On 03/15/2023 LPA Calderon reviewed elevator service records; no issues were noted. Allegation 4: Facility elevator permit expired. During this investigation, LPA Calderon interviewed R1-R7, A1, S2-S6, W1-W3. These interviews were conducted on 3/13/2023, 3/15/2023 and 04/26/2015. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, Medication administration records (MARS), Physicians Report for R1 and elevator service records. It is alleged that facility elevator permits expired. On 03/13/2023 LPA Calderon interviewed W1 for complaint. W1 states that W1 was inside the elevator and noted that the elevator permit had expired. On 03/15/2023 LPA Calderon toured the facility with A1 and walked into elevator 1 and 2 and noted that the elevator permit had expired. A1 states that the state is behind in providing new permits, but they are in the process of getting new permits. On 03/15/2023 LPA Calderon interviewed S6 who states that the elevator is serviced monthly or when need and they are in the process of getting new permits. On 03/15/2023 LPA Calderon reviewed letter from the department of industrial relations Elevator Unit dated 03/15/2023, elevator #086749077001, this application is complete and is being processed. 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. A face-to-face meeting was conducted with Administrator Janie Acosta, and a hard copy was provided.the state’s words, verbatim · CDSS document, Apr 26, 2023 · control 11-AS-20230310124102

Allegation investigated: Facility etaff failed to feed resident. Facility not supervising resident while in care. Facility staff failed to clean residents linens. Facility staff lock resident in room.

This report supersedes the report dated 04/13/2023 for clarifying the circumstances for the allegations. Although this report supersedes the previous report the complaint investigation findings remain the same: Unsubstantiated Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the Vista Del Mar Senior Living facility on 04/13/2023 and was greeted by Administrator Janie Acosta (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. During this investigation Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 11/14/2022. LPA Calderon interviewed A1, W2, S2-S7, R1-R10. These interviews were conducted on 11/09/2022, 11/14/2022 and on 04/13/2023. On 11/09/2022 LPA Calderon interviewed W1-W2 for complaint. On 11/15/2022 LPA Calderon requested copies of the following: Staff and Resident rosters, Needs and Service Plan, Physician Report, Medication Administration Record (MAR), incontinence records and training, Hospice and home health care records, video or color pictures and email between W1 and facility for R1. Unsubstantiated The investigation revealed the following: Allegation #1: Facility staff failed to feed resident. It is alleged Resident R1 was not fed by facility. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 reported staff would assist R1 with 3 meals daily. A1 relays that R1 was able to eat in the dining room. If R1 could not make the trip to the dining room due to health, staff would deliver meals to R1. On 11/14/2022 LPA Calderon interviewed S2-S7 for complaint. S2 relays that S2 worked 5 days per week with R1. S2 relays that R1 was capable of walking to the dinning room every day for meals with support from staff. S2 relays that facility staff provide R1 with 3 meals per day and noted that hospice staff would also ensure R1 ate meals. On 11/15/2022 LPA Calderon reviewed physician report for R1. Report relays that R1 had a special diet due to health conditions and able to eat meals independently. Staff S3-S7 reported staff were aware of R1’s dietary considerations. On 04/13/2023 LPA Calderon interviewed R2-R10 regarding complaint. R2-R10 relay that the facility serve 3 meals per day and provide meal plans for those with special diets. R2-R10 relay that staff deliver food to residents who are unable to eat meals in the facility dining room. Allegation #2: Facility not supervising resident while in care. It is alleged that facility staffing is insufficient and R1 was left unsupervised while in care. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that facility supported R1 needs. A1 relays that the facility maintains sufficient staffing to provide the residents with needed supervision. Staff S2 relays that R1’s medical and care needs were supported by facility staff. Staff S3-S7 relay that R1 had health issues and there was a sufficient number of staff to support R1’s service plan. Staff S3 relayed that there are 3 supervisors working on the floor and 2 staff for each resident during the day. S5 relayed that there is sufficient staff to serve residents in care. On 11/15/2022 LPA Calderon reviewed R1 physician report, needs and service plan, preplacement plan, and hospice care plan. LPA found R1 did have serious health conditions. On 04/13/2023, LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 did not express concerns with staffing or needs not being met. R2-R10 relayed that there are many new staff, but that staff do care of resident’s needs. Allegation #3: Facility staff failed to clean residents’ linens. The alleged facility staff failed to clean residents’ linens. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that R1 had health issues and had incontinence issues. A1 relays that staff assisted R1 with hygiene 2 to 3 times per day or when needed. Staff changed R1’s bed linens daily or and as needed. On 11/14/2022 LPA Calderon interviewed S2-S7 for complaint. S5 and S7 relayed that R1 was assisted with hygiene needs 2 to 3 times per day and bedding was changed daily. On 11/15/2022 LPA Calderon reviewed physician report, pre-placement, and hospice records for R1. On 04/13/2023 LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 report staff clean their rooms and change bedding one time per week or as needed. Allegation #4: Faculty staff locked resident in room. It is alleged that facility staff locked R1 in R1’s room. On 11/14/2022 LPA Calderon interviewed A1 for complaint. A1 relays that resident would wander due to health issues. A1 states that residents do leave their rooms and wander the hallways. A1 relays that the unit R1 resides in has security to prevent resident from leaving the unit unattended. A1 relays that there are no situations that support any staff locking a resident in their room. A1 relays that resident doors can be secured, but residents are able to leave their rooms freely and staff are able to enter rooms. Staff S2-S7 reported that R1 required assistance transferring from R1’s bed to R1’s wheelchair. Resident R1 was not able to leave R1’s room without assistance from staff. Staff S2-S7 reported residents are not locked inside their rooms. On 11/15/2022, LPA Calderon reviewed hospice records R1’s that indicate R1 is non-ambulatory and requires assistance to transfer. On 04/13/2023, LPA Calderon interviewed R2-R10 for complaint. Residents R2-R10 reported their room doors are not locked by staff. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility staff failed to feed resident” “Facility not supervising resident while in care” “Facility staff failed to clean resident linens” “Facility staff lock resident in room” is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator (A1).the state’s words, verbatim · CDSS document, Apr 13, 2023 · control 11-AS-20221107084404

Allegation investigated: Facility staff did not safeguard resident's personal belongings

