Whittier Glen Assisted Living

Allegation investigated: Facility does not have a Certified Administrator

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation for the allegation(s) above. LPA met with Wellness Director Sherrie Similton and the purpose of the visit was discussed. Initial visit conducted 3/12/21 LPA Villalobos interviewed Resident #1 (R1) Staff #1 (S2) and Staff#2 (S2). LPA requested copies of the following: Staff Roster as well R1's Physicians report, Needs and Services plans, Medication Records for March and February of 2021, and Admissions Agreement. On todays visit, LPA interviewed Staff #3-#5 (S3-S5) and residents #2-6 (R2-R6). The investigation revealed the following: In regards to the allegation "Facility does not have a Certified Administrator" it was alleged that the facility does not have an active administrator. (2) of (5) Staff interviewed denied the allegation. (3) of (5) Staff interviewed could not provide information regarding the allegation. Continued on LIC 9099-C Substantiated (6) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff show that low pressure toilets were being changed in the facility to replace them with better ones. No toilet was broken or non operational and all residents in rooms where the bathroom toilets were being changed, were provided with assistance in using other restroom toilets or commodes if they preferred. Interviews with R1 show that staff provided R1 with a commode and there were other restrooms in the facility for R1 to use. R1 used the commode with staff assistance. Based on interviews conducted; 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 allegations are unsubstantiated. In regards to the allegation "Facility is not obtaining renewed medication timely" it was alleged that the facility staff is not receiving and providing R1 with their medication in a timely manner. (5) of (5) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1 contacted his physician for medication changes. R1's family member picked up new medications and dropped them off to R1 without notifying the facility staff. S1 stated that R1 is not able to handle their own medication and so they had a conversation with R1 regarding medication management and that staff cannot provide R1 with the new medication unless they also confirm the physicians order for it. Once the medication order was confirmed, staff began to provide R1 with the medication. Staff denied not obtaining R1's medication in a timely manner. Based on interviews and file review conducted; 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 allegations are unsubstantiated. Exit Interview conducted and a copy of this report was provided. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews and file review show that administrator Mona Tirado last day at the facility was on 2/12/21. Between 2/12-3/10 there was an interim administrator Lori Waters assisting the facility, but documents for change of administrator were not provided to Licensing in this time. It was not until May 2021 when Licensing received documentation for change of Administrator to Sophia Chan. This shows that facility failed to maintain a qualified and currently certified administrator. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided and discussed.the state’s words, verbatim · CDSS document, May 23, 2023 · control 28-AS-20210304103655

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jun 2, 2023

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.... This was not met as evidenced by: Adminstrator Mona Tirado left the facility on 2/12/21 and was not replaced by a full time Administrator until 5/2/21. This poses a potential health and safety risk to residents in care and supervision.the state’s words, verbatim · CDSS document, May 23, 2023

Plan of correction: Facility Administrator to review Title 22 Regulations regarding 87405 Administrator - Qualifications and Duties and submit letter to LPA signed and dated by POC due date.

Allegation investigated: Staff mishandled a resident's medications while in care Staff did not meet a resident's dietary needs while in care Staff did not provide adequate care and supervision to a resident while in care

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegation(s) above. LPA met with Wellness Director Sherrie Similton and the purpose of the visit was discussed. Initial visit on 1/25/23 consisted of the following: LPA interviewed Staff #1-#2 (S1-S2) and Residents #2-#5 (R2-R5). LPA toured the physical plant of the facility and observed the food supply. LPA collected a copy of the staff and resident roster. LPA collected documents related Resident #1's (R1) File such as the facesheet, needs and services plan, medication record, and any related facility notes. LPA was unable to interview R1 as R1 was not available during the visit. On todays visit, LPA interviewed Staff #3-#6 (S3-S6) and resident #1(R1) and resident #6 (R6). LPA reviewed food menu for weeks of January and April 2023. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff mishandled a resident's medications while in care" it was alleged that R1 did not receive their medication for the month of January and weeks of December 2022. (6) of (6) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1 received their medication as prescribed for all months R1 received medicine management from the staff. LPA reviewed the medication records and observed R1 to have been receiving their medication as prescribed. Interview with R1 shows that R1 wanted to manage their own medication and as of 2/6/23, under order from physician, R1 has a safe to store and manage their own medication. LPA was not provided proof that staff did not provide R1 their medication prior to 2/6/23. Based on interviews, files reviewed and observations, there was not enough supportive evidence to corroborate 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 UNSUBSTANTIATED. In regards to the allegation "Staff did not meet a resident's dietary needs while in care" it was alleged that there was no protein being provided in residents meals. (6) of (6) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that protein is provided in multiple meals throughout the day to residents in care. Interviews also stated that residents can fill out a meal substitution form where they can request specific meals if they do not want what is on the menu. LPA observed the food supply to have protein based food. LPA reviewed the facilities meal schedules for various weeks and observed each day to have protein on menu. Based on interviews, files reviewed and observations, there was not enough supportive evidence to corroborate 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 UNSUBSTANTIATED. In regards to the allegation "Staff did not provide adequate care and supervision to a resident while in care" it was alleged that staff abuse and neglect R6. (6) of (6) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interview with R6 denies any abuse and neglect from staff. Interviews do not show that staff abuse and neglect R6. LPA did not observe any documentation on file of R6 being abused or neglected. LPA was not provided with proof that staff abuse or neglect R6. Based on interviews, files reviewed and observations, there was not enough supportive evidence to corroborate 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 UNSUBSTANTIATED. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2023 · control 28-AS-20230124104621

Allegation investigated: Staff are not feeding resident in care.

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint investigation visit for the allegation above. LPA met with Wellness Director Sherrie Similton and the purpose of the visit was discussed. On todays visit, LPA interviewed Staff #1-#5 (S1-S5) and residents #1-#6 (R1-R6). LPA reviewed food menu for weeks of January and April 2023. LPA reviewed toured the physical plant and observed the food supply. LPA collected copies of the resident and staff roster. LPA reviewed and collected copies of documents from R1's file. The investigation revealed the following: In regards to the allegation "Staff are not feeding resident in care." it was alleged that R1 has not received meals in the facility since Easter 2023 (4/9/23). (5) of (5) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. CONITUNED ON LIC9099-C Unsubstantiated Interviews show that R1 eats meals in the facility on occasion but will choose to eat meals in their room with food and snacks that R1 purchases themself. Interviews do not show that R1 is denied meals or not offered meals in the facility. File review shows that R1 is provided a special diet due to health reasons and all staff interviewed are aware of it. LPA observed the food supply and observed residents eating sufficient meal portions for lunch. Based on interviews, files reviewed and observations, there was not enough supportive evidence to corroborate 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 UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 2, 2023 · control 28-AS-20230427130936

Allegation investigated: Inadequate staff supervision resulting in resident being assaulted by another residents Staff spoke inappropriately to resident Facility is unlawfully evicting resident Staff did not safeguard resident’s personal items Staff did not provide meals to resident

********This is an amended version of the original report created on 4/21/2023*****. This report is being amended to remove confidential information. No other changes have been made to the report.************ Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint investigation for the allegations listed above. LPA met with Staff #5 (S5) and explained the reason for the visit. LPA Pena spoke with the Operations Manager, Michael Forsgren on the phone to discuss the purpose of today's visit as he is out of the office. S5 will be assisting LPA with the investigation during today's visit. On 03/28/2023, LPA Pena conducted the initial complaint investigation which included: tour of the facility; R1’s room, the dining room and common areas. LPA reviewed and obtained copies of Resident #1 (R1) files. LPA also obtained various documents from the facility files such as: Staff/Resident Roster, House rules, Eviction notices (02/21/2023 & 03/16/2023), Police report #23-1597, Unusual Incident/Injury Report dated 3/16/2023 with Administrator Self-reported SOC 341, list of Staff Training and Monthly Meal menu. Interviews were conducted with Resident #2 (R2)-Resident #8 (R8) and Staff #1 (S1)-Staff #4 (S4). During today's visit, LPA Pena obtained copies of the Staff & Resident Rosters, Unusual Incident/Injury Reports dated 02/07/2023 & 02/16/2023, toured the facility, and interviewed Staff #5 (S5) and Staff #6 (S6). ****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Regarding allegation: "Inadequate staff supervision resulting in resident being assaulted by another residents." It is alleged that R1 has been assaulted by different residents and a night staff on separate occasions. Interviewed staff members denied the allegation and stated that they always have problems with R1. Staff members indicated that R1 was always drunk and blame other people for his drinking problems by making up stories. Interviews conducted with R2 and R8, stated that the allegation was untrue. R2 stated that he never accosted R1 nor grabbed and spilled his food. R8 stated that he never dragged R1 from his legs and tried to hit him. The investigation revealed that local law enforcement responded to the facility on the evening of 03/15/2023 regarding a resident (R1) that had a knife on the 2nd floor. S2 was doing her rounds and observed R1 inebriated in his wheelchair and was arguing with residents. S2 asked R1 to return to his room, and R1 fell asleep on the way to his room. At approximately 9:00pm, S2 received a call from the local Police Dept. regarding a resident that had a knife. S2 immediately responded and found other residents using a table to block R1 from attacking them with a 6-inch knife. R2-R5 who were witnesses to the incident stated that R1 woke up and became aggressive, produced a knife and R2-R3 started defending R4-R5 and themselves. R1 received a laceration on his nose due to a table used in defense. No one else was injured during the incident. Police then arrived on scene and subdued R1. Paramedics arrived shortly after and R1 was taken to the hospital for medical treatment. S1 stated that PD refused to take R1 into custody due to R1 being in a wheelchair, but police report indicated that R1 will be cited for assault with a deadly weapon. On 3/16/2023, R1 was discharged from the Hospital and returned to the facility. S1 stated that he has made several calls to R1's Social Worker to assist with new placement but was unsuccessful. W1 confirmed S1's statement and added that W1 was also active in looking for another place for R1. Files reviewed indicated that on 2/21/2023, the facility issued a 30-day eviction notice to R1 due to prior history of verbal and physical threats against other residents, staff, police and paramedics while inebriated. On 3/16/2023, R1 has been issued a 3-day eviction notice due to being a danger to himself and others and was approved by CCLD on 3/20/2023. On 03/22/23, R1 was moved out of the facility to a medical clinic . Interviewed residents stated that R1 was the aggressor physically and verbally. Some residents stated that they were never assaulted or was spoken inappropriately by other residents or staff. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation. Regarding allegation: "Staff spoke inappropriately to resident." It is alleged that a resident was unable to sleep so he went to the hallway when a night staff yelled and cursed at him and told him to go back into his room. Interviews conducted with staff denied the allegation and indicated that they do not speak inappropriately, use profanity nor yell at residents. All staff members also indicated that they have not heard or witnessed anybody speaking inappropriately to residents. S2 and S4 denied speaking inappropriately to residents, or knowledge of any staff working during the day or night shift addressing R1 or any residents in an inappropriate manner. S2 stated that she was doing her rounds one night and observed R1 inebriated in his wheelchair and was arguing with residents. S2 asked R1 to return to his room, but she did not curse or yell at R1. Staff members also indicated that they receive monthly in-service training related to Residents Rights and Personal Rights. Residents interviewed indicated that they have not heard staff using profanity and staff do not yell at them. Residents also indicated that staff communicate with them in a respectful manner. Therefore there was insufficient evidence to corroborate with these allegation. Regarding allegation: "Facility is unlawfully evicting resident." It is alleged that on 3/16/2023, resident was advised that there were witnesses that he was the aggressor and that he had to leave and has until 3/23/23 to do so. And that the resident was asked to sign a document which he refused to sign and was not provided with anything in writing. Documents reviewed revealed that the facility issued eviction notices to R1. A 30-day eviction notice was issued on 02/21/2023 due to R1's previous history of verbal and physical threats against other residents, staff, police and paramedics while inebriated, breaking the house rules regarding alcoholic beverage and R1 was behind on his monthly rent payments. Additionally, S1 stated that based on R1's Physician's report, R1 cannot leave the facility unassisted. But R1 continued to leave the facility unassisted. LPA reviewed the Physician's report and confirmed the note. Another incident occurred on 3/15/2023 wherein R1 brandished a knife which demonstrated that he was a danger to himself and others. Due to this latest incident, S1 issued a 3-day eviction notice to R1 on 3/16/2023. CCLD approved the 3-day eviction notice and a copy was also sent to Dept. of Health Care Services. On 3/20/2023, S1 along with W1 provided R1 with a copy of the 3-day eviction notice which R1 refused to sign nor keep a copy for himself. LPA reviewed R1's facility file and confirmed that eviction notices were issued to R1 on 2/21/2023 and 3/16/2023. LPA also reviewed R1's Admission Agreements which stated Eviction Procedures and House rules acknowledged and signed by R1. Based on LPA review of documents and statements gathered from interviews conducted there was not enough supportive evidence to concur with the reported allegation. Regarding allegation: "Staff did not safeguard resident’s personal items." It is alleged that the staff did not have an explanation as to what happened to the resident's food and liquor (valued at $20) and $10 in cash that was left in his room. 4 out of 6 staff interviewed revealed that they saw the bottle of alcohol in R1’s room but did not see or know anything about the food and $10 cash. Staff members stated that staff would not have thrown any of the resident’s belongings. The facility's procedure is that the staff will secure and pack residents personal belongings when they leave the facility. Then wait for instruction as to where the belongings will be sent out to or forwarded. S1-S2 stated that when R1 left, they packed R1's belongings including the bottle of alcohol, put them in a box and held it, but did not know anything about the food and the $10 cash. S1 stated that they have already sent R1's personal belongings to R1's new place approximately 2 weeks ago. 7 out of 8 interviewed residents stated that none of their items have gone missing and they would tell staff if their items went missing. Residents also stated that facility staff safeguard their belongings and personal items. Residents indicated that they don’t have a problem with missing items and they feel safe leaving their items in their rooms. Some residents also stated that they lock their doors so nothing has happened or issues with missing items. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. Regarding allegation: "Staff did not provide meals to resident." It is alleged that on 3/18/2023, a resident was not given dinner, and on 3/19/23, resident was not provided with breakfast, lunch, and dinner. The resident was physically unable to leave the room to get his meals and staff did not want to bring him his meals to the room. Staff interviewed stated that the allegation is untrue. Staff members stated that there is plenty of foods for residents and meals are provided 3x daily, breakfast, lunch and dinner. S2 stated that she brought R1's food to his room personally after the incident. S2 also brought food (breakfast, lunch) to R1's room on 3/17/2023 & 3/18/2023. S1 stated that care staff takes meal attendance to make sure all residents get their meals. None of the staff members interviewed can corroborate R1's statement that someone brought him food for dinner on 3/19/2023. Staff members also indicated that the facility provides monthly menu to residents and if the resident does not like what's served, they have an alternate menu also. Staff can also bring food trays in the residents room for an extra fee. R2-R8 stated that the facility provide meals, and they get monthly menu as well as the alternate menu. Some residents go to the dining area to eat, but if they cannot, then they order it by phone or by filling out a slip and food can be picked up or delivered to their room. LPA reviewed the monthly menu and alternate menu. LPA also observed residents eating in the dining area and a staff passing out medication with a check list of residents who are present in the dining area. Documentation reviewed and interviews conducted do not corroborate this allegation. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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, and a copy of this report was provided to the Wellness Director, Sherrie Similton.the state’s words, verbatim · CDSS document, Apr 21, 2023 · control 28-AS-20230320125600

Allegation investigated: Staff are overmedicating a resident in care.

