Woodlake Loving Care

Allegation investigated: Staff restrain resident.

On 6/23/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by staff and stated the reason for their visit. The Administrator, Shakila Ardakani arrived shortly after to assist with today’s visit. To investigate the allegation(s), at approximately 10:00 AM, requested relevant documentation pertaining to the investigation such as but not limited to: Physician’s Report, Weight Log, and Appraisals. By 11:00 AM, LPA conducted a physical plant tour. From 10:00 AM to 01:00 PM, LPA attempted to interview five (5) residents (R1-R5), one (1) staff member (S1), and conducted record review. (continue to LIC 9099-C) Substantiated Regarding the allegation: Staff restrain resident. It was alleged staff would strap R1 to their wheelchair. To investigate the allegation, LPA attempted to interview five (5) residents and one (1) staff member. LPA attempted to interview R1, but they no longer reside at the facility. LPA attempted to interview R2-R5, but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with S1 revealed they would use a “seatbelt” that is attached to the wheelchair to prevent R1 from falling. When questioned if R1 had a physician’s order for the postural support of the seatbelt to the wheelchair, S1 stated, “No”. During LPA’s physical plant tour LPA observed three (3) wheelchairs. LPA observed one (1) of the three (3) wheelchairs to have a seatbelt attachment to the wheelchair. When questioned if the current residents residing in the facility have physician’s order for the postural support observed on the wheelchair, S1 stated, “No”. Based on interviews and observation, S1 stated R1 did use such postural support due to fall risk and LPA observed there to be a wheelchair with said postural device attached. Therefore, the allegation is SUBSTANTIATED at this time. Citation issued, please refer to LIC 9099-D. No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given, and a copy of this report was provided to the Administrator. Regarding the allegation: Staff do not feed resident(s). It was alleged staff did not feed R1. To investigate the allegation, LPA attempted to interview five (5) residents and one (1) staff member. LPA attempted to interview R1, but they no longer reside at the facility. LPA attempted to interview R2-R5, but due to their inability to validate the questions being asked, LPA terminated the interview. LPA’s interview with S1 revealed they go grocery shopping weekly and residents family members provide food as well. When questioned if R1 was not provided sufficient food, S1 denied the allegation. Per S1, R1 was diabetic which had dietary restrictions with a focus on “low carbs” and “higher protein”. During LPA’s physical plan tour, LPA did not observe there to be sufficient supply of seven (7) day nonperishable foods and two (2) day perishable foods. Per the Administrator, they are do for another grocery delivery and had just bought groceries not too long ago. However, LPA did observe the freezer to have bags of frozen meats/poultry, vegetables and fruit. Per S1, the food is defrosted ahead of time to prepare accordingly. Additionally, LPA did observe residents to be eating upon arrival and during the remainder of their visit. LPA observed staff to be in the kitchen preparing lunch. LPA’s record review showcased documentation of S1’s communication with staff regarding groceries needed for the week of 6/15/2026. Further record review confirmed a purchase receipt dated 6/17/2026 of said groceries. During LPA’s record review of R1’s physician’s report, the report confirmed R1’s diagnoses. LPA conducted a supplementary record review of R1’s diagnosis. LPA’s web search of said diagnosis revealed, “…portion control is key to managing blood sugar and weight”. Based on interviews, observations and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide liquids for resident(s) to drink. It was alleged staff did not provide R1 with water. To investigate the allegation, LPA conducted an interview with one (1) staff member. LPA’s interview with S1 revealed they did not withhold water from R1. Additionally, S1 stated all residents have their own water bottle with their names on it with water. During LPA’s visit, LPA observed all four (4) residents to have their own water bottles, labeled with their names, to be filled and accessible. LPA observed residents to be drinking their water and tea. (continue to LIC 9099-C) Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not provide accurate documentation on records. It was alleged staff falsified R1’s documentation. To investigate the allegation, LPA conducted a record review of R1’s files. LPA’s record review revealed there to be R1’s medication dated 2/26/2025 to 10/13/2025 from a licensed Pharmacy. LPA’s record review of R1’s Physician’s Report revealed it to have been performed and dated by a licensed physician. LPA’s record review of R1’s weight log revealed it had been documented by staff from July 2025 to September 2025. LPA’s record review of the four (4) residents confirmed them to have their own weight log to be dated. During LPA’s physical plant tour, LPA observed a scale to be present in the living room. Per LPA’s interview with S1, they use it to track and maintain weight records for the residents. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 31-AS-20250929162117

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jul 10, 2026

87608 Postural Supports. (a) ... Postural supports may be used under the following conditions.(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidenced by: Based on interviews and observations, S1 confirmed R1 used a postural support without a physician's order and LPA observed 1 of the 3 wheelchairs to have a postural support attached to it which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 23, 2026

Plan of correction: The Administrator/Licensee will review the regulation and email LPA Segovia a statement of understanding by POC due date. Additionally, the Administrator/Licensee will email LPA Segovia the physician's orders for the postural support of the four (4) residents by POC due date.