This report supersedes the report generated on 04/23/2023 for clarifying the circumstances for the allegation. Although this report supersedes the previous report complaint investigation findings remain the same: Substantiated Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the Vista Del Mar Senior Living facility on 04/13/2023 and was greeted by Administrator Janie Acosta (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. During the investigation, Licensing Program Analyst (LPA) Jose Calderon interviewed A1, S2-S4, R1-R7. These interviews were conducted on 04/12/2023. On 04/12/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, Needs and Service Plan, Physician Report, Medication Administration Record (MAR), Medication Release Form for R1. Substantiated The investigation revealed the following: Allegation #1: Facility staff did not safeguard residents’ personal belongings. On 04/12/2023 LPA Calderon interviewed R1 for complaint. R1 relays that R1 had purchased two packages and have them mailed to the facility. R1 relays that the front deck staff signed for the two packages and then lost one of R1 packages. R1 relays that the “green” mail card was signed by staff and R1 has proof. R1 does not know what happened to R1 package only that it was stolen or lost. On 04/12/2023 LPA Calderon interviewed S2 for complaint. S2 relays that S2 noted that a front desk employee had signed for the packages and R1 had shown S2 the “green” mail card with the staff signature. S2 relays that S2 asked front desk staff to follow up on the missing package, but no staff followed up and the package was lost and S2 did not follow up on the lost package. On 04/12/2023 LPA Calderon interviewed A1 for complaint. A1 relays A1 was not aware of the missing package and that the facility will replace the lost item or pay the R1 for the cost of the lost package. Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility staff did not safeguard residents’ personal belongings” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Janie Acosta (A1). Allegation #1: Facility staff did not safeguard residents’ medications. On 04/12/2023 LPA Jose Calderon interviewed A1 for complaint. A1 reported, R1 is administering medications independently as of 01/23. A1 relays that the facility Medication Administration Records, dated 09/22 to 01/23, support that R1’s medications were administered per physicians’ orders. A1 relays that A1 was not informed of R1 missing inhalers or medication. 04/12/2023 LPA Calderon interviewed R1 for complaint. R1 relays that when R1 moved into the facility 2 inhalers had gone missing. R1 relays that due to the two missing inhalers, R1 began storing and administering medication independently. Resident R1 reports, medications are now stored in a locked box supplied by the facility and has no issues with missing medication since 2022. On 04/12/2023 LPA Calderon interviewed S2-S4 for complaint. Staff S4 relays that R1 is storing and taking medications independently. Staff S4 trained R1 to administer medications independently. Staff S4 reports monitoring R1 to ensure R1’s medications are being taken daily. Staff S4 relays that the facility administered R1’s medications from 09/22-01/23 and records support that R1 was given medications needed. On 04/12/2023 LPA Calderon interviewed R2-R7 for complaint. R3 and R5 handle their own medications. R3 and R5 relay that they have not experienced staff mishandling their medications. Resident R2, R4, R6 and R7 relays that they have not experienced issues with missing or stolen medications. On 04/12/2023 LPA Calderon reviewed the Medication Administration Record (MAR) for R1 for 11/22-12/22. LPA Calderon found records indicate R1 received 2 inhalers. Allegation #2: Facility staff do not provide a safe environment for residents in care. On 04/12/2023 LPA Calderon interviewed R1 for complaint. R1 relays that R1 does not feel safe living in this facility due to staff entering R1 room. R1 reports locking R1’s room door and “does not like staff coming and going” inside R1’s room. R1 reports residing in a shared room and has a roommate. On 04/12/2023 LPA Calderon interviewed A1 for complaint. A1 relays that A1 did not know that R1 did not feel safe with staff entering R1’s room. A1 relays that staff do provide assistance to R1’s roommate who is sight impaired. A1 relays that staff do secure R1’s room door when they exit. On 04/12/2023 LPA Calderon interviewed S2-S4 for complaint. S2-S4 reported that staff enter R1’s room to clean and to provide assistance to R1’s roommate. S2-S4 relays that when exiting R1’s room R1’s door is secured. On 04/12/2023 LPA Calderon interviewed R2-R7 for complaint. R2-R7 reported they feel safe living in the facility and expressed no issues or concerns with staff. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “Facility staff did not safeguard residents’ medications” “Facility staff do not provide a safe environment for resident in care “is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Janie Acosta (A1).the state’s words, verbatim · CDSS document, Apr 13, 2023 · control 11-AS-20230411163806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 85072(b)(6) · Plan of correction due date: Apr 21, 2023

85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights.(6) To possess and use his/her own personal items, including his/her own toilet articles. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to ensure the safeguard of residents personal belongings. This poses a Safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 13, 2023

Plan of correction: Administrator will provide training from front desk clerks on how to sign for and secure residents packages by the due date of 04/21/2023

Allegation investigated: Facility does not ensure residents are served food that is of good quality Staff do not ensure residents special dietary needs are being met Staff yell at residents Staff do not speak to residents in an appropriate manner

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Sidonia Cordis, Resident of Care Services Director. The investigation consisted of following: Interviews and Record reviews. On 02/22/23, LPA Soto conducted interview with the Executive Director. The LPA also requested copies of the following documents: Resident Roster, Staff Roster, File for R#1, R#2, & R#3 - (Dietary restrictions, Pre-Appraisals, Physician's Report, Admission Agreement, Needs and Service Plan.) Menu, and Sample of moving in notification. On 04/06/23, LPA Soto interviewed S#2 - S#18, and R#1 - R#10. LPA toured the dining area and kitchen. Observed residents having lunch in the dining room. Observed the special diet board for residents in the kitchen. LPA also took pictures of the food being prepared and served for lunch. LPA also requested copies of the following documents: Unsubstantiated Resident roster and Staff roster, Copy of Training for food server and Copy of Dietary Hall Meeting notes. Based on the LPA's investigation, the investigation revealed the following. Allegation 1 – Facility does not ensure residents are served food that is of good quality. Interviews with S#1 – S#18, communicated they eat their lunch at the facility. The food is of good quality and good portions. They serve something different everyday and they have a variety of options in the menu. They also provide alternative items if they residents do not want what’s on the regular menu. They have a list of alternatives placed on the dining room tables and board right outside dining room, to make sure the resident knows what their options are. The food is cooked with low sodium, they do not prepare the food with too much salt, they provide residents with salt packages, when residents request it and can consume salt. Interviews conducted with R#2 -R#10, communicated the food is okay. They don’t put a lot of salt in the food, but they added if they need to. They also have a lot of alternatives and sometimes they don’t like what they serve, they just ask for the alternatives they have. The staff gets them what they want with no problem. LPA reviewed the main menu and the list of alternatives the facility offers healthy selections of food for the residents. LPA observed the food being prepared and served. The main dish was meat, vegetables, and a roll of bread. The residents were also having dessert pies (cherry and Apple.) The interviews, records and observations conducted do not concur with the above allegation. Allegation 2 - Staff do not ensure residents special dietary needs are being met. Interviews with S#1 – S#18, communicated that the facility always abides by the residents’ special diet, if they have one. When the resident is admitted they are given what is called (Moving in Notification) which has the resident allergies, if any, and any special diets or restrictions the resident needs to have. The moving notification also has a picture of the resident and it’s posted on a board in the kitchen to assure the kitchen is giving the residents their proper meals. Interviews conducted with R#2 -R#10, communicated that they some have food restrictions and the facility always gives them the meals they can eat. They have never had a problem with the meals. They like the food being served at the facility. LPA observed the board with the resident’s (Moving in Notifications) with pictures, allergies, special diets and restrictions. The interviews, records and observations conducted do not concur with the above allegation. Allegation 3 - Staff yell at residents. Interviews with S#1 – S#18, communicated, they have never yelled at any resident for any reason. Sometimes they speak in a loud voice to residents because some residents are hard of hearing. Interviews conducted with R#2 -R#10, communicated that they have never been yelled at by staff or anyone else. The staff is nice not mean. The interviews conducted do not concur with the above allegation. Allegation 4 - Staff do not speak to residents in an appropriate manner. Interviews with S#1 – S#18, communicated that they have never disrespect's or spoke to any resident inappropriate manner. They would never allow anyone talk to another person in that manner, they would report it right away and put a stop to it. Interviews conducted with R#2 -R#10, communicated that they have never been spoken to inappropriate manner at by staff or anyone else. The staff is always nice. The interviews conducted do not concur with the above allegation. 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 An exit interview was conducted with Sidonia Cordis, Resident of Care Services Director and a hard copy of report was provided.the state’s words, verbatim · CDSS document, Apr 8, 2023 · control 11-AS-20230213121645