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint investigation visit for the allegation(s) listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. Initial visit conducted on 2/14/23 involved the following: LPA interviewed Staff #1-#4 (S1-S4) and Resident #1-2 (R1-R2). LPA toured the physical plant of the facility and observed the food supply. LPA collected a copy of the staff and resident roster. LPA collected documents related Resident #1's (R1) File such as the face sheet, needs and services plan, medication record, and any related facility notes. On Todays visit, LPA interviewed residents #3-#7 (R3-R7) and Staff #5 (S5). LPA unable to interview staff #6-7 (S6-S7) as they no longer work in the facility and were unavailable for interview. LPA also contacted and interviewed Nurse Practitioner (NP) for R1. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Staff are overmedicating a resident in care." it was alleged that R1 was over medicated and in a coma like state for one week to two weeks starting 7/12/22, and the facility staff was aware but did not do anything about it. (5) of (5) Staff interviewed denied the allegation. (6) of (7) Residents interviewed could not corroborate the allegation. Interviews with staff do not show that R1 was observed to have been over medicated at any point while in the facility. Residents interviewed did not state to have seen R1 over medicated or aware of any residents being overmedicated. Review of medication records shows that R1 continued to take prescribed medications throughout the month of July 2022 up until they were taken to the hospital on 7/24/22 for a fall. R1 returned to the facility on 7/26 and later had a change in medication prescriptions. There are no notes showing that R1 was having adverse effects to their medication. Interviews with staff show they continued to follow physician orders regarding R1's medication as they must do. Interviews do not show R1 refusing medication. Interview with NP does not show that R1 had been in a coma like state or was over medicated by facility staff. Based on interviews, observations , and file reviews conducted; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 18, 2023 · control 28-AS-20230209175650

Allegation investigated: Staff did not provide resident sufficient notice prior to changing residents rate structure. Staff interfered with the resident council book by destroying the records and replaced the book with an empty book. Staff are not safeguarding the residents records.

Licensing Program Analyst (LPA) Ashley Calderon conducted an initial complaint investigation visit for the allegation(s) listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. Pre-Investigation LPM interviewed Resident #1 (R1) and Council Presdient. On todays visit 4/14/23, LPA collected resident / staff roster, Admission Agreement, Care Update Notice on Rate Change, and billing ledger report on rate change from August 2021-November 2021.LPA took pictures of the Council Books and LPA toured with Michael the facilities Business Office, Activity Office Room, and Wellness Room. LPA Calderon interviewed Operations Manager Michael Forsgren, interviewed via telephonically Administrator Rohnwinn 'Rhon' Hipolito Staff #1-#2 (S1-S2), attempt interview Staff #3 (S3) and interviewed resident #2-#10( R2-R10). Continuation on 9099-C... Unsubstantiated The investigation reveled the following: regarding allegation: Staff did not provide resident sufficient notice prior to changing residents rate structure. LPA Calderon interviewed Operations Manager Michael Forsgren, Administrator Rhon Hipolito who both denied above allegation stating residents receive a 60 day notice in writing when rent it changed and sufficient notice is provided. Interview with staff, S1 and S2 were not present during the rent increase in 2021. LPA interviewed residents R3, R4, R7-R10 all denied above allegation stating they or their representative get written notification on rent increase. Interviews with R5 and R6 stated they have not encountered a facility rent increase since admission. LPA collected Rent Increase Notice that stated increase on rent will occur within 60 days of date provided on the notice letter. LPA Calderon reviewed Billing Ledger alongside with Michael and increase on rent bill occurred within 60 days of written notice. LPA reviewed facility Admission Agreement which states facility provides a written letter at least with a 60 day notice on Basic Services/ Assisted Living Services. Regarding allegation: Staff interfered with the resident council book by destroying the records and replaced the book with an empty book. On 4/12/23 LPM Fierros and LPA Villalobos Interviewed via telephonically R1 who is not aware of the above allegation. LPA Villalobos interviewed telephonically Council President who was unaware of information regarding this allegation. LPA interviewed R2-R10 all who were not aware of a council book pertaining to the council meetings and were not aware if the book was destroyed, interfered and/or if book disappeared. LPA interviewed Michael denied the above allegation stating book staff did not interferer with the council book, it was not destroyed or did not disappear. Michael stated an additional book with residents names and responses was made for resident's privacy and minute minutes are kept in another book for residents to view. LPA Interviewed Rohn who denied the above allegation and was not aware of the council book being interfered with. Interview with S2 denied the above allegation, denied the book being interfered with in any way, S2 stated old records are kept in the Activity Office, residents minute meetings if requested S2 provides copies of meetings minutes, families and visitors have not asked to have access to the council book. Continuation on 9099-C... Regarding allegation: Staff are not safeguarding the residents records. Interview with Michael, Rohn, and S1 and S2 all denied the above allegation and stated residents records are safeguard, kept behind locked doors or locked cabinets inaccessible to clients. LPA interview with residents, R7-R10 all denied above allegation records are kept safe and staff are professional. LPA observed rooms that have residents files locked when staff weren't present, records were kept in cabinets/ shelves and rooms were inaccessible to residents. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Apr 14, 2023 · control 28-AS-20230410123136

Allegation investigated: Staff are not providing a safe environment for residents in care.

********This report supersedes the original report created on 4/13/2023. Reason for supersede is to ensure report is visible on transparency website. Findings have not changed.*********** Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Operations Manager, Michael Forsgren and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of Resident & Staff Rosters and conducted a tour of facility and common areas. LPA reviewed files for Resident #1 (R1) - Resident #2 (R2) and requested copies of the following documents: Identification and Emergency Information Sheets, Physician Reports, Resident Appraisals, and Incident Report (4/04/2023). At 1:48pm, LPA interviewed Resident #1 (R1) telephonically. LPA also interviewed Resident #2 (R2) - Resident #5 (R5) and Staff #1 (S1) - Staff #4 (S4). The investigation revealed the following: In regards to the allegation "Staff are not providing a safe environment for residents in care.", it is alleged that a resident is being threatened by another resident in the facility because of his religion. Interviews conducted with 4 out of 4 staff members all denied the allegation. All staff members interviewed indicated they have not seen or witnessed R2 made inappropriate comments or threatened other residents due to their religion. *****CONTINUED ON LIC9099-C***** Unsubstantiated S1 stated that he investigated this incident after it was reported to him by R1. According to S1, he spoke to the alleged perpetrators R2-R3, who both denied the allegation and stated that they did not threaten any residents due to their religion. S1 indicated that R1 has been making confused allegations. All staff members confirmed that Easter Service was conducted at the facility on Easter Sunday, attended by residents and staff. S1 confirmed that there was an incident on 4/04/2023 which involved R2 and R5. The incident indicated that R2 hit R5 with his wheelchair and this was reported to CCLD. Facility staff also called the police and 911. S1 stated that statements were taken by the police and will be assessed for further action, no arrests were made. S1 stated that he spoke to R2 and gave him a warning that if he continues to exhibit this type of behavior and that it would result in eviction. Interviews conducted with 4 of 5 residents indicated that R2 has never intimidated, threatened or attacked them. R2 stated that the wheelchair incident was an accident and did not mean to harm anybody intentionally. 4 out of 5 residents interviewed indicated that they feel safe and comfortable in the facility. During the facility tour, LPA observed that residents were socializing and get along well with each other in the common areas. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate 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 UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 13, 2023 · control 28-AS-20230406095433

Allegation investigated: Resident's medications are being stolen by staff while in care.

Licensing Program Analyst (LPA) Glenn Trueman conducted an initial complaint investigation visit for the allegation listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. On todays visit, LPA interviewed Staff #1-#2 (S1-S2) and interviewed Operations Manager from 9:15 AM to 10:00 AM Resident's R2-R7 were interviewed from 10:00 AM to 11:00 AM. LPA collected a copy of the staff and resident roster. LPA reviewed Resident R 1's file and facility submitted the face sheet, needs and services plan, physicians report, and admissions agreement. In regards to the allegation Resident's medications are being stolen by staff while in care, based on interviews conducted and information gathered Resident's 2-7 who were interviewed stated that they are administered medication 3x a day and it has gone smoothly all the time. They stated they have not missed any medications and staff are great and will always find them if they are not there and ensure they don't miss any dosage.. Unsubstantiated All interviewed stated no pills have ever been stolen and are never missing. Staff interviewed stated that Resident R 1 self administers medication now and when the facility did administer there have not been any times that medication has been taken or stolen. Said they have documented on the Mar's Log all medication given to R 1. Stated that there has been no law enforcement or FBI who have come to the facility to investigate any allegations regarding R1's medication. Review of medication and Mar's Log from November 2022 thru January 2023 revealed that doses were administered to R 1 and checked off on the dates given. When the PRN Oxycodone was requested by R 1 it was checked off on the dates administered. 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 allegations are unsubstantiated.the state’s words, verbatim · CDSS document, Apr 13, 2023 · control 28-AS-20230410112405

Allegation investigated: Facility not preventing residents from becoming intoxicated while in care. Resident threatened other residents in care with a knife. Knives are accessible to residents in care. Facility is not providing a safe environment for residents in care.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Michael Forsgren (Operations Manager) and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of resident and staff rosters, interviewed Operations Manager, Resident 2 - Resident 7 (R2 - R7), Staff 1 (S1), and attempted to interview R1 via phone. LPA also obtained copies of R1's 30 day eviction notice, R1's 3 day eviction notice, R1's handbook and house rules with signature, Community Care Licensing (CCLD) approval letter for R1's 3 day eviction notice, R1's physician report, R1's progress notes, R1's unusual incident/injury reports and police report of 03/15/23 incident. The investigation revealed the following: regarding the allegation "facility not preventing residents from becoming intoxicated while in care", it is alleged that excessive drinking in rooms that leads to public intoxication in the hallways, floors, dining and activity rooms and in the yards immediately surrounding the facility. (Continued to LIC 9099C) Unsubstantiated Interview with the Operations Manager revealed that per the resident handbook and house rules alcoholic beverages are allowed in the facility, in moderation and must be enjoyed in the residents rooms and not permitted in the facility's common areas. He also stated that R1 has been the only resident not abiding by this house rule. R1 was drinking in the room, but not in moderation. However, the facility did their due diligence because per R1's progress report the Operations Manager reminded R1 of the house rules regarding alcohol on 01/30/23, 02/13/23 and 02/19/23. Due to R1 not abiding by the rules regarding alcohol, leaving the facility unattended, and not paying the monthly rent, the facility served R1 with a 30 day notice on 02/21/23. However, due to an incident involving R1 threatening other residents with a knife on 03/15/23, a 3 day eviction notice was issued on 03/21/23 and on 03/22/23 R1 was moved to a medical clinic. R2 through R7 could not corroborate the allegation and stated that R1 was the only resident not abiding by the house rules, but the facility has already evicted R1. R1 also could not corroborate the allegation and stated that R1 followed all house rules. Regarding the allegation "resident threatened other residents in care with a knife", it is alleged that a recent incident required the assistance of 8 police officers and ambulances. A resident threatened other residents with a large fixed blade knife. Per interviews and documents reviewed, on 03/15/23 around 9pm R1 pulled a knife on R3 - R6. In the altercation R1 was the only one that sustained injuries. The police were called and a police report was made, but the police did not arrest R1 due to being on a wheelchair. R1 was taken to the hospital and released back to the facility on 03/16/23 at 5:30pm. Operations Manager tried to have R1's social worker relocate R1 to another facility instead of being brought back to the facility. However, no other place was available. Operations Manager reported the incident on 03/16/23 to Community Care Licensing (CCLD) and submitted a 3 day eviction notice for approval and served R1 with the notice pending CCLD approval. On 03/20/23, CCLD approved the notice and the Operations Manager served R1 with an official 3 day eviction notice on 03/21/23. On 03/22/23, R1 was moved out of the facility to a medical clinic. Interviewed with R1 revealed that R1 bought the knife at a local 99 cents. R2 through R7 confirmed that this incident occurred and it is an isolated incident. Although this allegation did occurred, the facility did their due diligence by trying to have R1's social worker relocate R1, reporting to CCLD and seeking a 3 day eviction notice. (Continued to LIC 9099C) Regarding the allegation "knives are accessible to residents in care", it is alleged that residents have access to knives. Interview with Operations Manager and staff revealed that all facility's knives are kept inaccessible to residents in the kitchen. The door leading to the kitchen is locked and no residents are allowed to enter the kitchen. All residents interviewed could not corroborate the allegation and confirmed the Operations Manager statement. During today's visit, theLPA observed a locked kitchen door and knives are kept in the kitchen. R1 stated that the knife that R1 had on 03/15/23 was bought by R1 at a local 99 cents and R1 did not let the facility know about this knife. Per R1's physician report, R1 cannot leave the facility unassisted and facility has made R1 aware of this. However R1 has refused to listen and has left the facility unassisted. R1's progress notes show that facility spoke to R1 about this issue on 02/07/23, 02/11/23 and 02/17/23. This is one of the issues that let to the 30 day eviction notice served on 02/21/23. R1 stated that R1 is fully capable of leaving the facility unattended despite what the physician report states. Regarding the allegation "facility is not providing a safe environment for residents in care", it is alleged that there is a group of men who live at this facility (they also recently moved in) who get drunk in the afternoon and have engaged in "multiple" fights. Fights have occurred in hallways, the dining room, and outside during the last month. Operations Manager and staff denied this allegation, and stated the only fight that has occurred within the last month was the incident that occurred on 03/15/23 between R1 and R3 through R6. It was an isolated incident. All residents interviewed could not corroborate this allegation and stated that this is a safe facility, and that what occurred on 03/15/23 was an isolated 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 are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Mar 28, 2023 · control 28-AS-20230320090047

Allegation investigated: Facility staff are not communicating with resident's representative in a timely manner. Facility staff forced resident/representative to sign inappropriate document(s) while in care. Facility staff are not protecting resident(s) from other resident in care.

***This report supersedes the original report created on 3/27/2023. Reason for supersede is to ensure report accurately refers to residents interviewed. Findings have not changed.*** Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the allegations listed above. During today’s visit, LPA met with Business Office Manager Diana Marquez and explained the purpose of today's visit. Initial visit was conducted by LPA Tao and consisted of the following: LPA Tao interviewed staff#1 (S1) and review records. LPA obtained copies of resident roster, staff roster, resident#1's and resident#2's file. On Todays visit, LPA Villalobos interviewed Staff #2-6 (S2-S6) and Residents #1-6 (R1-R6). S1 no longer works in the facility and was unable to be contacted for interview. The investigation revealed the following: In regards to the allegation "Facility staff are not communicating with resident's representative in a timely manner." it was alleged that the facility staff are not responding and/or ignoring communication with R1's responsible party.... (CONITNUED ON LIC 9099-C) Unsubstantiated ***This report supersedes the original report created on 3/27/2023. Reason for supersede is to ensure report accurately refers to residents interviewed. Findings have not changed.*** (6) of (6) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1's responsible party contacted the facility multiple times to speak with the management. Specific dates were not provided to LPA. Interviews with staff show that due to the nature of questions asked by R1's responsible party, the administrator or facilities legal department would be the ones to address R1's responsible party. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff forced resident/representative to sign inappropriate document(s) while in care" it was alleged that S1 attempted to force R1 to sign new house rules and level of care plan . (6) of (6) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews with staff deny forcing any residents in care to sign documents for any reason. Interview with R1 stated they denied signing any forms provided by S1. Review of R1's file did not show any documents that R1 was forced to sign. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. In regards to the allegation "Facility staff are not protecting resident(s) from other resident in care." it was alleged that staff was not protecting residents from R2. (6) of (6) Staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews stated that R2 has recently become disruptive and aggressive while in living in the facility. Interviews with residents stated that anytime R2 had an incident, staff was able to separate R2 immediately and address the situation. File review shows documentation of incidents dated 9/3/22 and 9/7/22 involving R2 were reported and completed timely. Cops were called on both incidents but R2 was not arrested. File review shows that R2 was also served an eviction notice on 9/19/22 for violating facility rules. Review of R2's file did not show that they needed a 1 on 1 or 24/hr supervision. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2023 · control 28-AS-20220919170436

Allegation investigated: Staff are not keeping accurate accounting records for residents in care

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent visit for the allegation above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. Initial visit on 2/14/23 consisted of: LPA interviewing Staff #1-#4 (S1-S4) and Resident #1-2 (R1-R2). LPA toured the physical plant of the facility and observed the food supply. LPA collected a copy of the staff and resident roster. LPA collected documents related Resident #1's (R1) File such as the facesheet, needs and services plan, medication record, and any related facility notes. On Todays visit LPA interviewed Staff #5 (S5), Residents #3-5 (R3-R5) and reviewed R1's facility ledger account and balance statements. Staff #6 (S6) no longer works in the facility and was unavailable for interview. The investigation revealed: In regards to the allegation "Staff are not keeping accurate accounting records for residents in care" it was alleged that the facility does not have an accurate accounting record for R1... ((CONTINUED ON LIC 9099-C)) Substantiated Regarding the allegation "Staff retaliate against individuals who cooperates with compliant investigations" it was alleged that the facility staff will intimidate residents to not complain and deny incidents in the facility. (5) of (5) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews with residents do not show that staff intimidate residents in any way. LPA was not provided with specific example of how staff intimidate the residents of the facility. All staff interviewed denied that they would intimidate residents or tell them to not complain or keep quiet about incidents in the facility. Interviews with staff state that they encourage residents to speak out in regards to any problems they are having in the facility. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview held and a copy of the report was provided (5) of (5) Staff interviewed denied the allegation. (4) of (5) Residents interviewed could not corroborate the allegation. Interviews showed that R1 received a rate increase for level of care after being provided a 60 day notice from the facility. Interviews also stated that R1 continues to pay the monthly amount before the increase to the facility took place even though they were provided the 60 day notice. The account files for R1 reviewed show that the increase was applied 2 months after the notice was provided. The documents do show the change in total amount due by R1 monthly and what the accurate current balance is. In the account file reviewed, there is a charge of $7.40 applied on 8/31/21 and $203.23 applied on 10/20/21. These charges are identified only as "care charges" or "ancillary charges". Interviews could not detail the reason for these charges which are separate from level of care and room and board charges. Interviews stated it is the Business Manager who manages the account files and will log and file the receipts for the charges on any residents account; however, the facility files did not have receipts of documentation as to what these charges are for at the time of the visit. S6 was the Business Manager at the time and no longer works in the facility. Based on interviews and files reviewed, the facility did fail to maintain accurate accounting records for R1's file due to not having accurate documentation of certain charges made to R1 as stated above. The preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was discussed and provided.the state’s words, verbatim · CDSS document, Mar 21, 2023 · control 28-AS-20230209174510

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87213 · Plan of correction due date: Mar 31, 2023

87213.Finances.The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that...; shall maintain adequate financial records. This was not met as evidenced by: LPA reviewed R1 facility ledger statements and observed charges on R1's account that the facility was unable to provide a reason for. This poses a potential health and safety risk to residents in care and supervision.the state’s words, verbatim · CDSS document, Mar 21, 2023

Plan of correction: Facility to provide in service training on proper documentation of charges or credits provided to residents in care by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting a case management visit to cite deficiencies found during a health and safety check. LPA Maldonado met with Rhonwinn Hipolito- Executive Director (ED) & Michael Forsgren- Operations Manager (OM) and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, Facesheet and Physician's Reports for Residents# 1-5 (R1-R5), and conducted a tour of the physical plant, including rooms and restrooms (RR) for R1-R5, with assistance of ED and OM. LPA discovered the following: R1's room had a foul smell. Private RR was inspected and toilet was observed to be splattered with feces around the seat. R1 stated RR has not been cleaned in a while (unable to specify time) and has asked staff several times for cleaning services, but has not received it. Per Needs and Services Plan, R1 is to receive housekeeping and Laundry services once a week and as needed. R2's room carpet was observed to be dirty and had dark spots throughout, as though something was spilled. R2 stated it has been this way for some time (unable to specify time). R4-R5 share a room. R4's blanket on the bed was observed to have 3 small feces stain. R4 stated it needs to be washed, however staff do not pick up the laundry and R4 has to take their belongings to the laundry room, located at the end of the hallway. Per R4's Needs and Services Plan, R4 is non-ambulatory, making it difficult for R4 to bring their laundry basket to the laundry room. Per R4-R5's Needs and Services Plan, housekeeping and Laundry services are to be provided once a week and as needed. RR was inspected and noted to smell like urine, non-skid mat was not observed in the shower, and the shower was dirty. A soiled brief was observed in a trash can near R4's bed that did not have a lid. R5 also stated if assistance was required, it would be hard to call for help using the call system in their room due to it being inaccessible by furniture placed in front of it. During today's visit, deficiencies were observed and will be cited on LIC809-D. An exit interview was conducted and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 17, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Mar 31, 2023

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Based on observation and interview, licensee failed to maintain (2) of (5) resident restrooms inspected, clean and odorless, and (1) of (5) resident room carpets clean, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2023

Plan of correction: Administrator will have the carpet cleaned in R2's room, and the restrooms cleaned in R1, R4 and R5's rooms. Pictures of the cleaned toilets and bathtubs will be emailed to LPA by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80088(f)(1) · Plan of correction due date: Mar 21, 2023

80088 Furniture, Fixtures, Equipment, and Supplies(f) Solid waste shall be stored...in a manner that will not transmit...odors...(1)All containers...used for...solid wastes shall have tight-fitting covers kept on the containers... This requirement was not met as evidenced by: Based on observation and interview, the licensee failed to maintain trash bins with a lid to dispose of soiled adult briefs in R4's room, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2023

Plan of correction: Administrator will obtain a trash bin with a tight fitting lids in R4's room to dispose of soild waste appropriately. A picture of the bin will be sent to LPA via email by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 21, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have...the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations...and equipment. This requirement was not met as evidenced by: Based on observation and interview, the licensee failed to allow safe access to the signal system in R5's room, as there is furniture placed in front of it making it inaccessible, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2023

Plan of correction: Administrator will rearrange R4's room furniture to give easy and safe access to the signal system. A picture of the rearranged furniture will be sent to LPA via email by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(3)(C) · Plan of correction due date: Mar 21, 2023

87307 Personal Accommodations and Services (3)Equipment and supplies necessary for...maintenance of adequate hygiene...shall be...available to... resident...if...unable...the licensee shall assure provision of:(C)Clean linen, including blankets... This requirement was not met as evidenced by: Based on observation and interview, the licensee failed to ensure R4 had clean blankets on their bed, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2023

Plan of correction: Administrator will ensure R4 receives laundry services as needed. A picture of clean bed linens on the bed will be sent to LPA via email by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for a case management visit in order to conduct Health and Safety check in response to an incident report received by the licensing agency on 3/16/23. LPA Maldonado met with Rhonwinn Hipolito- Executive Director (ED) & Michael Forsgren- Operations Manager (OM) and explained the purpose for the visit. During todays visit, LPA Maldonado obtained a copy of the resident and staff roster, Resident# 1's (R1) Needs and Services Plan, toured the physical plant, and conducted a health and safety check with ED and OM. Other records previously obtained by Licensing Program Manager ( LPM) Fierros for R1 are as follow: Facesheet, Physician's Report, Incident Reports for previous and current incidents with attached SOC341's, Progress Notes, Police Report, 30-Day Eviction Notice, and 3-Day Eviction Notice. The facility reported that on 3/15/23 Staff# 1 (S1) observed Resident# 1 (R1) inebriated in R1's wheelchair and was arguing with other residents. S1 asked R1 to return to their room and R1 fell asleep on the way to their room. S1 returned to do rounds to allow R1 to "sleep it off". At about 9:00PM, S1 received a call from local police department (PD) stating a resident in the facility had a knife. S1 responded the report where S1 found R1, resident# 2 (R2) and resident# 3 (R3) in the hallway near the TV room. R1 had brandished a 6" knife at R2 and R3. R2-R3 picked up a small table to block R1 from getting close to them. Residents# 4 (R4) and #5 (R5) witnessed the incident and reported that R1 became aggressive, produced the knife at R2-R3 and they defended themselves with the table, which resulted in R1 sustaining a laceration to their nose. No one else was injured during the incident. PD arrived at the facility to assess and de-escalate the situation. The paramedics arrived shortly after and transported R1 to the hospital for medical treatment. Per OM, PD refused to take R1 into custody due to being in a wheelchair, but did cite R1 for assault. R1 was discharged from the hospital and back to the facility on 3/16/23. The facility issued R1 with 30-Day eviction notice on 02/21/23 due to history of verbal and physical threats against other residents, staff, police, and paramedics, while inebriated. (Report Continued on LIC809-C...) ED has made several calls to R1's social worker to assist with new placement; however, new placement has been unsuccessful. Due to this incident, R1 has been issued a 3-day eviction notice that is currently under review with the licensing agency. No media attention has been drawn to the recent incident. During today's visit, LPA observed a sufficient supply of perishable and non-perishable foods for residents in care. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns and no deficiencies cited. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 17, 2023

Allegation investigated: Staff participated in resident council meeting without resident council approval

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation for the allegation listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. On today's visit , LPA interviewed Staff #1-5 (S1-S5) and Residents #1-#6 (R1-R6) and collected documents related to the facilities resident council meeting. The investigation concluded the following: In regards to the allegation "Staff participated in resident council meeting without resident council approval " it was alleged that S1 participated in the facilities resident council meeting without approval. (5) of (5) staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1 is the president of the resident council and R1 invited S1 to attend the meeting on 3/9/23. Interviews with R1 confirms this information that S1 was invited to attend the meeting as a guest prior to it starting. S1 also confirmed the same. Based on interviews and files reviewed; 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. Exit interview held and a copy of the report was provided Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 14, 2023 · control 28-AS-20230313084233