Allegation investigated: Facility did not provide responsible party with residents records as requested.

This amended report supersedes report dated 04/08/23. Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Janie Acosta, Executive Director. The investigation consisted of following: Interviews and Record reviews. LPA Soto conducted interview with the Executive Director. The LPA also requested copies of the following documents: On 04/06/23, LPA Soto conducted interviews with S#1 - Executive Director, S#2 - S#18, and R#1 - R#10. The LPA also requested copies of the following documents on 04/06/23: Copy of R#1 file - (Face Sheet, Dietary restrictions, Pre-Appraisals, Physician's Report, Hospital/ER visits, request from Attorney requesting file R#1(Dated 03/29/23), POA (dated 03/07/20,) copy of record release from facility for R#1 file(Dated – 3/31/23,) Copy of request for file from Witness #1 (Dated 03/24/23.) Unsubstantiated Based on the LPA's investigation, the investigation revealed the following. For Allegation – Facility did not provide responsible party with resident’s records as requested. Interview conducted with S#1, communicated that they received the request on 03/27/23 for R1 records, via fax. She contacted the requestor on 03/27/23, after she received request and was coordinating with requestor via email and text to come and obtain file on 03/31/23. On 03/29/23, the Executive Director received PR Attorney request for R#1 entire file via fax. Facility provided copy of R#1 file on 03/31/23. Attorney’s representative went to facility to obtain and received copy of R#1’s entire file. Interviews conducted with S#2 – S#18, staff communicated they have no knowledge of facility not providing records to Responsible Parties of residents. Interviews conducted with R#1 – R#10, 10 of 10 residents interviewed communicated that they have never had the need to request to see their file. LPA reviewed the attorney’s file request dated 03/29/23, requesting entire file for R#1. LPA also reviewed the copy of records release letter dated (03/31/23.) The facility provided R#1’s file within the allotted time under Title 22 regulations, which states, the facility has two Business days to provide resident or responsible party the requested resident file. The interviews and records reviewed do not concur with the above allegation. 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 An exit interview was conducted with Janie Acosta, Executive Director and a hard copy of report was provided.the state’s words, verbatim · CDSS document, Apr 8, 2023 · control 11-AS-20230327134551

Allegation investigated: Staff did not properly assess residents needs for care Staff did not prevent residents from pushing each other Staff are not providing a comfortable environment for resident

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Wednesday, February 08, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Executive Director Janie Acosta. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: During the course of the investigation on 09/20/2022 and 02/08/2023, LPA Bunker interviewed staff 1-4 (S1-S4) and residents 1-23 (R1-R23). LPA Bunker asked questions relevant to the nature of the complaint. S1-S4 and R1-R23 all stated staff properly assess residents' needs for care, staff prevents residents from pushing each other, and staff is providing a comfortable environment for residents. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation #1: Staff did not properly assess resident's needs for care Staff 1-4 (S1-S4) and residents 2-23 (R2-R23) stated all residents are properly assessed upon admission and resident's care and supervision needs are being met. Resident 1 (R1) stated he is in the memory care unit and that he is independent. R1 stated the people in memory care have more problems than he has and he doesn't belong there. R1 stated the residents in memory care have physical and mental problems. R1 stated he is not in the same category. R1 stated he has bad memory; he is forgetful and can't remember things. S1-S4 and R2-R23 stated staff properly assess residents before admission. S1-S4 and R2-R23 denied the allegation. Allegation #2: Staff did not prevent residents from pushing each other. S1-S4 and R1-R23 stated staff does prevent residents from pushing each other. If staff witness any pushing or punching, they will intervene and make the residents stop immediately. S1-S4 and R1-R23 stated physical abuse is not allowed at the facility. S1-S4 and R1-R23 denied the allegation. Allegation #3: Staff are not providing a comfortable environment for resident S1-S4 and R1-R23 stated they are provided with a comfortable living environment. R1-R23 stated they were happy and comfortable living at the facility. S1-S4 and R2-R23 denied the allegation. Investigation revealed the following: Staff 1-4 (S1-S4) and residents 2-23 (R2-R23) interviewed stated the above allegations are false. Staff 1-4 (S1-S4) stated resident 1 (R1) was properly assessed. S1-S4 stated R1 is high functioning and not able to take care of himself. S1-S4 stated R1 is supposed to be in the memory care unit according to his doctor’s orders and recommendation, he is not an assisted living resident. S1-S4 and R1-R23 stated punching another resident is prohibited and not allowed. The facility has zero tolerance, and staff will intervene to prevent an incident like this from occurring. S1-S4 stated that staff are mandated reporters and must report all incidents to Community Care Licensing and the appropriate agencies. S1-S4 and R1-R23 stated residents residing in the facility communicate with other residents. S1-S4 and R1-R23 stated residents go outside and they are around other residents. R2-R23 stated they are happy and like living here. S1-S4 and R2-R23 stated the allegations are false. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 8, 2023 · control 11-AS-20220914141831