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Facility staff member asked resident to lend them money and never paid them back.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced initial complaint investigation for the allegation listed above. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. On today's visit , LPA interviewed Staff #1-5 (S1-S5) and Residents #1-#6 (R1-R6) and collected the following documents: Copies of documents from R2's file, Staff and Resident Roster, Staff file for S5, and copy of the food menu for March. The investigation concluded the following: In regards to the allegation "Facility staff member asked resident to lend them money and never paid them back" it was alleged that S1 borrowed money from R1 and did not return their money. (5) of (5) Staff interviewed denied the allegation. (5) of (6) Residents could not corroborate the allegation. Interviews and file review show that S1 no longer works in the facility as of 2/9/23. Interview with R1 states that S1 borrowed money from R1 sometime in January 2023..... Continued on LIC 9099-C Substantiated Interviews with staff show that residents are offered seconds after everyone has received a meal and residents can request different meals ahead of time also. Interviews do not show that the facility runs out of meals or refuses to provide other options to residents. Based on interviews, observations and files reviewed; 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 allegation is unsubstantiated. In regards to the allegation "Facility staff does not respond to residents’ call buttons in a timely manner. " it was alleged that staff will take long to address residents call button. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews with residents detail staff responses from call buttons to be anywhere between 2-10 minutes depending on how busy staff can be. During the visit and unknown to staff, LPA entered room #207 and pulled the emergency cord. Staff arrived within 2 minutes to check in on residents of that room because of the pull cord. Interviews with staff state that no emergency signals are ignored. Based on interviews and observations; 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 allegation is unsubstantiated. In regards to the allegation "Facility staff retaliates against residents for making complaints." it was alleged that facility staff neglect the care of residents because of residents that make complaints. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that staff retaliate against residents for making complaints. Interviews with staff state that they will always listen to resident complaints and address any issue. LPA did not observe residents being neglected at the time of the visit. Based on interviews and observations; 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 allegation is unsubstantiated. In regards to the allegation "Facility staff are not ensuring safety of residents' personal possessions." it was alleged that there has been theft of clothes, radios, and small amounts of cash at the facility. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews do not show that there have been witnesses to acts of stealing in the facility. LPA was not provided with a name of who was stealing items in the facility..... Continued on LIC 9099-C (1) of (6) residents interviewed stated clothes has gone missing from their possession but was not sure who took it. Staff interviews deny stealing any personal possessions from residents in care. Based on interviews and observations; 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 allegation is unsubstantiated. In regards to the allegation "Facility staff member did not respect residents' privacy by knocking on their door before entering their room." it was alleged that S2 enters residents rooms without knocking or permission. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. Interviews show that staff will go from room to room for multiple reason throughout the day. There are clients who need assistance with medication, assistance with grooming, and assistance in room cleaning. Staff will also conduct room checks when residents are not responsive to door knocks. Interview with S2 denies that they have ever entered a residents room without knocking and identifying first. LPA was not provided with proof of S2 entering resident rooms unannounced. During the visit, LPA observed S2 knock on doors and announce themselves before entering. Based on interviews and observations; 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 allegation is unsubstantiated. In regards to the allegation "Facility staff did not seek a resident timely medical attention." it was alleged that facility staff did not call 911 in a timely manner for R2. (5) of (5) staff interviewed denied the allegation. (5) of (6) Residents interviewed could not corroborate the allegation. File review shows that R2 had a fall in the dinning room on 3/1/23 and also receives assistance from a hospice agency. Incident report collected states that the resident received first aid and their hospice agency was contacted and also was taken to the hospital. Interview with R2 corroborates the information on the incident report. Interviews show that S3 immediately assisted and assessed R2 then contacted responsible parties. Hospice agency determined it would be best for R2 to go to the hospital and so they were taken. During interview, R2 stated they agreed to wait for the hospice agencies decision about going to the hospital. Based on interviews, observations, and files reviewed; 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 allegation is unsubstantiated. Exit Interview conducted and a copy of this report was provided. LPA reviewed the facilities employee handbook which states staff are too not borrow money from residents. No other staff or residents were aware of the incident. LPA observed text communication between R1 and S1 that shows details of S1 borrowing money and acknowledging that they owe R1. This shows that during their employment at the facility, S1 did not abide by the facilities plan of operation. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 14, 2023 · control 28-AS-20230306081511

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(5) · Plan of correction due date: Mar 23, 2023

87208.Plan of Operation.(a) Each facility shall have and maintain a current, written definitive plan of operation...The plan and related materials shall contain the following:(5) Staffing plan, qualifications and duties. This was not met as evidenced by: S1 borrowed money from R1 and did not return their money. This is against the facilites staff handbook which is part of the plan of operation, and poses a potential health and safety risk to residents in care and supervision.the state’s words, verbatim · CDSS document, Mar 14, 2023

Plan of correction: Facility to provide inservice training on the plan of operation policies to staff and create a plan to address borrowed money incident between R1 and S1, by POC due date.

Allegation investigated: Facility did not notify Licensing of covid positives in a timely manner

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint visit for the allegation above. LPA met with Michael Forsgren (Operations Manager) and explained the reason for the visit. Initial visit conducted on 1/25/23 consisted of the following: LPA interviewed Staff #1-#2 (S1-S2) and Residents #1-#4 (R1-R4). LPA toured the physical plant of the facility. LPA collected a copy of the staff and resident roster. LPA collected documents related to covid outbreak from the facility and observed required postings around the facility. On Todays visit, LPA interviewed Staff #3-5 (S3-S5) and residents #5-6 (S5-S6). The investigation revealed the following: In regards to the allegation "Facility did not notify Licensing of covid positives in a timely manner" it was alleged that the facility did not notify licensing of all covid positives in a timely manner.... Continued on LIC 9099-C Substantiated (5) of (6) residents interviewed could not corroborate the allegation. Interviews show that residents who tested positive for covid 19 were isolated in their rooms as there were no currently available isolation rooms to quarantine in. Interviews with S1 stated that contact with LA County Response team initially advised the facility not to move residents into different zones. It was not until 1/3/23 that the facility was contacted by Department of Health Nurse and an outbreak was declared. Facility was then advised to separate residents into red and green zones. LPA reviewed site visit from Department of Health dated 1/5/23 stated that they observed the facility to be using proper zoning strategy. Based on interviews and files reviewed; although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. In regards to the allegation "Facility did not notify residents of covid outbreak in a timely manner" it was alleged that the facility failed to notify all residents of covid outbreak in the facility. (5) of (5) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. Interviews show that the facility notified each individual and their responsible parties when the said individual would test positive. Other residents were not informed of who was positive as to not violate personal rights. Review of documentation shows that the outbreak was not declared until 1/3/23 by the Department of Public Health. Interviews show that required postings were place on the outer doors coming into the facility and around the building to notify residents and staff of the outbreak. on 1/25/23 during the initial visit, LPA observed covid 19 required postings on the main entrance to the facility as well as staff following covid 19 guidelines. Based on interviews and files reviewed; although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted and a copy of this report was provided. (5) of (5) staff interviewed denied the allegations. (5) of (6) residents could not corroborate the allegation. File review of facility documents shows that there was an outbreak of covid positives in the facility starting in December 2022. The outbreak was declared on 1/3/23 by the Department of Public Health. LPA observed that (3) staff and (1) resident had initial positives dating back to 12/8/22, but were not reported to Licensing until 12/20/22. This shows that the facility failed to notify Licensing of covid positives in a timely manner. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided and discussed.the state’s words, verbatim · CDSS document, Mar 10, 2023 · control 28-AS-20230117134559

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Mar 17, 2023

(a) Each licensee shall furnish to the licensing agency such reports... (2)Occurrences, such as epidemic outbreaks, ... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported... to the licensing agency and to the local health officer when appropriate. This was evidence by: LPAs review showed (3) staff and (1) resident who were covid positive on 12/8/22 were not reported until 12/20/22, this poses a potential health and safetey risk to residents in care and supervision.the state’s words, verbatim · CDSS document, Mar 10, 2023

Plan of correction: Facility to provide licensing report of covid positives for 12/8-12/9/22 to Licensing as well as provide documentation in letter that staff who creates incident reports has read and understands Title 22 Reporting Requirements by POC Due Date Citation cleared at the time of visit

Allegation investigated: Facility staff stole resident's personal property

Licensing Program Analyst(s) (LPAs) Jose Villalobos and Erik Zaragoza conducted an intial complaint investigation visit for the allegation listed above. LPA's met with Office Manager Diana Marquez and the purpose of the visit was discussed. During todays visit, LPAs toured the physical plant, interviewed residents #1-#7 (R1-R7) and staff #1-#4 (S1-S4). Staff #5 (S5) no longer works in the facility and was unable to be interviewed. LPA's also collected copies of the staff and residents rosters. The investigation revealed the following: In regards to the allegation "Facility staff stole residents's personal property" it was alleged that staff entered R1's room and took documents from R1's personal property. (4) of (4) staff interviewed denied the allegation. (6) of (7) Residents interviewed could not corroborate the allegation. LPA was not provided with date of incident.... Continued on LIC 9099-C Unsubstantiated Interview with R1 stated a staff member entered R1's room to collect hospital notes from R1 but took other documents as well. R1 called out for the staff member to return the documents and the staff did. Interviews with staff deny any knowledge of incident occurring. S5 no longer works in the facility and was unavailable for interview. Based on LPA's observations and interviews; although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 2, 2023 · control 28-AS-20230223082336

Allegation investigated: Staff are not honoring resident privacy during resident council meetings Staff did not assist resident with medical treatment after resident informed staff of falling Facility failed to report resident's incident pet Title 22 reporting requirements. Facility is falsifying incident reports.

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint visit regarding the above allegation(s). LPA Flores met with Michael Forsgren Operations Manager and explained the reason for the visit. The investigation consisted of the following: On 7/6/22 The visit consisted of the following: LPA Flores requested a copy of the resident/staff roster. LPAs Flores and Villalobos interview resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) and staff #1(S1),#2(S2),#3(S3), LPA Flores reviewed R1's file and requested the following copies; physician report dated 9/26/19 and 5/9/22, identification and emergency information, unusual incident report, personal rights residential care facilities for the elderly, needs and care assessment plan dated 5/7/2019. On 7/8/22 LPA requested a copy of hospital discharge, and incident report from family representative. On 1/27/23 LPA Flores interview staff #4(S4) and attempted to interview staff #5(S5) and #6(S6). (CONTINUED LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation Staff are not honoring resident privacy during resident council meetings. It is alleged staff member assigned to take notes during the Residents' Council Meeting was providing names of residents filing issues/problems with the administration. Interviews conducted with residents revealed, 2 out of 6 residents interview stated to have been or are involved in the resident council meeting and the only staff present is the activity director, who has been invited to assist with taking minutes for the residents. 2 out of 6 residents are aware there is a resident council meeting but do not participate in it and have not heard of privacy/confidentially not being provided during the meetings. 1 out of 6 residents did not know much about the resident council meeting. Interview with Executive Director revealed activity director types the notes taken during the meetings and provides the information of repairs needed in order for the facility to address them without identifying the residents. Interviews with staff revealed 2 out of 3 staff stated not to be a part of the council meeting and 1 out of 3 staff stated to have been assisting with the council meeting since July 2022, takes notes and types the minutes. Documents reviewed revealed Resident Council Meeting Minutes for January 2022 - June 2022 have notes of topics discuss in each meeting with suggestions from residents and a response from each department which is shared with the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not assist resident with medical treatment after resident informed staff of falling. It is alleged resident #1(R1) had taken a serious fall outside the facility and R1 had to call 911 her/himself to get any help. Interviews with residents revealed 3 out of 6 residents interview stated to have received assistance when medical care has been needed and emergency medical technicians (EMTs) were contacted to transport residents to the hospital when needed. 2 out of 6 residents stated to have not required medical assistance and/or had fall but are aware they will obtain assistance if necessary. Interview with R1 revealed that on 6/28/22 R1 had fallen around 3:00am in the morning outside the facility. R1 returned inside the facility on their own. Upon staff assisting R1, staff asked R1 if they should call 911 to which R1 responded to staff, "not to see a need to call". R1 change her/his mind and choose to call 911 on their own. Interview with executive director revealed it is facility's policy to contact 911 if a resident sustains a head injury and night staff stated R1 stated to have fallen on her knees and pointed at forehead when describing the fall, no injuries were noted by night staff. Interviews with 3 out of 3 staff interview stated it is procedure to call 911 if residents sustained a head injury. During document review it was observed unusual incident report dated: 7/1/22 notes R1 fell outside the facility approximately at 3:00am. (CONTINUED ON LIC 9099C) Med Tech offered to send R1 out to the hospital and declined at the time but R1 call 911 later. Physician's Report dated: 5/9/22 notes R1 is able to leave the facility unassisted and to communicate needs on their own. Personal Rights signed on 10/10/19 note R1 has the right to receive and reject medical care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility failed to report resident's incident pet Title 22 reporting requirements and Facility is falsifying incident reports. It is alleged resident reported to Med-Tech about a fall, staff refused to take a report and facility's staff failed to sign accident report. Interviews with residents revealed, 5 out of 6 residents interview stated facility maintains documentation and when necessary family or responsible party are notify of incidents and have no concerns regarding facility's documentation. 1 out of 6 residents stated an incident report was not provided to the resident until 6-7 days after the incident occurred. Executive Director stated an unusual incident report was created and submitted to the department within 7 days per regulation. Interviews with staff revealed 3 out of 3 staff stated facility creates unusual incident report to submit to the department within 7 days, no other reports are provided to residents and facility notifies responsible parties of any incident. Documents reviewed reveal unusual incident report dated: 7/1/22 was submitted to the department on 7/4/22 report was submitted by, reviewed, and approved by Executive Director Pamela Junge. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Michael Forsgren Operation Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 2, 2023 · control 28-AS-20220630153013

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management visit to note deficiencies. LPA Flores met with and explained the reason for the visit. During the investigation of complaint #28-AS-202206300153013 it was discovered that facility's Resident Council Meeting Minutes for January 26, 2022 reviewed notes facility's response to the resident council concerns. One of the concerns noted on 1/26/22 was regarding resident #1(R1). The response provided by facility's staff to the residents council concern provides R1 medical diagnosis/directives in the minutes taken which violates the personal rights of the resident. Resident Council Meeting minutes are provided to residents upon request. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Michael Forsgren Operation Manager an a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Feb 3, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) ...residential care facilities for the elderly shall have... personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement is not met as evidence by: Based on documents reviewed Licensee did not ensure medical diagnosis/directives were maintain confidential for residents in care which poses an immediate health, safety, or personal rights violation for the residents in care.the state’s words, verbatim · CDSS document, Feb 2, 2023

Plan of correction: Administrator will ensure staff is properly train on section 87468.2 Personal Rights - maintaining personal information confidential for Residents in care and will submit a plan for training by POC due date 2/3/23 and a copy of training and signing logs by 2/9/23.

Allegation investigated: Staff did not ensure that a needs appraisal was conducted for resident upon admission Facility does not currently have a certified administrator

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Michael Forsgren (Operations Manager) and explained the reason for the visit. The investigation consisted of the following: On 12/29/2022, LPA obtained copies of staff & resident rosters, facility December 2022 menu and alternative menu, administrator certificate application and course completed, and interviewed the Operations Manager. LPA also obtained copies of R1's appraisal/needs and service plans, physician report, admission agreement, admission record/face sheet, 60 day notice of monthly rate increase dated 08/20/2021, 30 day eviction notice dated 12/20/2022, emails between facility and R1's power of attorney and account balance. Today’s visit, LPA obtained a copy of resident and staff rosters, interviewed Staff 1 – Staff 3 (S1 – S3) and Resident 1 – Resident 7 (R1 – R7), obtained copies of face sheets, pre-appraisal and appraisal/needs and services plan for R1 – R7, and toured the kitchen. (CONTINUED TO LIC 9099C) Substantiated The investigation revealed the following: regarding the allegation "staff did not ensure that a needs appraisal was conducted for resident upon admission”, it is alleged that facility did not do a pre-appraisal and appraisal/needs and services plan for R1 upon admission. Interview with the Operations Manager revealed that per their records R1 was admitted on 10/10/2019 and a pre-appraisal and appraisal/needs and services plan was completed on 11/27/2019. The Operations Manager was hired on 11/16/2022 and thus could not provide a reason why the pre-appraisal and appraisal/needs and services plan was completed a month after R1’s admission. Staff interviewed could not provide a reason either. Residents interviewed could not corroborate with the allegation. LPA reviewed R1’s pre-appraisal and appraisal/needs and services plan and confirmed that the pre-appraisal and appraisal/needs and services plan was completed on 11/27/2019 and that R1 was admitted on 10/10/2019. Regarding the allegation "facility does not currently have a certified administrator”, it is alleged that the Operations Manager does not have an administrator certificate. Interview with the Operations Manager revealed that he was hired on 11/16/2022 and the earliest administrator courses were available on 12/02/2022 – 12/04/2022 and 12/09/2022 – 12/11/2022. He completed the courses and submitted his administrator application on 12/17/2022. LPA reviewed the administrator certificate application, courses completed and proof of submission to Community Care Licensing Division Administrator Certification Section, and confirmed the Operations Manager's statement. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided. The investigation revealed the following: regarding the allegation "Illegal eviction". Interview with the Operations Manager revealed that an eviction notice was served to R1 and R1' relative who is R1's power of attorney on 12/20/2022 with an effective date of 01/19/2023.The reason for eviction is due to non-payment of the full monthly care fee. R1's has accrued a balance of $4862.42 dating back to January 2022. The total monthly rate for R1 is $1725, but R1 has only paid $1300. Interview with R1 revealed that they are not paying the $425 difference until the facility explains the reason for the increase because her care needs have not changed and therefore an increase should not have occurred. LPA reviewed the 60 day notice dated 08/20/2021 that was given to 35 residents including R1 with the reason why the increase occurred which was "the cost of labor continues to increase, and Covid-19 have also added increased cost for cleaning supplies and needed personal protective equipment (PPE) for staff". LPA confirmed that the eviction notice was submitted to the Community Care Licensing Department on 12/20/22. Reviewed of the eviction notice shows that it is a lawful eviction per Title 22 Section Code 87224 and R1 refused to sing it. Regarding the allegation "staff retaliated against resident for exercising their right to be involved in the residents council", it is alleged that R1 was elected as the president of the resident's council in May 2021 and the facility retaliated with an increase in the monthly care fee effective 10/20/2021 and with the eviction notice served on 12/20/2022. Operations Manager and staff interviewed denied the allegation. Operations Manager explained that the monthly care fee increased for 35 residents not just R1 and they provided a 60 day notice on 08/20/2021 with the reason which was "the cost of labor continues to increase, and Covid-19 have also added increased cost for cleaning supplies and needed personal protective equipment (PPE) for staff". The eviction notice was served because a balance accrued due to R1 not paying the full monthly care fee. . Regarding the allegation "staff did not allow resident to participate in planning their care", it is alleged that R1 was presented with an care plan around September 2022 and she was not included in creating the care plan. It is also alleged that R1 does not recall getting a care plan when she was admitted to this facility. Interviewed with Operations Manager and staff revealed that per their records a care plan was created, reviewed and signed by R1 on 11/27/2019 (R1 was admitted 10/10/2019). They also stated that an update was made to the care plan on 10/08/2022 and was presented to R1 for review and signature, but R1 refused to signed it and did not provide a reason. Interview with R1 revealed that R1 does not remember reviewing or signing a care plan on 11/27/2019. R1 stated that R1 refused to signed the care plan provided to her in Spetember or October 2022 because R1's relative told R1 not to sign it. Interviews with the other 6 residents revealed that they could not corroborate with the allegation. LPA reviewed care plan dated 11/27/2019 and R1 signed it and the updated 10/08/2022 care plan R1 refused to sign it. (CONTINUED TO LIC 9099C) Regarding the allegation "facility failed to provide nutritious meals", it is alleged that the facility is not providing a balance nutritious meal because most meals have only carbs. Operations Manager and staff interviewed denied the allegation. Interviews with residents revealed that 5 out of 7 residents could not corroborate with the allegation. LPA toured the kitchen during lunch time and observed that the meal being served contain a good balance of protein, carbs and veggies. Regarding the allegation "facility did not provide documents requested to relative", it is alleged that R1's relative requested documents and the facility did not provided the documents. Operations Manager denied the allegation and stated all documents pertaining to R1 were handed to 2 of R1's relative that came to pick up the documents on 11/23/2022. Operations Manager also stated that R1's relative has requested corporate internal documents and documents with information about other residents and these are the documents they can't provide to R1's relative. The documents provided on 11/23/2022 were R1's billing records from 10/10/2019 to present and entire health record. Residents interviewed revealed that 6 out of 7 residents could not corroborate with the allegation. LPA reviewed a document signed by R1's relatives that picked up the documents on 11/23/2022. 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. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Jan 18, 2023 · control 28-AS-20221223121344

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87456(a)(2) · Plan of correction due date: Jan 27, 2023

87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidence by: Based on interviews and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. R1's pre-appraisal and appraisal/needs and services plan was not completed prior to being admitted.the state’s words, verbatim · CDSS document, Jan 18, 2023

Plan of correction: Facility is to ensure that Title 22 Section 87456 regulations are met at all times. Additionally, a statement indicating facility understands and will comply with Title 22 Section 87456 will be submitted to CCLD by 01/27/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87406(a) · Plan of correction due date: Jan 27, 2023

87406 Administrator Certification Requirements (a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidence by: Based on interviews and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. The Operations Manager did not have an administrator certificate prior to being employed.the state’s words, verbatim · CDSS document, Jan 18, 2023

Plan of correction: Facility is to ensure that Title 22 Section 87406 regulations are met at all times. Additionally, a plan to comply with Title 22 Section 87406 will be submitted to CCLD by 01/27/2023. The Operations Manager has already completed the administrator courses and submitted the administrator application to Community Care Licensing Division Administrator Certification Section on 12/27/2022.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced visit to conduct the required annual inspection focused on Infection Control Domain. LPA met with Operations Manager Michael Forsgren and the purpose of the visit was discussed. On todays visit LPA followed the Infection control domain, toured the physical plant, reviewed six (6) resident and four (4) staff files, and the medication records for six (6) residents. LPA Villalobos discussed infection control practices with staff, toured the facility inside and out between. The facility physical plant consists of a two story building structure that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. Physical plant inside and outside is clean, sanitary and in good repair. The facility second floor consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. The following was observed: Rooms have required furniture and supplies. Facility had an area with locked cabinet for medications. Facility is clean and in good repair. Water temperature met Title 22 Regulations measuring between 105-120 F. .Cupboards, freezer, stove, microwave, refrigerator and counters are clean. Bathrooms for the above mentioned rooms were observed and meet title 22 regulations. There was a 7 day supply of non-perishables available and a 2 day supply of perishables available. Resident records inaccessible to residents in care. Required postings were observed. First Aid Kit and manual were observed. Smoke detectors and carbon monoxide detector operate properly and fire extinguishers are properly charged. Working washers and dryers. Working telephone. There are no bodies of water located on the premises. Adequate seating in common areas for licensed capacity. Furniture in all facility rooms appropriate, clean and in good repair. There is an outdoor activity space/ patio with a shaded area and furnished for outdoor use. LPA collected Infection Control plan and proof of Liability Insurance at the time of visit. Visit was completed using the Infection control inspection tool. No deficiencies were cited on todays visit. Exit interview was conducted and a copy of report was provided to Operations Manager Michael Forsgren.the state’s words, verbatim · CDSS document, Dec 19, 2022

Allegation investigated: Facility mismanged resident's medications. Staff did not administer medications per doctor's orders. Staff did not treat the resident with dignity.

***Please note: This LIC9099 report supercedes LIC9099 report dated 09/13/2022 to include additional information; However, the findings remain the same.*** On 09/13/22, LPA Maldonado made an unannounced, subsequent complaint visit to at the facility regarding the above mentioned allegations. LPA Maldonado met with Executive Director Pamela Junge and explained the purpose for the visit. LPA Maldonado requested a copy of the staff and resident roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Medication Administration Records (MARs) for February-March 2022, Incident Reports for February-March 2022, and Hospital Discharge Documents. LPA also interviewed Staff# 1-4 (S1-S4) and Residents# 2-7 (R2-R7). LPA was unable to interview R1 due to resident no longer residing at the facility. (Report Continued on LIC9099-C...) Unsubstantiated On 03/23/22, LPA Kruz Long made an initial complaint visit and obtained a copy of the Staff schedule, Resident roster and Resident #1's records (Hospital discharge documents, Preplacement Appraisal Information, Physicians Report). LPA Long also interviewed Staff #1 in the conference room at 11:15 am. Regarding allegation: Facility mismanaged resident's medications. Executive Director Pamela was unable to provide R1's MARs as resident was able to administer and store own medications. Per R1's physician's report, it was confirmed R1 was able to store/administer own medications. Per R1's hospital discharge documents, it was discovered that R1 was prescribed Tramadol 25mg, 0.5 tabs as PRN (as needed) medication for pain, to be taken for 7 days. The medication was ordered and started on 2/26/22 at 8:34 a.m. and was to be taken until 3/5/22. Per R1's facesheet, it was discovered that R1 resided at the facility from 3/01/22-04/01/22. The documents revealed that by the time the R1 would have arrived at the facility, R1 would only have a few more days of medication left to be administered. During interviews conducted with R2-R7, (3) of (6) residents stated staff assist them with administering their medications and have never had an incident where medications were mismanaged. (6) of (6) residents stated they have no knowledge of residents stating that the facility mismanaged the residents medications. During interviews conducted with S1-S4, (4) of (4) staff stated they have no knowledge of an incident where the facility mismanaged resident medications. If they had knowledge, they would report it right away to Licensing, their physician, and the families. Regarding allegation: Staff did not administer medications per doctor's orders. During interviews conducted with S1-S4, staff always administer medications per doctor's orders. During interviews with R2-R7, (3) of (6) residents who are assisted by staff with administering their medication, stated that they have no concerns with staff not administering their medications per doctor's orders. (6) of (6) residents have no knowledge of an incident where a resident expressed that staff did not administer their medication per doctor's orders. Regarding allegation: Staff did not treat the resident with dignity. During interviews conducted with R2-R7, (6) of (6) residents state they have never felt like staff did not treat them with dignity. (1) of (6) residents stated there is 1 resident they witnessed to be teased behind their back about their weight and "feels bad" about that occurring. During interviews conducted with S1-S4, no one has witnessed or has knowledge of other staff not treating residents with dignity. Al staff interviewed stated if they had knowledge, they would report it. (Report Continued on LIC9099-C...) Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported allegations. 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. During the visit, no deficiencies were observed or cited. An exit interview was conducted with Operations Manager Itzayana Barba and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 7, 2022 · control 28-AS-20220318101435

Allegation investigated: Resident sustained an injury while in care Staff did not ensure that resident's needs were met

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit for the above allegations. LPA met with Administrator Pamela Junge and explained the reason for the visit. The initial visit was conducted telephonically, due to Covid-19 protocols, on 1/4/21. The investigation consisted of the following: LPA interviewed Resident #1 (R1) and Staff #1- #4. LPA unable to interview Resident #2 (R2) due to client not residing in the facility any longer. LPA requested copies of the following: Staff and Resident Roster, Facesheet, Physicians report, and Needs and Services plans for R1-R2 On todays visit, LPA interview Staff #5 (S5) and Residents #3-5 (R3-R5). The investigation revealed the following: In regards to the allegation "Resident sustained an injury while in care" it was alleged that R2 sustained a facial injury from an unwitnessed fall due to staff negligence in the summer of 2020. (4) of (5) Staff interviewed denied the allegation. (4) of (4) residents interviewed could not corroborate the allegation. Continued on LIC 9099-C Unsubstantiated LPA reviewed 2 incident reports in R1's file dated 6/27/18 and 8/21/19. Incident reports did not mention facial injuries. There were no incident reports provided for the timeline provided to LPA. Interviews with staff do not show that R1 had sustained a facial injury from an unwitnessed fall in 2020. Based on LPA's observations and interviews; 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. In regards to the allegation "Staff did not ensure that resident's needs were met " it was alleged that staff neglect R1 and R1's needs were not being met. (4) of (5) Staff interviewed denied the allegation. (4) of (4) residents interviewed could not corroborate the allegation. LPA was not provided examples as to how R1's needs were not being met. Interview with R1 shows that R1's needs are being met by staff. Interviews with staff shows how staff would meet R1's needs. LPA reviewed R1's needs and services plan to corroborate the information. Based on LPA's observations, interviews, and file review; 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. Exit Interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 3, 2022 · control 28-AS-20201224062946

Allegation investigated: Resident's diapering needs were not met. Resident's hygiene needs are not being met.