Type of visit: Required - 1 Year

On 11/04/2022 at 09:00 AM Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Annual required visit to Vista Del Mar Senior Living Facility (197608029) with a primary focus on infection control measures. LPA Jose Calderon was met by Administrator Reggie Jones and the purpose of today’s visit was explained. The facility is licensed to serve 300 elderly residents 59 years and older. There are currently 225 elder residents in care. There are 167 non-ambulatory and 75 ambulatory clients of which 38 residents are in the Memory Care Unit. The facility is a 2-story structure with 278 bedrooms and 4 common bathrooms, multimedia rooms, movie room, commercial kitchen, large dining room, large common patio, conference meeting room and staff offices. The facilities’ last fire drill was conducted on 10/24/2022 by Long Beach Fire Department. LPA Jose Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Jose Calderon observed the following during inspection of resident’s rooms: 105,106,113,206,207,212 mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers. LPA Jose Calderon observed fully stocked storage closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Jose Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 108 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 106 degrees Fahrenheit, and bathroom #3 hot water temperature properly measured at 109 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 109 degrees Fahrenheit. The commercial kitchen hot water temperature properly measured at 121 degrees Fahrenheit. Facility (60) Carbon Monoxide and (60) Smoke Detectors hard wired and connected were tested and are working properly. The facility (12) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. No weapons are stored in the premises. Commercial Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility. Emergency bottle water is in the kitchen storage room. Medications are centrally stored and in a locked storage cabinet in the medication room. Facility first aid kits (12) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio furniture accessible to all residents. LPA Jose Calderon reviewed Ten (10) resident files were reviewed and found to be complete. LPA Jose Calderon reviewed Ten (10) resident medications and they were all found to be administered according to doctor's orders. LPA Jose Calderon reviewed Ten (10) staff files were checked and have the required documents. LPA Jose Calderon noted that the facility does not handle resident's money/cash resources. LPA Jose Calderon noted all the required documents are posted in the facility in a clearly visible area. LPA Jose Calderon noted the Administrator Reggie Jones Certification # 6048873740 expiration date of 07/22/2022 was NOT valid at time of visit. Administrator Reggie Jones provided written proof that his renewal with the state of California is in process. . During the visit, LPA Jose Calderon observed the facility infection control practices. LPA Jose Calderon observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA Jose Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Jose Calderon observed the facility has a 90-day supply of Personal Protective Equipment (PPE) located in a storage room. LPA Jose Calderon advised the Administrator Reggie Jones to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Jose Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Reggie Jones.the state’s words, verbatim · CDSS document, Nov 4, 2022

Allegation investigated: Unqualified staff administered medications to residents. Facility had scabies outbreak. Facility had rignworm outbreak. Facility has roaches. Facility has bed Bugs. Food is not of the quality necessary to meet the needs of the residents. Facility is not clean.

On 11/3/22, Licensing Program Analysts (LPA) Martessa Brown conducted a subsequent visit unannounced complaint visit in order to render investigation findings. LPA Brown called and spoke to front desk and conducted a risk assessment before entering and there are no Covid-19 cases. LPA was greeted by Reggie Jones and explained the purpose of today's visit regarding the above allegations. The investigation consisted of the following: LPA conducted interviews with the Administrator, (8) staff and (9) clients. A review of the current staff and resident roster, staff service records, incident reports and other pertinent records was reviewed. A tour of the physical plant was conducted on 3/9/2021 and 8/4/22. Investigation revealed the following: Allegation: Unqualified staff administered medications to residents. Next page Unsubstantiated Complaint details stated caregivers apply antibiotic ointments to residents. On 3/9/21, LPA conducted interview with former administrator Brad DeHann and he stated only medical technician are able to administer medication. On 8/4/22, LPA conducted interviews resident #1-9 regarding the above allegation. Residents stated they have not received medications/ointments through caregivers. Residents stated only medical technician give them their medication and doesn’t have any concern. On 8/4/22, LPA conducted interviews with administrator and staff members #1-8 regarding the above allegation. Administrator and staff stated medications are prepared by medical technician and staff nurse per shift and complete mars book. LPA reviewed medication training records. Based on interviews conducted and documentation the above allegation is unsubstantiated. Allegation: Facility had scabies outbreak. Complaint details allegation stated facility has scabies. On 3/9/21, LPA conducted interview with former Administrator Brad DeHann and he stated 5 residents in memory care unit had scabies. LPA verified scabies protocol and notified right away residents, Doctors, DPH, CCLD and completed incident reports. On 8/4/22, LPA conducted interviews resident #1-9 regarding the above allegation. Residents stated they were not aware of a scabies outbreak in the facility. On 8/4/22, Interviews were conducted with Administrator Jones and staff members, 4 out of 8 staff confirmed scabies outbreak in memory care on June 2022. Staff and administrator stated they follow scabies protocol the and Department of Public Health was notified. LPA contacted the Health Department and confirmed scabies outbreak was reported on 6/10/22 , 1 confirmed case and 4 suspected and was cleared on 6/21/22. LPA reviewed incident reported on 6/9/22 regarding 1 confirm case and possible contacts. LPA reviewed facility's Scabies protocol procedures and doctor’s orders. Documents and interviews confirm that facility followed scabies protocol. Based on interviews conducted and documentation. The above allegation is unsubstantiated. continuation next page. Allegation: Facility had ringworm outbreak. On 3/9/21, LPA conducted interview with former Administrator Brad DeHann and he stated doctor had contacted them and validated there was no residents with ringworms. 8/4/22, LPA conducted interviews resident #1-9 regarding the above allegation. Residents stated they were not aware of a of any ringworm outbreak in the facility. On 8/9/22, LPA conducted interviews with Administrator and staff members #1-8 regarding the above allegation. They stated there was no ringworm outbreak and had no concerns. LPA also contact the Health Department and reviewed documents and there was no report to indicate a ringworm infestation. Based on interviews conducted and documentation. The above allegation there was no evidence of ringworms in the facility therefore the allegation is unsubstantiated. Allegations: Facility has roaches and bed bugs complaint details stated the facility has roaches and bedbugs due to the facility not being clean. On 3/9/21, LPA conducted interview with former Administrator Brad DeHann and he stated one resident had a concern. Regarding bed bugs he stated none during that time. Pest control comes out regularly. On 8/4/22, LPA conducted interviews resident #1-9 regarding the above allegation. Residents stated they had no bed bugs or roaches in their room. LPA conducted interviews with administrator and staff members #1-8 regarding the above allegations they stated there was no roaches, 3 staff stated there was one room with bed bugs and they promptly called pest control and took care of the problem . They also stated pest control comes twice a month. LPA reviewed Orkin’s pest control records and from invoice on January 2021 to present and receipts indicated preventive measure were taken for spot check for insects. LPA observed the facility bedrooms and common area and did not see any signs of roaches or bedbugs. based on interviews and documents facility has pest control coming out twice a month for preventive measure. Based on interviews conducted and documentation. The above allegation is unsubstantiated. Continuation next page. Allegation: Food is not of the quality necessary to meet the needs of the residents. Complaint details stated food is not cooked. On 3/9/21, LPA conducted interview with former administrator Brad DeHann and he stated cooks are qualified and trained and facility has dieticians. On 8/4/22, LPA conducted interviews resident #1-9 regarding the above allegation. Residents stated they had no problems with receiving under cook food or being cold. Residents also have not heard any complaints from other residents LPA conducted interviews with administrator and staff members #1-8 regarding the above allegations they stated food is serve 3 times a day and had no concern with the food quality. LPA reviewed staff training food handler certificates, menus and detain logs. LPA toured the facility kitchen. Based interviews conducted and documentation. The above allegation is unsubstantiated. Allegation: Facility is not clean. Complaint details stated has mold on walls and carpet smells. On 3/9/21, LPA conducted interview with former Administrator Brad DeHann and he stated facility is clean daily, bedrooms are vacuumed, and deep clearing is done weekly. On 8/4/22, LPA conducted interviews resident #1-9 regarding the above allegation. Residents stated they had no problems with facility not being clean. They stated housekeeping cleans their bedrooms every day, bathrooms and take out the trash. They stated had no concerns. LPA conducted interviews with administrator and staff members #1-8 They stated housekeeping cleans every day and also deep cleans. LPA reviewed housekeeping Deeping cleaning schedule for all floors. LPA toured the facility bedrooms, common areas and all 3 floors, and the facility was clean. Based on interviews conducted and documentation. The above allegation is unsubstantiated. 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. An exit interview was conducted with Administrator Reggie Jones, and a sign hard copy was provided.the state’s words, verbatim · CDSS document, Nov 3, 2022 · control 11-AS-20210301103601