This is an amended 9099 report of the original report dated 10/27/2022. The purpose of the amended report is to clarify and identify resident(s) that were interviewed. Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by the new Administrator (A2: Pamela Jung). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation(s). An initial 10-Day visit was conducted by LPA Angelica Rea on 03/28/22 with (then) Administrator (A1: Sophia Chan), Staff #1, Staff #2, Staff #3, and Resident #2. Unsubstantiated LPA/RA Ceniceros interviewed (between 8:15 a.m. - 9:30 a.m.) two (2) staff members (A2 and S2), in care. Resident #1 could not be re-interviewed as the resident was transferred to a skilled-nursing facility following hospitalization on (03/20/22). LPA/RA Ceniceros reviewed (between 9:30 a.m. – 10:15 a.m.) the requested documents: Admissions Agreement (dated 12/30/21), Emergency I.D. & Information (dated 12/30/21), Physician’s Report (dated 12/21/21), Pre-placement Appraisal (dated 12/30/21), ALWP ISP (dated 07/20/21), Functional Capability Assessment (dated 04/13/22) for Resident #1 (R1); Staff & Residents' rosters; "Care Companion" program app (via iPhone). Regarding Allegation #1: this investigation revealed based on interviews conducted corroborated that the facility staff alternates diapering needs every two (2) hours. A review of R1's Assisted-Living Waiver Program's (ALWP) Individual Service Plan (ISP) documented under: Need/Concern: Participant is at risk of incontinence due to periods of weakness and diminished physical functioning (Pg 9 of 12). A review of R1's Admission Agreement on Pg 19 documented: Full Level 4 Care: Toileting. A review of R1's Physician Report documented under: Physical Health Status: Yes bowel and bladder impairment; Able to care for toileting needs? No. Facility utilizes a "Care Companion" program app (via iPhone) to monitor all residents who require full-service care; and, via cell phone (w/the program app) is assigned to the "on-duty" caregivers and med techs who documents their entries once a resident has been checked for incontinence care. [LPA/RA Ceniceros observed the Care Companion program app demonstration (via Staff #2's assigned cell phone.)] Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident's diapering needs were not met is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed based on interviews conducted corroborated that the caregivers provide hygiene needs to the residents that require full-service care. A review of R1's Assisted- Living Waiver Program's (ALWP) Individual Service Plan (ISP) documented under: Physical / Health: Requires assistance to complete ADLs (Pg 7 of 12). A review of R1's Admissions Agreement (Pg 19) documented: Full Level 4 Care: Assistance with grooming. A review of R1's Physician Report documented under: Physical Health Status: Att risk if allowed direct grooming and hygiene items? Yes; under: Capacity for Self Care: Able to groom self? No. Facility utilizes a "Care Companion" program app (via iPhone) to monitor all residents who require full-service care; and, a cell phone (w/the program app) is assigned to all "on-duty" caregivers and med techs who documents their entries once a resident has been checked for hygiene needs. [LPA/RA Ceniceros observed the "Care Companion" program app demonstration (via Staff #2's assigned cell phone.)] Based on the evidence gathered and interviews conducted and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Resident's hygiene needs are not being met is found to be UNSUBSTANTIATED. An exit interview was conducted and a copy of the Complaint Report provided to Medication Technician, Katie McDonald.the state’s words, verbatim · CDSS document, Oct 27, 2022 · control 28-AS-20220321101032

Allegation investigated: Facility mismanged resident's medications. Staff did not administer medications per doctor's orders. Staff did not treat the resident with dignity.

Licensing Program Analyst (LPA) V. Maldonado made an unannoucend subsequent complaint visit to at the facility regarding the above mentioned allegations. LPA Maldonado met with Executive Director Pamela Junge and explained the purpose for the visit. On 03/23/22, LPA Kruz Long made an initial complaint visit. During the visit, LPA Long obtained and reviewed a copy of the Staff schedule, Resident roster and Resident #1's records (Hospital discharge documents, Preplacement Appraisal Information, Physicians Report) and interviewed Staff #1 in the conference room at 11:15 am. During today's visit, LPA Maldonado requested a copy of the staff and resident roster, and the following documents for Resident# 1 (R1). LPA also interviewed Staff# 1-4 (S1-S4) and Residents# 2-7 (R2-R7). LPA was unable to interview R1 due to resident no longer residing at the facility. (Report Continued on LIC9099-C...) Unsubstantiated Regarding allegation: Facility mismanged resident's medications. Executive Director Pamela was unable to provide R1's MAR as resident was able to administer and store own medications. During review of R1's physician's report, it was confirmed that R1 was in fact able to store and administer own medications. It was also discovered that R1 was prescribed a PRN (as needed) medication for 7 days. The medication was ordered and started on 2/26/22 at 8:34 a.m. and was to be taken until 3/5/22. During interviews conducted with R2-R7, (3) of (6) residents stated staff assist them with administering their medications and have never had an incident where they mismanaged the residents' medications. (6) of (6) residents stated they have no knowledge of residents stating that the facility mismanaged the residents medications. During interviews conducted with S1-S4, (4) of (4) staff stated they have no knowledge of an incident where the facility mismanaged resident medications. If they had knowledge, they would report it right away to Licensing, their physician, and the families. Regarding allegation: Staff did not administer medications per doctor's orders. During interviews conducted with S1-S4, staff always administer medications per doctor's orders. During interviews with R2-R7, (3) of (6) residents who are assisted by staff with administering their medication, stated that they have no concerns with staff not administering their medications per doctor's orders. (6) of (6) residents have no knowledge of an incident where a resident expressed that staff did not administer their medication per doctor's orders. Regarding allegation: Staff did not treat the resident with dignity. During interviews conducted with R2-R7, (6) of (6) residents state they have never felt like staff did not treat them with dignity. All residents interviewed stated that staff at the facility are great. (1) of (6) residents stated there is 1 resident they witnessed to be teased behind their back about their weight and "feels bad" about that occurring. Otherwise, staff are great to everyone else. During interviews conducted with S1-S4, no one has witnessed or has knowledge of other staff not treating residents with dignity. Al staff interviewed stated if they had knowledge, they would report it. Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported 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 Executive Director Pamela Junge and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 13, 2022 · control 28-AS-20220318101435

Allegation investigated: Facility is unkept Resident not receiving beverages Staff neglect resulting in resident assaulting other residents

Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Executive Director, Pamela Junge who assisted with today's visit. Regarding the allegation that the facility is unkept. The investigation consisted of: tour of facility, including several resident rooms, interviews with Executive Director, Staff #1, Staff #2, and Resident #1- Resident #5. LPA did not observe that the facility was unkept during today's visit. Staff interviewed stated that the facility is cleaned on a daily basis, and resident room(s) are cleaned once per week and as needed. Residents interviewed were unable to corroborate the allegation. 4 out of 5 residents stated that the facility is not unkept. Regarding the allegation that Resident #1 is not receiving beverages, the investigation consisted of interviews with Executive Director, Staff #1, Staff #2, and Resident #1- Resident #5. Staff interviewed stated that residents are served beverages as they come into the dining room. Staff interviewed stated that they serve all the residents beverages, and they do not intentionally leave any residents out. Residents interviewed were unable to corroborate the allegation. 4 out of 5 residents stated that they receive beverages and they have not observed any resident(s) not receive beverages. Unsubstantiated Regarding the allegation that staff neglect is resulting in resident assaulting other residents, the investigation consisted of interviews with Executive Director, Staff #1, Staff #2, and Resident #1- Resident #5. Staff interviewed stated that they have not observed any resident(s) assaulting other residents. Staff stated there was a report of a resident altercation in July 2022, and the required parties were notified. However, there were no witnesses to the incident. Residents interviewed were unable to corroborate the allegation. They stated that they have not witnessed any resident(s) assaulting other resident(s). Residents stated that they have observed that some residents do not get along with each other, and they have observed verbal altercations between residents. However, they have not witnessed physical altercations between residents. 4 out of 5 residents stated that they have not observed resident(s) assaulting other resident(s). Based on LPA's observations and interviews, investigation revealed: 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. No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Executive Director, Pamela Junge.the state’s words, verbatim · CDSS document, Sep 1, 2022 · control 28-AS-20220823150735

Allegation investigated: Facility is retaining residents that threaten the safety of other residents while in care.

Licensing Program Analyst (LPA) Jose Villalobos conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Administrator Pamela Junge Administrator and explained the reason for the visit. Initial visit was conducted on 7/26/22 and consisted of the following: LPA requested a copy of the resident/staff roster. LPA interviewed resident #1-#3 (R1-R3) and Staff #1 (S1), LPA collected the following documents from R2 and R3's file; physicians report, Admissions agreement, identification and emergency information, unusual incident reports on file, needs and services plan. On todays visit, LPA interviewed staff #2-#6 (S2-S6) and resident #4-#7 (R4-R7). LPA also toured the physical plant. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiated In regards to the allegation "Facility is retaining residents that threaten the safety of other residents while in care." it was alleged that R2 and R3 are threats to the safety of other residents and the facility does nothing about it. (6) of (6) Staff interviewed deny the allegation. (4) of (7) Residents interviewed could not corroborate the allegation. Interviews show that R2 shouts and screams around the facility. Interviews conducted show that staff will intervene and calm R2. There are times where R2 will shout at other residents. LPA reviewed incident report dated 7/16/22 that shows R2 threw a facility computer. Interviews do not show that R2 or R3 have assaulted residents or that facility staff is aware of that and ignoring it. 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 are unsubstantiated. Exit interview was conducted with administrator Pamela Junge and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220720132522

Allegation investigated: Resident’s bathroom is not wheelchair accessible.

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint visit for the allegation listed above. LPA met with Administrator Pamela Junge and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, interviewed staff #1-#6 (S1-S6), interviewed resident #1-#6 (R1-R6), collected documents from R1's file. LPA also toured the physical plant and rooms #103 #110 #123 #202 and #227. The investigation revealed the following: regarding the allegation "Resident’s bathroom is not wheelchair accessible.", it was alleged that R1 is not able to wash their hands because their wheelchair does not fit into the bathroom. (6) of (6) staff interviewed denied the allegation. (5) of (6) residents interviewed could not corroborate the allegation. LPA observed the rooms of the facility that had residents who use wheelchairs. LPA observed R2, R3, and R4 able to fit into the bathrooms attached to their rooms while using their wheelchairs. Continued on LIC 9099-C Unsubstantiated R1 was unable to fit their wheelchair into their bathroom as the wheelchair is a larger size but did not have issues with entering their room or any other rooms of the facility. R1 is able to ambulate onto a walker to get inside the bathroom. Interviews show that staff accommodate R1 with their personal needs when R1 does not want to go into the bathroom. Interviews also show that R1 is able to access a sink to wash their hands in the med room as an accommodation when needed. 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 are unsubstantiated. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2022 · control 28-AS-20220817091233

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jose Villalobos conducted a case management visit after discovering deficiencies during a complaint investigation for control number: 28-AS-20220720132522. Regarding Resident #1(R1), interviews and documentation shows that the facility retained a resident who's primary need for care and supervision results from either: an ongoing behavior, caused by a mental disorder, that would upset the general resident group. California Code of Regulations Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D. Exit Interview conducted with Administrator Pamela Junge. A copy of this report along with Appeal Rights were provided.the state’s words, verbatim · CDSS document, Aug 25, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87455(c)(3)(A) · Plan of correction due date: Sep 9, 2022

87455 Acceptance and Retention Limitations c) No resident shall be accepted or retained if any of the following apply: (3) The resident's primary need for care and supervision results from either:(A)An ongoing behavior, caused by a mental disorder, that would upset the general resident group; This what not met as evidenced by: R1's primary diagnoses led to an ongoing behavior of shouting at yelling at staff and residents that upsets the general resident group. This poses a potential health and safety risk to residents in care and supervision.the state’s words, verbatim · CDSS document, Aug 25, 2022

Plan of correction: Administrator to reach out to Department of Mental health (DMH) for assistance regarding R1. Faciltiy to reassess R1 to review proper placement. Administrator will send letter to LPA of contacts made to DMH and reassessment by POC Due Date.

Allegation investigated: Staff are over medicating residents

Licensing Program Analyst (LPA) Alberto Lopez made unannounced subsequent visit. LPA met Pamela Junge, Executive director and explained the reason of the visit. Initial visit was on competed by LPA Wong on 04/05/2022 Allegation: "Staff are over medicating residents." The investigation consisted of the following: On today's date, LPA Lopez obtained resident and staff roster, reviewed Resident# 1-2 File and obtained copy of their face sheet, physician report and Medication Administration Record (MARs) for March 2022 and other documentation that assisted in the investigation. LPA reviewed 7 resident’s medications and they were all accurate and accounted for. LPA interviewed four (4) (R1-R4) residents, and all reported that staff always give them correct medication and dosage and on the right time. All four residents stated that staff never messed up their medication. They also stated that they do not know of residents ever been over medicated in the facility. Unsubstantiated LPA interviewed four (4) Staff (S1-S4) (all MedTech) and all four staff reported they always follow doctor's order for resident medication, they would only give resident medication which doctor prescribed or approved and its never happened for a resident in the facility to get over medicated and all four denied the allegations. All four staff stated that medications are counted at the beginning of the shift and at the end of the shift to account for all medications. LPA also interviewed 2 relatives and Hospice Nurse (W1-W3) and none collaborated the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Pamela Junge. A hard copy of the report was providedthe state’s words, verbatim · CDSS document, Aug 4, 2022 · control 28-AS-20220329125652

Allegation investigated: Facility staff is interfering with residents ability to shower

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Executive Director Pamela Junge and explained the reason for the visit. The investigation consisted of the following: LPA obtained a copy of the residents and staff rosters, copy of R1’s admission agreement, conducted a tour of room 106, 127 and 202, and interviewed the Administrator and Resident 1 – Resident 2 (R1 – R2). The investigation revealed the following: regarding the allegation "facility staff is interfering with resident’s ability to shower.", it is alleged that R1’s shower grab bar in room 106 is too high. R1 has been using the shower in room 127 because the grab bar is lower than the grab bar in room 106. R1 has requested to move from room 106 to room 127, but has been denied due to the room not being ready for residents to move in. (CONTINUED TO LIC 9099C) Unsubstantiated Interviews conducted with staff revealed that as of last week they offered the resident to move to room 202 because that room is ready, and the shower has the grab bar similar to the shower in room 127. Staff also stated that they have not interfere with R1’s ability to shower because they have allowed R1 to use the shower in room 127 while they found a more permanent solution. R1 has not taken action in moving to room 202 as of today. Interview conducted with R1 revealed that R1 is still being allowed to use the shower in room 127 and has not moved to room 202 due to a fee of $500 and grab bar in the shower of room 202 appears to be loose. The $500 fee to move to another room is mentioned in R1’s admission agreement which was signed on 03/23/2022. However, the Executive Director stated that R1 has moved rooms twice before and that fee was waived and they told R1 that the fee was going to be waived again, but they asked R1 to find people to assist in moving to room 202. Interview conducted with R2 who is R1s roommate, revealed that the grab bar on the side of the shower is a bit high, but there is another grab bar in front of the shower that is lower and also there is a shower seat with grab bars in their shower that they can both use for more support. Both R1 and R2 are in a wheel chair. LPA toured room 106, 127, and 202 and observed the following: the shower in room 106 has the side gab bar install a bit high in a horizontal way due to the design of the shower, but there is another grab bar in lower vertical position install in the front of the shower. There is also a shower seat with grab bars inside the shower for more support. LPA confirm that room 127 is not ready for residents to move in. The carpet needs to be replaced. Room 202 is ready and the shower grab bar is similar to the grab bar in room 127 shower. LPA confirmed that the grab bar in room 202 is a bit loose, but not significantly. However, during the visit staff started working on tightening the grab bar. 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 are unsubstantiated. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 27, 2022 · control 28-AS-20220718081108