Allegation investigated: Staff refused to take resident back into care

On 04/19/2022 around 09:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Reggie Jones. The Investigation consisted of the following: On 04/19/2022 LPA Calderon interviewed Administrator S1 and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, LA Downtown Medical Center medical records, Physicians Report for R1. On 04/19/2022 LPA Calderon interviewed staff S2-S4 regarding complaint and on 04/19/2022 LPA Calderon interviewed R2-R10 for complaint. On 04/19/2022 LPA Calderon interviewed W2 for complaint and on 04/19/2022 LPA Calderon left 3 messages to interview W1 for complaint. Unsubstantiated The investigation revealed the following: Allegation: Staff refused to take resident back into care It is alleged on facility Staff refused to take resident back into care. On 04/19/2022 LPA Calderon interviewed W2 for complaint, W1 states that R1 is violent with staff and residents and has late stage dementia per the doctor’s information. W2 states that R1 has also been violent with her personally and W2 children and therefore R1 is in the memory care unit of the facility. W2 states that the facility called W2, and W2 took R1 to the doctor’s office for evaluation. On 04/19/2022 LPA Calderon interviewed S1 who stated that R1 was aggressive with staff and other residents and R1 was taken by R1 family to the hospital to be evaluated and medication adjusted. S1 states that the facility never refused to take R1 back, just that they needed R1 medication adjusted for dementia. On 04/19/2022 LPA Calderon interviewed S2-S4 all state that R1 had become more aggressive with female staff and residents and R1 was taken to the hospital for R1 medication to be adjusted. On 04/19/2022 LPA Interviewed R2 – R10 all residents do not live in the memory care unit, but state they have no issues with receiving transportation to and back from the doctors or hospital when needed. On 04/19/2022 LPA Calderon attempted to interview R1 who has dementia and was not able to answer any questions regarding the complaint. On 04/19/2022 LPA Calderon received and reviewed the needs and services plan, physician report, LADMC hospital report for R1. Reports support that R1 has late stage dementia and has aggressive traits due to the dementia, R1 medication was adjusted and R1 was returned to the facility. On 04/18/2022, 04/19/2022 left message for W1 to call. On 04/18/2022 LPA Calderon emailed W1 who did respond by email. 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. A exit interview was conducted with Administrator Reggie Jones, and a hard copy was providedthe state’s words, verbatim · CDSS document, Apr 19, 2022 · control 11-AS-20220415125015

Allegation investigated: Resident sustained a fracture while in care Facility failed seek timely medical attention Facility has insects

Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with James Bender, the facility Vice President. The investigation consisted of following: Interviews and Record reviews. IB investigator Dennis Douglas investigated for allegations 1 & 2. On 02/15/20, LPA Soto interviewed via telephone Executive Director Brad Dehaan for allegation 3. LPA Soto received the following documents on 12/15/20: Resident Roster, Staff Schedule, Face sheet (ID/Emergency contact), Physician’s Report, Admissions Agreement, and Pre-Appraisal. Substantiated Based on IB investigation; it was revealed that R1 alleged R1 was dropped on the floor by staff members, S1 & S2 as they attempted to lift R1 from R1’s wheelchair. During the investigation, R1 was interviewed by CCL/IB (Community Care Licensing Investigation Branch) investigator and R1 disclosed that staff members S1 & S2 attempted to pick R1 up after they observed R1 on the floor next to R1 bed. R1 stated R1 was on the floor because R1 decided to execute what R1 called a "controlled slide" out of R1’s bed. R1 explained that S1 picked R1 up by R1’s legs, while S2 picked R1 up by R1’s hands. R1 stated R1 slipped out of S2 hands causing R1 to fall on the floor. As a result, R1 injured his shoulder. R1 advised S1 and S2 that they injured R1’s shoulder, but they claimed R1 injured R1’s shoulder by falling out of R1’s bed. R1 was adamant that R1 did not "fall" out of R1’s bed. R1 "slid" out of R1’s bed, which did not result in injuring R1 shoulder. During the investigation, it was revealed that R1 had informed several different sources (a family friend, hospital staff, and additional staff members at the facility) that it was facility staff that caused R1 injury. Both S2 & S1 deny dropping R1 but acknowledged attempting to pick R1 up off the floor but was unable to because R1 was too heavy. Per the medical records, it indicated R1 indeed sustained a "Mildly Displaced Fracture of the Proximal Humerus Extending to the Greater Tuberosity." It appears more likely than not that the injury sustained to R1’s shoulder was the result of R1 being dropped by facility staff. Therefore, the Allegation 1 – resident sustained a fracture while in care is "substantiated" at this time. Allegation # 2 – Facility failed to seek timely medical attention – During IB investigation; it was revealed that R1 alleged R1 was dropped on the floor by staff members, S1 & S2 as they attempted to lift R1 from R1’s wheelchair. During the investigation, R1 was interviewed by CCL/IB (Community Care Licensing Investigation Branch) investigator and R1 disclosed that staff members S1 & S2 attempted to pick R1 up after they observed R1 on the floor next to R1 bed. After the incident R1 complained of pain in R1's shoulder, staff only provided pain medication. Staff did not send R1 immediately after incident, staff waited several days after incident to send R1 to the ER only after R1 insisted on being sent to the ER Therefore, the allegation is substantiated. Allegation 3 – facility has insects. The Interview conducted with Executive Director, he stated that the facility did have cockroaches in the facility. Orkin pest control came to spray the facility on the 3 following dates: 09/02/20, 11/17/20, & 12/04/20. LPA reviewed Orkin pest Control invoices for those dates. The cockroaches had been eliminated from the facility. Therefore, the allegation is substantiated. Based on Investigator Douglas observations and interviews which were conducted and records reviewed, violations were found and are being cited on the attached LIC 809D per Title 22, Division 6, Chapter 8 of the California Code of Regulations; and an immediate Civil Penalty in the amount of $500.00 issued, although an enhanced civil penalty is being considered. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations. An exit interview was conducted with James Bender, Vice President and a hard copy of report was provided along with Appeal Rights.the state’s words, verbatim · CDSS document, Apr 18, 2022 · control 11-AS-20201214150519