Allegation investigated: Facility overcharged resident.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Executive Director Pamela Junge and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed Resident #1 (R1) file and obtained copies of the following documents: Admission Agreement and Billing Statements from January 2022 - July 2022. The investigation revealed the following: in regards to the allegation "facility overcharged resident", it is alleged that R1 has been hospitalized since 06/25/22 and her personal belongings were removed from the facility on 06/30/22 as she would not be returning to the facility. Despite moving out R1's belongings, R1 allegedly received a bill in the amount of $1,882 for the month of July 2022. Executive Director indicated that facility sends out next month's bill about 7-10 days prior to the 1st of the month in order to ensure the Residents and/or Payees receive the bill before the due date. (CONTINUED ON 9099C) Unsubstantiated Executive Director indicated R1 is not responsible for the full $1,182.28, however there is an outstanding balance of $182.28 that R1 is responsible for due to past balance. Review of Billing Statements confirms this balance. R1 will not be charged Room & Board charges for the month of July 2022. Executive Director indicated R1 will be receiving this new updated bill with the correct charges. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 14, 2022 · control 28-AS-20220708130414

Allegation investigated: Staff not abiding to admission agreement Staff did not advise residents of complaints filed against the facility Resident is being charged for services not received

Licensing Program Analyst(s) (LPA) Jose Villalobos and Mary Flores conducted a subsequent complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Administrator Pamela Junge. Purpose of the visit was discussed. Initial visit was conducted on 12/1/21 and consisted of the following: LPA interviewed Staff #1 (S1) and Resident #1 (R1). LPA toured the physcial plant and room #229. LPA reviewed and collected copies of R1's resident file. LPA also recieved a copy of the staff and resident roster. On Todays visit , LPA interviewed Staff #2-#5 (S2-S5) and Resident #2-#5 (R2-R5). LPA reviewed and collected copies of R1's resident file. Continued on LIC 9099-C Unsubstantiated The investigation revealed the following: In regards to the allegation, "Staff did not provide a copy of the admission agreement " it was alleged that the facility staff did provide an copy of R1's admission agreement when requested by family. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews show that a copy of R1's admission agreement was requested by relatives of R1 and were not provided by staff. Interviews show that R1 provided the facility staff with a letter stating that R1 gives their relative permission to receive such information. LPA observed the letter on file which was dated on 9/28/21. LPA's initial visit was conducted on 12/2/21 where the admissions agreement had yet to be provided to the relative that requested the agreement, this shows that the staff failed to provide the admissions agreement when requested. In regards to the allegation, "Facility has inadequate record keeping for the residents" it was alleged that the facility could not provide a breakdown of R1's current pay rate as stated in the admissions agreement. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews show that R1's pay rate according to their admissions agreement Schedule A is $1300. Interviews state that R1's rate was calculated by adding $1200 as the base monthly fee and $100 for assisted living level of care rate. R1 has been receiving medicine management since they were admitted and that is defined as "level 1" care in the admissions agreement. R1's admissions agreement on file does not show the breakdown of the 1300 explained during interviews and staff interviewed were not able to explain why it did not show on the admissions agreement. Due to this discrepancy, the facility failed to have adequate record keeping of R1's file. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the allegation(s) are found to be substantiated. California Code of Regulations, Title 22, citations are being cited on the attached LIC 9099D. A copy of this report was provided to Administrator Pamela Junge. Appeal rights were discussed and provided. The investigation revealed the following: In regards to the allegation, "Staff not abiding to admission agreement" it was alleged that the facility is raising the rate for R1 and did not provide a notice as required. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews show that R1 was provided a 60 Day notice of the rate change in August 2021 prior to the new rate taking place on November 2021. LPA reviewed R1's file and observed the notice dated and signed by S1. Based on observations, interviews and files reviewed there was not enough supportive evidence to corroborate with the reported allegation. In regards to the allegation, "Staff did not advise residents of complaints filed against the facility " it was alleged that the staff did not inform residents of complaints against the facility. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents could not corroborate the allegation. Interviews do not show that staff inform residents of complaints on the facility but licensing reports are posted with other required postings for residents to see. Review of title 22 regulations do not state that staff need to inform residents of complaints filed against the facility. Based on interviews and file review conducted, there was not enough supportive evidence to corroborate with the reported allegation. In regards to the allegation, "Resident is being charged for services not received " it was alleged that R1 is not being provided the services required per the admissions agreement. (5) of (5) staff interviewed denied the allegation. (4) of (5) residents interviewed could not corroborate the allegation. Interviews show that R1 receives assistance with medication, is provided 3 meals a day, has help with laundry, and has their room cleaned by staff. Review of R1's file does not show other services being paid for and not provided by the facility. Based on observations, interviews, and files reviewed, there was not enough supportive evidence to corroborate with the reported allegation. Although the allegation(s) 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(s) are UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided to Administrator Pamela Jungethe state’s words, verbatim · CDSS document, Jul 6, 2022 · control 28-AS-20211122141422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Jul 22, 2022

87507.Admission Agreements.(e)The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative...The licensee shall provide additional copies to the resident or resident’s representative upon request. This was not met as evidenced by: R1's family requested a copy of the admissions agreement as of 9/28/21 after R1 stated to staff to provide it and facility did not provide it. This poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jul 6, 2022

Plan of correction: Administrator to provide licensing with a letter stating that they have reviewed title 22 section 87507 by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(A) · Plan of correction due date: Jul 22, 2022

87507 Admission Agreements (g) Admission agreements shall specify the following:(3) Payment provisions, including the following: (A) Rate for all basic services... Basic services rate(s), including: 1. A comprehensive description of any items and services provided.. This was not met as evidence by: R1's admissions agreement did not have a break down of how R1s rate was calculated and staff interviewed were not able to explain. This poses a potential health and safety risk to residents in care and supervision.the state’s words, verbatim · CDSS document, Jul 6, 2022

Plan of correction: Administrator to provide licensing with a letter stating that they have reviewed title 22 section 87507 by POC due date.

Allegation investigated: Resident was left in soiled diapers for an extended amount of time. Staff did not communicate with authorized representative.

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Pamela Junge (Executive Director) and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed Resident #1 (R1) file and obtained copies of Identification and Emergency Information Form, Physician's Report, Resident Appraisal, and Service Request. LPA also interviewed the Executive Director, Staff #1 - Staff #3, and Resident #1 - Resident #8. The investigation revealed the following: in regards to the allegation "resident was left in soiled diapers for an extended amount of time", it is alleged that on 06/05/22 (R1) was observed in a soiled diaper. It is unknown how long (R1) was in the soiled diaper. Interviews conducted with staff members deny the allegation. Staff members interviewed indicated R1 does not use diapers and does not require continence assistance, but does require prompting. Review of R1's Service Request Plan & Physician's Report indicates that R1 is continent of bowel and bladder and is independent of toileting assistance. (CONTINUED ON 9099C) Unsubstantiated R1 indicated that she does not need toileting assistance from facility staff. R1 indicated she does not recall if she was soiled on Staff members interviewed indicated that residents are checked on at least every 2 hours and will assist residents by taking them to the bathroom or with diaper changes. 8 out 8 residents interviewed indicated that they are happy with the services they receive at the facility. Therefore there was insufficient evidence to corroborate with this allegation. In regards to the allegation "staff did not communicate with authorized representative", it is alleged that sometime between 05/30/22 - 06/01/22, R1 was moved to a different room without explanation. It is alleged that R1's Responsible Party was not notified of the room change. Interview with Executive Director confirmed that R1 was temporarily moved to a different room due to roommate incompatibility. Executive Director indicated she attempted to notify R1's Responsible Party on 05/29/22 when R1 was moved, but was unable to reach Responsible Party and left a voicemail informing them of the room change. Executive Director indicated she also spoke to R1's Responsible Party on 06/06/22 and informed them of the temporary room change. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 16, 2022 · control 28-AS-20220607114242

Allegation investigated: Facility not following doctor's orders.

Licensing Program Analyst (LPA) Luis Mora conducted a subsequent unannounced complaint visit to determine the validity of the above-mentioned allegation. LPA met with Pamela Jungi (Executive Director) and explained the reason for the visit. The investigation consisted of the following: On 03/03/2022, LPA obtained a copy of resident and staff rosters, copies of face sheet, physician report, preplacement appraisal information, medication records, and hospice care documents for Resident 1 (R1). LPA also interviewed the Wellness Director, Hospice Care Case Manager, and Resident 1 (R1). On today's visit, LPA obtained a copy of resident and staff rosters, copies of February & March 2022 medication log for Resident 1 - Resident 7 (R1 - R7). LPA interviewed the Executive Director, Staff 1 - Staff 2 (S1 - S2), R2 - R7 and Hospice Care Nurse. Regarding the allegation "facility not following doctor's orders", it is alleged that the hospice care agency ordered the facility 02/12/22 to stop using the baby powder under R1's belly flap. (CONTINUED TO LIC 9099C) Unsubstantiated The baby powder was not prescribed by any doctor and was provided to the facility by R1's responsible party. The facility was applying baby powder around R1's private area and under R1's belly flap. On 02/12/2022, it is alleged that a nurse from the hospice care agency and R1's responsible party were at the facility and ordered the facility to stop using baby powder on R1. On 02/19/2022, R1's responsible party visited R1 and observed S1 still using the baby powder. It is believed that the baby powder was causing a rash under the belly flap and that is the reason why the facility was asked to stop using it. Interviews conducted with the nurse and case manager from the hospice care agency revealed that they have no documentation stating to stop using the baby powder in their records for R1. Interviews conducted with staff revealed that they stopped using the baby powder under the belly flap area per R1's responsible party request and also placed a sticker on the baby powder bottle that states "don't use under belly". Furthermore, the claim that the baby powder is the reason for the rash is unlikely unless R1 has an allergic reaction to the baby powder. Review of R1's physician report indicate that R1 has no known allergies. On 02/24/2022, the hospice care agency ordered Nystatin and provided it to the facility on 02/26/2022 to use for the belly flap rash. Furthermore, it was also alleged that facility was not providing R1 with the PRN medication Tylenol when it was needed. On 02/23/2022, R1's responsible party took R1 to the doctor and R1 received a tetanus shot. R1 is non-verbal and therefore unable to communicate when in pain. Interviews conducted with staff revealed that they did gave R1 Tylenol on 02/24/2022 at 6:26pm because R1 was refusing to take the medication all day. R1's medication records show that the PRN medication Tylenol was administer on 02/24/2022 6:26pm, 03/06/2022 2:55pm and 8:15pm, and 03/07/2022 5:00pm. Interviews conducted with residents revealed that they have no issues with receiving their PRN or any medication. 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. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 20, 2022 · control 28-AS-20220222111310

Allegation investigated: Resident sustained an injury from a fall while in care

Licensing Program Analyst (LPA) Jose Villalobos conducted a complaint inspection for the above allegation. LPA met with Executive Director Pamela Junge and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters and Incident report dated 4/1/22. LPA reviewed Resident #1 (R1) file and obtained copies of Face Sheet, Physician's Report, Services Plan, and admissions agreement. LPA interviewed Staff #1-#4 (S1-S4) and residents #1-#3 (R1-R3). LPA toured the physical plant. The investigation revealed the following: In regards to the allegation "Resident sustained an injury from a fall while in care" it was alleged that R1 sustained an injury in the facility while intoxicated due to lack of supervision. (4) of (4) staff interviewed denied the allegations. (3) of (3) residents interviewed could not corroborate the allegation. Interviews show that R1 and R2 were privately drinking in R2's room on 4/1/22 when staff walking by observed residents in room 113 acting out of character. Continued on LIC 9099-C Unsubstantiated Upon speaking with R1 and R2, staff noticed residents were intoxicated and R1 had a bump on their forehead. Staff called paramedics and assisted R1 and R2. Interviews do not show lack of supervision as residents were in private behind closed doors. There are no existing laws or regulations that prevent residents from eating or drinking what they please. R1 stated to not have been made to do something against their will. Review of R1 and R2's file does not show limitation on what they are able to eat or drink. R1's file does not show that they need a certain amount of supervision from staff. Based on the interviews conducted, observations and files reviewed, there was not enough supportive evidence to concur with the reported 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. Exit Interview was conducted with Pamela Junge and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 14, 2022 · control 28-AS-20220407162336

Allegation investigated: Staff not administering medication as prescribed.

Licensing Program Analyst (LPA) Nune Margaryan conducted a complaint inspection on the above allegation. LPA arrived unannounced and met with the Executive Director Sophia Chan and explained the purpose of the inspection. The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed Resident #1 (R1) file and obtained copies of Face Sheet, Physician's Report, and Resident Appraisal. LPA interviewed Executive Director, Staff #1 (S1) and Resident 2 (R2). LPA also reviewed a random sample of residents medications during today's visit and observed medications to be not documented properly and given as prescribed. LPA was unable to interview R1 because R1 was not at the facility during the visit. Continue 9099C Substantiated The investigation revealed the following: It was alleged the facility was not providing residents medication as prescribed. Interviewed staff indicated residents are provided with medication as prescribed. R2 stated that staff not providing medication as prescribed. Upon reviewing R1's Medication Administration Log (MAR log), LPA observed that the 325 mg, 500 mg and 650 mg Acetaminophen were ordered by doctor on 12/31/21 and not given to R1 as prescribed. 650 mg Acetaminophen was not seen at the facility at the time of visit. The MAR log was signed off that Rosuvastatin Calcium 10 mg administered as prescribed but the medication was still packaged and not dispensed for 3/6/22. Upon reviewing R2's MAR LPA observed that Loratadine 10mg signed off for 03/14/22 and administrated as prescribed, but the medication was still packaged for 03/14/22. Based on LPA interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Deficiencies cited under California Code of Regulations Title 22. See 9099D. Exit interview conducted and copy of the report with appeal rights was provided to Executive Director.the state’s words, verbatim · CDSS document, Mar 23, 2022 · control 28-AS-20220316094043

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Mar 24, 2022

If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: Facility failed to provide Acetaminophen 325 mg, 500mg and 650 mg R1 as prescribed. Facility failed to provide Loratadine 10mg R2 as prescribed. This poses an immediate Health and Safety risk to clients in carethe state’s words, verbatim · CDSS document, Mar 23, 2022

Plan of correction: The Licensee shall conduct staff training on medication documentation to ensure that they are providing medication to residents as prescribed.