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 22, 2022

87468.1 (a)(3) 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 was not met as evidenced by Based on observations and interviews Staff dropping R1 and fracturing his shoulder. Which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 18, 2022

Plan of correction: Executive Director implement a plan of training for all staff. What types of training will be taught, when, and who will perform the trainings? Send to LPA on or before POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Apr 22, 2022

87465(g) -The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).this was not met as evdenced by: Based on observations and interviews staff did not call or take R1 to the ER in a timely manner. Which poses a potential health and safety risk for persons in carethe state’s words, verbatim · CDSS document, Apr 18, 2022

Plan of correction: Executive Director implement a plan of training for all staff. What types of training will be taught, when, and who will perform the trainings? Send to LPA on or before POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 22, 2022

87303(a) 873039a) 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 was not met as evidence by: Based on observations and interviews Facility had roaches, which poses a potential health and safety risk for the persons in care.the state’s words, verbatim · CDSS document, Apr 18, 2022

Plan of correction: Executive Director will implement a plan on best practices to ensure the facility will not have a pest problem in the future. Send to LPA on or before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(h)(5) · Plan of correction due date: Apr 22, 2022

87405(h)(5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs, including those services identified in the residents' Pre-Admission Appraisals, specified in Section 87457, Pre-admission Appraisal, and Reappraisal, as specified in Section 87463. This was not met as evidence by: Based on observations and interviews Administrator failed to get immediate help for R#1. Which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Apr 18, 2022

Plan of correction: Administrator will create a plan and how to report and seek immediate help for residents by POC due date.

Allegation investigated: Facility is not following COVID protocol

On 02/23/2022 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above, today’s complaint investigation was conducted face to face with Administrator Reggie Jones. The Investigation consisted of the following: On 02/23/2022 LPA Calderon interviewed witness 1 for complaint. On 01/12/2022 LPA Calderon interviewed Administrator S1 and conducted a tour of the physical plant. On 02/23/2022 LPA Calderon obtained copies of Staff and Resident rosters, deep cleaning records and disinfection records for the facility. On 01/12/2022 LPA Calderon interviewed S2-S4. On 02/23/2022 LPA Calderon interviewed R1-R10 for complaint. The investigation revealed the following: Unsubstantiated Allegation: Facility is not following COVID protocol. It is alleged that the Facility is not following COVID protocol. On 01/12/2022 LPA Calderon interviewed S1-S4 who stated that staff does clean and disinfect all common areas and that all residents and staff wear mask and follow DPH and DSS guide lines regarding Covid-19. On 02/23/2022 LPA Calderon interviewed R1-10 who all state that the facility is cleaned daily, and all staff and residents must wear masks while inside the facility. On 02/23/2022 LPA Calderon interviewed W1 who states that the facility does not supply clean masks to staff but can state that the facility is cleaned daily. W1 also suggest that the facility does not pay for overtime due to Covid-19. On 02/23/2022 LPA Calderon reviewed the cleaning documents and the facility common areas and rooms are done daily. 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. A telephonic exit interview was conducted with Administrator Reggie Jones, and a hard copy was provided by hand for the facility recordsthe state’s words, verbatim · CDSS document, Feb 23, 2022 · control 11-AS-20220111140048

Allegation investigated: Facility is not allowing resident to have visitors. Resident is being neglected while in care.

On 02/23/2022 around 9am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above, today’s complaint investigation was conducted face to face with Administrator Reggie Jones. The Investigation consisted of the following: On 02/15/2022 LPA Calderon interviewed witness 3 for complaint. On 02/23/2022 LPA Calderon interviewed Administrator S1 and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Physicians Report. On 02/23/2022 LPA Calderon interviewed S2-S6. On 02/23/2022 LPA Calderon interviewed witness 1 – 2. On 02/23/2022 LPA Calderon interviewed R1 for complaint. On 02/23/2022 LPA Calderon reviewed Needs and Services Plan, Physician Report, prior admission report from prior facility, hospital records, power of attorney and email from POA and facility all for R1. On 05/02/2022 LPA Calderon interviewed R2 - R9 for complaint. The investigation revealed the following: Unsubstantiated Allegation: Facility is not allowing resident to have visitors. It is alleged that the Facility is not allowing resident to have visitors. On 02/15/2022 LPA Calderon interviewed W3 who stated that the POA would not allow W3 to visit the resident and that the facility refused for W3 to enter the facility and visit R1. On 02/23/2022 LPA Calderon interviewed S1 who stated that POA who is the W1 would not allow W3 to visit R1. W1 – W2 state that they will not allow W3 to visit R1 since R1 gets agitated when R1 speaks to W3 and it is not good for his health. On 02/23/2022 LPA Calderon interviewed R1 who states R1 is very happy with the care given by the facility and that R1 understood what R1 was signing at the hospital and that R1 does not want to see W3. On 05/02/2022 LPA Calderon interviewed R2 – R9 who state that they have no issues with family members visiting when they want to. Allegation: Resident is being neglected while in care. It is alleged that Resident is being neglected while in care. On 02/15/2022 LPA Calderon interviewed W3 who stated that she does not have any issues with the current facility care but does have issues with the prior facility care for R1. On 02/23/2022 LPA Calderon interviewed S1 who stated that S1 has not received any feedback from W1-W3 regarding the care of R1 and that no staff have told S1 of any issues with care. On 02/23/2022 LPA Calderon interviewed W1-W2 who stated that facility is giving great care to R1. On 02/23/2022 LPA Calderon interviewed S2-S6 all state that R1 is given the best care possible, even if R1 refuses care from staff. On 02/23/2022 LPA Calderon interviewed R1 who state that he loves living at the facility and has no issues with the care given to R1. On 05/02/2022 LPA Calderon interviewed R2 – R9 all state that the facility provides the best care possible and no staff neglects any resident. 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. A telephonic exit interview was conducted with Administrator Reggie Jones, and a hard copy was provided by hand for the facility recordsthe state’s words, verbatim · CDSS document, Feb 23, 2022 · control 11-AS-20220214121625

Allegation investigated: Resident requires a higher level of care. Resident left in a soaked diaper and urine saturated dressing.

On 12/01/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility, LPA was greeted by Assistant Administrator Reginal Jones. LPA explained the purpose of today's inspection visit was to complete the complaint investigation. The investigation consisted of the following: An interview with the administrator, staff #2-#8 (S2-S8), resident #1-R11 (R1-R11), witness #1 (W1). A review of service records, medical records, photographs, and other pertinent documents was reviewed. A collateral visit at Asahi Residential Care and a tour of the facility on 06/02/21 and 11/30/21. Evaluation Report continues on LIC 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident requires a higher level of care. The complainant alleges resident #1 (R1) required a higher level of care. The complainant did not provide additional details on this allegation. Records indicate that there was no lack of care or supervision with (R1’s) care. Progress notes indicate that (R1) was reassessed each time she was returned from a hospital stay and interventions included repositing and changing every 2 hours. (R1) was readmitted to the hospital on 12/11/20. and was discharged 01/16/21. Medical records indicated during (R1’s) discharge that she would require a higher level of care and that the hospital will be responsible for an appropriate placement for (R1’s) care who eventually was placed on hospice care. Interviews conducted with residents #2-#11 all revealed that have no signs of any residents that require higher-level care. According to staff #1-#8 (S1-S8) there are no residents that are being retained at this facility that require a higher level of care that would violate Title 22 Regulations 87615 Prohibited Health Conditions. The facility continues to implement employee training programs that address the nature of these issues. Based on the information gathered, there is no evidence to support the allegation mentioned above. Allegation: Resident left in a soaked diaper and urine saturated dressing. It is alleged resident #1 (R1) was left in a soaked diaper saturated with urine. The complainant did not provide additional information on this allegation. The administrator (S1) stated caregiver’s responsibility is to assist the residents with activities of daily living (ADL). Caregivers could be responsible for up to 10 residents at one time. When a caregiver is notified of a diaper or bedding change, the caregiver will address the matter immediately. Moreover, caregivers are trained to use aided equipment to help maneuver residents who are heavy to clean them. (S1) claims in the situation with (R1) when admitted in 2015 was medically evaluated as independent health condition declined each time she was in and out of the hospital. (S1-S2) claims that (R1) was being assisted by caregivers (R1) was being assisted with diaper changes every two (2) hours and repositioned. (S2-S8) all verified residents are monitored at least three times during each shift within the eight hours. (S2) further asserted, it would be improbable to have (R1) in soiled diapers for more than (2) two hours as she was changed every two (2) hours. Interviews with residents #2-#11 (R2-R11) all claimed they had no problems with the staff and found them to be attentive and responsive to their care and needs. Evaluation Report continues on LIC 9099-C INVESTIGATION REVEALED THE FOLLOWING: Allegation: Resident has a worsening wound and pressure injury while in care. It is alleged resident #1 (R1) had a worsening wound and pressure injury while in care. The complainant claims that (R1’s) wound deteriorated and developed more deep tissue injuries. According to service records and (S2) Declaration, (R1) was sent to the hospital on 11/16/20 and returned on 11/17/20. During (R1’s) stay at the hospital, she developed a Stage 1 pressure wound. Despite all interventions including reposition and diaper changes, (R1)'s wounds developed to Stage 2 while at the facility. According to (S2) the facility made attempts for Home Health assistance and was unsuccessful. According to an incident report (R1) was readmitted on 12/11/20 at the hospital for further evaluation and intervention. (S2) reports there was no wound care plan in place when the facility was treating the (R1) for Stage 1 or 2 pressure injuries. According to medical records (R1) when admitted on 12/11/20 had pressure ulcer at Stage 4. An interview with (W1) stated that he was aware that (R1) had pressure injuries and was unable to determine the stage level as it was difficult to do an in-person visit during the COVID pandemic. An interview with (R1) claims she had pressure injuries while she was being cared for at the facility and it was painful. Based on interviews and physical evidence, there is sufficient proof to support the allegation mentioned above. Based on the Department's observation and interviews, records, and photographs reviewed, the preponderance of evidence standard has been met, therefore the allegation of "Resident has a worsening wound and pressure injury while in care" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D. An exit interview was conducted with Reggie Jones. The Rights were discussed, and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report. Furthermore, (R2-R11) felt their care and supervision are being met and were complimentary of the staff. According to (S1) the staff went above and beyond what was expected and that (R1) was not charged additional fees for the additional services performed. An interview with (R1) could not recall if she was left in soiled clothing or diapers. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above. The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R1)'s service records, and interviews conducted and found no evidence to support the allegations: "Resident requires a higher level of care" and "Resident left in a soaked diaper and urine saturated dressing". 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. An exit interview was conducted with Reggie Jones and a copy of the report was provided by email.the state’s words, verbatim · CDSS document, Dec 1, 2021 · control 11-AS-20201210140829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87631(3)(A) · Plan of correction due date: Dec 15, 2021

87631 Healing Wounds (3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional. This requirement was not met as evidenced by: Based on LPA observations, interviews conducted and record reviews, the Licensee failed to ensure to address R1's diagnosed by skilled professional for the Stage 1&2 wounds. No wound care plan in place. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2021

Plan of correction: Licensee agrees that a Plan of Correction in place by 12/15/21. The licensee will adhere to Title 22 Section 87631 and develop a written plan. POC must be sent to licensing office by POC date 12/15/21.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Dec 15, 2021

87466 Observation of the Resident State regulations require the licensee to ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by: Based on LPA observations, interviews conducted, and record reviews, the Licensee was aware of R1's wounds condition and incorrectly diagnosed the wound condition. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 1, 2021

Plan of correction: Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 12/15/21 to the licensing office.

Allegation investigated: Staff are not meeting residents dietary needs

On 09/15/2021 around 12:00 pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator Reggie Jones. The Investigation consisted of the following: On 08/20/2021 LPA Calderon reviewed all complaint notes. On 08/26/2021 LPA Calderon interviewed Administrator Reggie Jones and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record Needs and Service Plan, Pre-Placement Appraisal, Physicians Report. On 08/26/2021 LPA Calderon interviewed staff S2-S3 regarding complaint and on 08/26/2021 LPA Calderon interviewed R1-R5 for complaint. Finally, LPA Calderon interviewed S4 for complaint The investigation revealed the following: Unsubstantiated Allegation: Staff are not meeting residents’ dietary needs It is alleged on facility Staff are not meeting residents’ dietary needs. On 08/26/2021 LPA Calderon interviewed S1 who states that he has been working with R1 for some time regarding her diabetic meals and that R1 is very picky regarding what she eats and changes her mind many times. S1 states that they do follow the doctor’s instruction and that R1 changes the meal plan all the time. S1 states that R1 has mental issues and they are aware of her issues. LPA Calderon interviewed R1 who claimed staff has been feeding her greasy food for many months and that she must purchase food so that she does not starve herself. R1 states that the facility does not follow her doctor’s instruction and she must change what the facility kitchen sends to her daily. On 08/26/2021 LPA Calderon interviewed R2-R4 all confirm the food could be better but that the kitchen does follow their doctors’ instructions and they have many choices of food to pick every day and they do not have any issues with the food. LPA Calderon interviewed S2-S4 all confirm issues with R1 regarding her food and her overall care by staff. Staff confirms that they make sure to follow the doctor’s instructions regarding R1 food, but that R1 changes her mind many times and they cannot keep up with what R1 is requesting to eat. On 08/20/2021 LPA Calderon reviewed R1 facility medical information, confirmed R1 has dementia and sees things that are not there. 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. A exit interview was conducted with Licensee James Bender, and a hard copy was provided.the state’s words, verbatim · CDSS document, Sep 20, 2021 · control 11-AS-20210819151330