Type of visit: Case Management - Other

During the health and safety check for complaint #28-AS-20220318093921. Licensing Program Analyst (LP) Angelica Rea observed that the water temperature measured at 130.6 * F in staff restroom, 127.4 * F in kitchen/coffee bar area, 129 *F in common bathroom on 2nd floor, and 125.6 * F in Room #201. This poses a health and safety risk to residents in care. Deficiency cited on attached 809-D. Appeal rights and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Mar 21, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 22, 2022

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not being met as evidenced by: LPA Rea observed that the water temperature measured at 130.6 * F in staff restroom, 127.4 * F in kitchen/coffee bar area, 129 *F in common bathroom on 2nd floor, and 125.6 * F in Room #201. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 21, 2022

Plan of correction: The Administrator will ensure that hot water provided for the use of residents shall be maintained between 105 and 120 degrees F at all times. Administrator will adjust the thermostat on the water heater to ensure water provided is within the required range. Administrator shall provide evidence that the deficiency has been corrected by 3/22/2022.

Allegation investigated: Resident sustained a fall while in care Staff did not notify authorized representative of an incident involving a resident Staff did not seek timely medical attention for a resident Facility has inadequate record keeping Facility has inadequate staffing for the facility Resident's sliding door is in disrepair

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint visit regarding the above allegation. LPA met with Administrator Sophia Chan and Wellness Director Brooke Lamotte. The purpose for the visit was explained. The investigation consisted of the following: LPA obtained a client and staff roster and interviewed Staff #1 – #6 (S1 – S6), and Resident #1-#6 (R1 – R6). Reviewed and obtained copies of R1's File, and toured the physical plant. LPA interviews staff from R1's Hospice Agency. In regards to the allegation "Resident sustained a fall while in care ", it was alleged that R1 fell in the facility due to lack of care and supervision. (6) of (6) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews show that S1 was pushing R1's wheelchair when R1 suddenly pulled forward and reached out as if to grab something resulting in R1 falling.... Continued on LIC 9099-C Unsubstantiated R1 was assessed and assisted back onto their wheelchair immediately after. This concludes that staff was present and provided care and supervision to R1 even though R1 fell. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported 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. In regards to the allegation "Staff did not notify authorized representative of an incident involving a resident ", it was alleged that R1 fell on 3/1/22 and R1's authorized representative was not notified in a timely manner. (6) of (6) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1 fell around 5:40pm and family was contacted minutes after. Staff spoke to R1's authorized representative via phone call after speaking to a separate family member first. R1's authorized representative arrived to the facility within an hour after hearing of the incident as well. Review of documents on file show that R'1s authorized representative is also the durable power of attorney (DPOA). Interviews show that although R1's DPOA was not contacted first, they were still contacted in a timely manner. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported 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. In regards to the allegation "Staff did not seek timely medical attention for a resident", it was alleged that staff did not assess R1 and provide first aid on 3/1/22. (6) of (6) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews show that R1 was assessed after falling and no physical injuries were observed that required immediate medical attention besides first aid care. R1 was assisted to their room and provided an ice pack by staff. LPA Villalobos reviewed an incident report stated that Resident was assessed and provided first aid. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported 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. Continued on LIC 9099-C In regards to the allegation "Facility has inadequate record keeping ", it was alleged that the facility does not keep hospice care documents and notes on file in order to contact them regarding any incidents or changes that occur with R1. (6) of (6) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Interviews show that on 3/1/22 facility staff did contact R1's hospice agency about R1's fall. Hospice agency staff confirmed. LPA reviewed R1's files in the facility and was provided with R1's Hospice binder with contact information. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported 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. In regards to the allegation "Facility has inadequate staffing for the facility", it was alleged that facility staffing is not enough to provide adequate care and supervision to residents. (6) of (6) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Review of staff roster demonstrates that the facility keeps med techs and caregivers on all shifts. Interviews show that even though 2 staff quit recently, other staff have worked overtime and the facility works with a 3rd party agency in order to keep the facility staffed. During the visit LPA observed sufficient staffing providing care and supervision to residents. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported 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. In regards to the allegation "Resident's sliding door is in disrepair ", it was alleged that the sliding door in R1's room did not lock. (6) of (6) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPA toured the room with S1 and S1 was able to demonstrate that the door locked. LPA also recorded the door being locked. Based on the interviews conducted and observations, there was not enough supportive evidence to concur with the reported 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. Citation is being cited on a separate 809. Exit Interview conducted with administrator Sophia Chan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 10, 2022 · control 28-AS-20220302112849

Type of visit: Case Management - Deficiencies

On the above date, Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation at the above facility. During the complaint investigation, LPA observed that incident report regarding Resident#1 (R1) was not reported to licensing within the required time. Incident took place on 3/1/22 and it was provided to LPA on 3/10/22, past the 7 days required. According to the California Code of Regulations (Title 22, Division 6, Chapter 1), LPA observed the following deficiency and issued a citation. An exit interview was conducted and a copy of the Facility Evaluation Report and Appeal Rights were provided to Administrator Sophia Chan.the state’s words, verbatim · CDSS document, Mar 10, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Mar 25, 2022

(a) Each licensee shall furnish to the licensing agency such reports... (1) 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... (D) Any incident which threatens the welfare, safety or health of any resident.... This was evidence by: LPA interviews and file review show that Resident fell on 3/1/22 and it was not reported until 3/10/22 when LPA visited the facility, this poses a potential health and safetey risk to residents in care and supervision.the state’s words, verbatim · CDSS document, Mar 10, 2022

Plan of correction: Adminstrator was able to provide LPA with the Incident Report at time of visit. POC cleared during the visit.

Type of visit: Office

An informal conference was held via Microsoft Teams on 1/20/2022. The purpose of this informal meeting was to discuss the facility staffing issues. Present in the meeting were: Licensing Program Analyst (LPA) Jose Villalobos, Regional Manager (RM), Facility Administrator Sophia Chan and Wellness Director Brooke Lamaonte. Licensing was informed that on 1/15/22, there were staffing shortages in the facility that led to there being only 1 med tech/ care giving staff for all residents of the facility. Sophia and Brooke explained that it was a one time incident due to miscommunication between staff and staff testing positive for covid-19 that coverage was not done at a timely matter. The facility did acquire more staff to cover shifts. Sophia and Brooke explained that the facility has recently opened a new position focused on showering residents that would serve as an additional caregiver staff when needed in order to be more prepared. Licensing informed Sophia and Brooke that they are able to reach out to Licensing regarding staffing issues. LPA to forward the following PINS for administrator to review: PIN 22-04 ASC PIN on 21-32.1 ASC Community Care Licensing (CCL) reminded Administrator that Department of Public Health Guidelines must be followed as well CCL's regulations to remain in compliance otherwise citations may be warranted. No deficiency was issued during today's meeting. An exit interview was conducted and a copy of this report was emailed to Administrator for signature.the state’s words, verbatim · CDSS document, Jan 20, 2022

Allegation investigated: Resident's funds are being stolen.

Licensing Program Analyst (LPA) Jose Villalobos initiated a complaint investigation for the allegations listed above. Today’s complaint investigation was conducted with Administrator Sophia Chan. Purpose of the visit was discussed. On Todays visit , LPA interviewed Staff #2-#3 (S2-S3) between 10am-10:45am and Residents #1-#2 (R1-R2) from 1pm-1:45pm. LPA toured the physical plant and room #121 from 12:30pm-1pm. LPA reviewed and collected copies of R1's resident file and S1's Staff file between 10:45am-12:30pm. LPA also recieved a copy of the staff and resident roster. S1 was not available for interview as S1 no longer works in the facility. The investigation revealed the following, in regards to the allegation "Resident's funds are being stolen", it was alleged that S1 was responsible for unusual spending in R1s bank account while S1 was responsible for R1's finances... Continued on LIC 9099-C Substantiated Interviews with staff show that an audit was conducted by the facility that revealed the unusual spending in R1's bank account in 2021. When approached with questions, S1 resigned from the facility. Interviews with R1 show that purchases were made on R1's account by S1 without R1's knowledge. LPA reviewed R1's file and did not find documentation authorizing the use of her debit card for purchases. File review shows that R1 is self responsible and that the facility does not manager R1's finances, yet S1 was able to access R1's bank account. Based on interviews conducted and files reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, citations are being cited on the attached LIC 9099D. A telephonic exit interview was conducted with Staff Christina, and a hard copy was provided. Appeal rights were discussed and provided.the state’s words, verbatim · CDSS document, Jan 5, 2022 · control 28-AS-20211229150408

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 21, 2022

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:(3)To be free from punishment, humiliation, intimidation, abuse, or other actions... This deficiency was evidenced by the following: Resident #1 (R1) had been financial abused by Staff #1 (S1) leading to non-authourized purchases made to R1's bank account. This poses a potential health and safety risk to residents under care and supervision.the state’s words, verbatim · CDSS document, Jan 5, 2022

Plan of correction: Administrator had notified ombudsman via SOC 341 but will need to porivide a copy to Licensing. S1 was also removed as staff. Administrator conduct training for staff on Resident Personal Rights and provide LPA with proof by POC due date.

Allegation investigated: Requests for assistance are not being responded to in a timely manner Residents in wheelchairs are blocking facility exitway. Facility is cold Resident was not provided medication in a timely manner. Food not being prepared in a safe manner.

Licensing Program Analyst (LPA) Christine Wong conducted an unannounced complaint visit to address the above allegations and met with Caregiver-Tanya Ramos and explained the reason of the visit. At around 10:00am, the Executive Director- Sophia Chan arrived and assist with the visit. The investigation consisted of the following: LPA toured the facility and interviewed six (6) residents, executive director and six (6) staff and obtained copy of the resident and staff rosters. The investigation revealed of the following: Allegation#1 "Requests for assistance are not being responded to in a timely manner. " LPA interviewed six (6) residents and five (5) residents stated that the staff responded quick and it usually takes about couple minutes for them to come and assist them. LPA interviewed the staff and all denied the allegation. The executive director reported it would never happened or acceptable for a resident to wait for an hour for asssitance. (See LIC 9099C for Continuation) Unsubstantiated Executive Director also stated that currently the facility had some issues with the security system for the pendant. After the pendent was cleared, it would ring again or even the resident was not present in the facility and the pendent would ring itself too. The facility is in the process of fixing it and contacting another company for a new system. Allegation#2 "Residents in wheelchairs are blocking facility exit way." LPA interviewed six (6) residents and all denied the allegation and stated that not seeing any residents in wheelchairs are blocking the exit way. LPA also interviewed staff and all denied the allegation too and reported only sometimes when residents with walker are lining up to the dining room for lunch, it may be crowded there but staff usually would monitor and ensure the residents are standing on the side way and not blocking the entrance or the exit way. LPA observed the situation only happened around lunch time but the staff did step up and monitor the entrance or exit way were not blocked. Allegation#3 "Facility is cold. " LPA interviewed six (6) residents and four (4) residents reported they do not feel the facility or their rooms are cold. LPA interviewed the staff and denied the allegation. The executive director reported the facility thermostat are usually set between 71.5 to 72.5 degrees F. The facility has a AC unit which controlled about 5 to 6 rooms in each unit. The thermostat are all set to 72 degrees, so if the temperature are lower than 72 degrees and the heater will be picked up. For summer time, when the temperature hits 76 degrees, the air conditioning would kick in. LPA observed all the thermostat in the facility and all are set to 72 degrees. Allegation#4 "Resident was not provided medication in a timely manner. " LPA interviewed six (6) residents and four (4) residents denied the allegation and reported they do receive the medication on time and correct medication. They never experienced any medication problems in the facility. The executive director also stated all residents' medication needs to be written ordered or approved by the doctor before administer the medication to the residents. Allegation#5 "Food not being prepared in a safe manner. " LPA interviewed six (6) residents and all residents reported all kitchen staff wears hairnet, gloves and masks while they prepared the food. They do not see any problems or issues with the kitchen staff. LPA interviewed staff and they denied the allegation. The executive director also reported all kitchen staff are required to wear hairnet, masks and gloves while they prepared the food. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore all the allegations are UNSUBSTANTIATED. Exit interview was conducted with administrator Sophia Chan and a copy of report and appeal right was provided.the state’s words, verbatim · CDSS document, Dec 27, 2021 · control 28-AS-20211220120618

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Villalobos conducted an un-announced Annual visit with focus on Infection Control. LPA met with Administrator Sophia Chan. The purpose of the visit was discussed. LPA Villalobos discussed infection control practices with staff, toured the facility inside and out between 10:30am-11:15am, reviewed food supply, reviewed five (5) resident files along with their medications between 11:30am-12:30pm, and reviewed five (5) staff files between 1pm-1:45pm. The facility physical plant consists of a two story building structure that contains the following: First floor consists of resident rooms with individual bathrooms, 1 living room, Dining Rooms, courtyard, 3 offices, medication room, kitchen, and laundry area. Physical plant inside and outside is clean, sanitary and in good repair. The facility second floor consists of the following: resident bedrooms with individual bathrooms, laundry room, outdoor porch seating area, and Activity room. The following was observed: Bedrooms #106 #110 #128 and 202 were observed. All rooms have required furniture and supplies. Facility had an area with locked cabinet for medications. Facility is clean and in good repair. Water temperature met Title 22 Regulations measuring between 105-120 F. .Cupboards, freezer, stove, microwave, refrigerator and counters are clean. Bathrooms for the above mentioned rooms were observed and meet title 22 regulations. There was a 7 day supply of non-perishables available and a 2 day supply of perishables available. Client records inaccessible to unauthorized persons and will be located in a locked cabinet. Emergency disaster plan, personal rights and complaint procedures are posted. First Aid Kit and manual is complete and readily available. Smoke detectors and carbon monoxide detector operate properly and fire extinguishers are properly charged. Working washers and dryers. Working telephone. There are no bodies of water located on the premises. Adequate seating in common areas for licensed capacity. Furniture in all facility rooms appropriate, clean and in good repair. There is an outdoor activity space/ patio with a shaded area and furnished for outdoor use. Visit was completed using the Infection control inspection tool. No deficiencies were cited on todays visit. Exit interview was conducted and a copy of report was provided to Sophia Chan.the state’s words, verbatim · CDSS document, Oct 20, 2021