Allegation investigated: Facility has bed bugs Facility did not report an unusual incident

On 09/20/2021 around 11:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Licensee James Bender. The Investigation consisted of the following: On 9/20/2021 LPA Calderon interviewed reporting party. On 09/20/2021 LPA Calderon interviewed Licensee James Bender and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, R1-R2 record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list) and housekeepers training documentation and cleaning procedures, plus VA hospital records. On 09/20/2021 LPA Calderon interviewed staff S2-S4 regarding complaint and on 09/20/2021 LPA Calderon interviewed R1-R5 for complaint. The investigation revealed the following: Substantiated Allegation: Facility has bed bugs It is alleged on Facility has bed bugs. On 09/20/2021 Responsible Party (RP) was informed by the VA Hospital that R1 had bed bugs bites and a rash and was treated medically. Reporting party states that social services for the VA was not informed by the facility prior to the medical report. On 09/20/2021 LPA Calderon interviewed S1 who confirmed R1 did in fact have bed bugs and contracted the beds from R2. On 09/20/2021 LPA Calderon interviewed S2-S4 who all confirm that R1-R2 had bed bugs. On 09/20/2021 LPA Calderon interviewed S2-S5 who can confirm beds in the past but no current issues. On 09/20/2021 reviewed facility paperwork and VA hospital paperwork which confirmed R1 had bed bugs. Allegation: Facility did not report an unusual incident It is alleged on facility did not report an unusual incident. On 09/20/2021 LPA Calderon interviewed reporting party who confirmed facility did not report the bed bugs to social services VA and have been informed of same in the past. On 09/20/2021 LPA Calderon interviewed S1 who confirmed they did not report the bed bugs to social services of DSS prior to the complaint being generated. On 09/20/2021 LPA Calderon interviewed S2-S4 who all confirm they did report the bed bugs to upper management and does not know if upper management reported the bugs to social services VA or DSS. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A exit interview was conducted with Licensee James Bender, and a hard copy was provided.the state’s words, verbatim · CDSS document, Sep 20, 2021 · control 11-AS-20210914155451

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(A) · Plan of correction due date: Oct 1, 2021

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by Based on records reviewed and interviews conducted the licensee failed to ensure Residents #1 was afforded a safe and comfortable accommodations. R1 was infected with bed bugs while in placement at facility. This poses a health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2021

Plan of correction: Administrator will follow protocols of Department of Public Health. Administrator will provide copy of actions taken by' facility based on Department of Public Health's instructions. Due date 10/01/2021.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(A)(2) · Plan of correction due date: Oct 1, 2021

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as epidemic outbreaks... This requirement was not met as evidenced by: Based on records reviewed and interviews conducted the licensee failed to report the bed bug outbreak to VA social services or Department of Social Services. This poses a health & Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2021

Plan of correction: Administrator will ensure additional training regarding proper reporting from staff to upper management to reporting parties. Administrator shall submit to LPA by POC

Allegation investigated: Resident sustained multiple pressure injuries while in care. Resident sustained multiple falls while in care. Staff did not give resident medication as prescribed. Resident was severely dehydrated. Staff did not ensure resident was fed. Staff did not notify authorized representative of resident's change of health. Staff did not safeguard resident's personal belongings.

On 08/19/2021 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator James Bender. The Investigation consisted of the following: On 02/10/2021 LPA Calderon interviewed S1-S4 and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list for R1. On 02/11/2021 LPA Calderon interviewed (W1). On 02/11/2021 LPA Calderon interviewed W2. On 02/19/2021 LPA Calderon interviewed Residents R2 – R11. IB interviewed S1 on 02/24/2021, RN W1 on 03/01/2021, S2-S4 on 04/16/2021. IB reviewed medical records on 02/21/2021 and LPA Calderon reviewed all facility paperwork on 04/27/2021 The investigation revealed the following: Unsubstantiated The investigation revealed the following: Allegation: Resident sustained multiple pressure injuries while in care. IB investigator reviewed R1 medical records and conducted interviews with witnesses and facility staff. Review of Hospital records and photographs document a sacral area and a perirectal area wound. However, there is no information that these wounds were formally staged. The first charting of the sacral area wound was not until R1 had been hospitalized for approximately 34 hours. Information obtained from Witness #1 (W1) supports the possibility that the wound could have developed in the hospital, not necessarily while in the care of Vista Del Mar. Review of R1 facility record does not document pressure injuries or wounds. The Administrator and facility staff were interviewed and denied R1 having multiple pressure injuries. Allegation: Resident sustained multiple falls while in care. IB Investigator interviewed W1 to obtain professional opinion is that R1 did sustain multiple witnessed falls is June and July which were not reported by the facility but did not see any evidence there were multiple unreported falls suffered by R1. LPA Calderon interviewed S1-S4 and all confirm that R1 did have falls due to age, not waiting for staff while moving from wheelchair to bed. According to records reviewed R1 required prompts to not move out of wheelchair or bed with out assistance due to R1 dementia. The facility conducted a fall risk assessment in conjunction with R1 family and the falls were being addressed. Allegation: Staff did not give resident medication as prescribed. It is alleged staff did not give resident medication as prescribed. LPA Calderon interviewed S1-S4 all confirm that R1 medication was given correctly and there was no mistake with R1 MAR. LPA Calderon interviewed R2-R11 and all confirm no issues with medication and staff does a great job. LPA Calderon reviewed resident medications and Medication Administration Record and did not observe any discrepancies. Allegation: Resident was severely dehydrated. IB review of records revealed the facility documented their attempts to provide R1 fluids, although her oral intake abilities were diminishing as her dementia progressed. She was also on a diuretic medication. W1 stated that R1 was most likely dehydrated when she got to the hospital, but it was not a result of staff neglect at Vista Del Mar. The facility staff and Administrator denied neglect and stated R1 was provided fluids but was difficult for R1 to intake due to decline in health. Allegation: Staff did not ensure resident was fed. LPA Calderon interviewed S1-S4 and all confirm resident was given food, but R1 sometimes refused to eat. LPA Calderon interviewed R2-R11 and all residents confirm3 meals a day and no issues with food. Review of records revealed R1 was declining and often refused food. Allegation: Staff did not notify authorized representative of resident's change of health. LPA Calderon interviewed S1-S4 and all confirm communication with POA for R1 and any change of health was advised in writing. LPA Calderon interviewed R2-R11 all residents confirm that their families are given updated regarding their change in health. Allegation: Staff did not safeguard resident's personal belongings. LPA Calderon interviewed S1-S4 all confirm that R1 personal items were safe and no one stole the belongings. LPA Calderon interviewed R2-R11 and all confirm that no one has ever stole any of their personal items. 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. A telephonic exit interview was conducted with Administrator James Bender, and a hard copy was provided face to face for records.the state’s words, verbatim · CDSS document, Aug 19, 2021 · control 11-AS-20210126160314