Type of visit: Required - 1 Year

On 4/2/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct the required Annual Inspection. Upon arrival, LPA was greeted by the Administrator Shakila Ardakani, who granted access to the facility. LPA explained the reason for the visit. LPA Khurshudyan reviewed the required postings posted on the entrance wall and throughout the facility. At approximately 11:00am LPA requested staff and residents’ rosters for review. The inspection tool was used to complete the visit. At 11:35pm LPA, with the help of the Administrator, began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, and all rooms are designated for residents’ use only. There are three (3) bathrooms, a kitchen, common areas: living and dining rooms, and an outdoor area. Facility has an approved fire clearance for six (6) Non-ambulatory residents, all of which one (1) may be bedridden for bedroom #3, and a Hospice waiver for two (2) residents. Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps inside the locked kitchen cabinet. Sufficient amount of emergency supply of food / water was readily available inside the storage located outside closer to bedroom #1 exit. Food storage and preparation areas are clean and inaccessible to pests. LPA observed one (1) fire extinguisher located on the kitchen wall. The fire extinguisher was last serviced on 1/24/2026. Dish soap and other chemicals were observed to be stored under the sink inside the locked cabinet and inaccessible to residents in care. Continue on LIC809-C Bedrooms: LPA observed bedrooms to be properly furnished with beds, linens, night stands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean. Residents have enough personal hygiene products. Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits at the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:35pm, LPA measured the room temperature to be 71 degrees Fahrenheit. There is a linen closet with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards found inside the facility. Facility has landline, LPA checked it was operational. Bathroom: The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. The hot water temperature was measured at approximately 12:05pm to be 114.9 degrees Fahrenheit. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. LPA observed non-skid mats and grab bars inside the bathrooms. Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by staff at approximately 12:55pm and were observed to be operational. Garage: There is a garage in the property which is currently being used for storage. Laundry Room: Functioning washer and dryer is located in the separate locked laundry room outside of the facility, adjacent to facility entrance. Laundry detergents and other chemical supplies observed locked inside the laundry room. Backyard/Front yard: LPA observed sufficient yard space and fenced backyard with appropriately covered shaded area available for residents to rest. There is outdoor furniture under the shaded area. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. During the physical walk through LPA observed all exit areas to be free of clutter and obstruction. There is no body of water. Staff/Client File review: Facility records are kept inside the locked commercial/metal cabinet located in the office. Between 11:50am -2:25pm LPA conducted records review of five (5) staff files and five (5) residents’ records. Files were complete and updated. Continue On LIC809C Medications: At approximately 1:50pm, LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. LPA observed centrally stored medications locked inside the cabinet located in the office and inaccessible to residents in care. Complete First-aid kit is also available and placed in the office. No potentially dangerous items were found in the facility. The facility operates with two (2) shifts and has one to two (1-2) staff members for each shift. LPA conducted interviews with the Administrator, one caregiver and three (3) residents who were able to communicate and answer questions. Facility plan/sketch is posted on the wall along with other posting requirements. LPA collected LIC500, LIC9020, and copy of Liability Insurance, and copy of Administrator certificate at the time of the visit. The Administrator certificate will be expiring on 9/21/2027. The facility has no outstanding balance of licensing fees. No Deficiency issued during today’s visit. Exit interview conducted, a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 2, 2026

Type of visit: Case Management - Other

On 12/18/25, Licensing Program Analysts (LPAs) Perchuhi Milena Khurshudyan and Tihesha Smith, conducted an unannounced Case Management visit to this facility. Upon arrival LPAs met with Shakila Ardakani Administrator and explained that the reason for this visit is to continue an investigation of the case management visit initiated on 12/08/2025. The purpose of today’s visit is to address issues and concerns regarding admission, readmission, and retention of resident #1 (R1) to the facility. On 10/17/25, LPA Khurshudyan received an Incident Report (IR) regarding R1, who developed wound on the right toe and per home health nurse evaluation R1 required antibiotic. On 10/23/25, LPA received another Incident Report regarding R1 being transferred to hospital due to wound infection on the toe. Prior to this visit LPAs Smith and Khurshudyan reviewed all available documents pertaining to R1’s health conditions. Upon further review of available medical records, including but not limited to Home Health, records, wound evaluate R1’s health condition, care plan, and the facility’s improper assessment practices related to R1’s return from the hospital. During this visit at approximately 1:20pm, LPAs conducted a brief physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. Between 10:45am to 12:00pm, LPAs spoke with facility Administrator and reviewed additional medical records. Continue on LIC809-C Overall investigation revealed that on or before 10/17/25, R1 developed pressure injury(s) on their right toe and other pressure points including buttock. R1 was receiving home health care assistance. However, the wound(s) was not healing, and wound care specialist was contacted to attend R1 for further assistance. Between 10/17/25 and 10/23/25, the condition of the pressure injury(s) worsened and R1 was sent to the hospital. At the time of admission to the hospital, R1 was diagnosed with multiple unspecified pressure injuries and Sepsis. Hospital records state that resident was recommended to continue medical care in skilled nursing facility. However, per R1’s family request and refusal to transfer R1 to skilled nursing facility (SNF), R1 was readmitted back to the facility. R1 was discharged back to the facility with PICC/IV line for continuation of care. The hospital discharge records did not provide any information to verify that R1’s Sepsis was colonized, and the pressure injuries were healing. Overall investigation revealed that while in the facility R1 developed prohibited health condition, was hospitalized and later on 10/28/25 was readmitted to the facility without proper discharge record identifying the status of the infection and pressure injuries. Based on inspection, observation and record review the following citation was issued and recorded on LIC809D. An immediate $500.00 Civil Penalty will be issued for retention and readmission of the residents with prohibited health condition. Deficiency issued during today’s visit, check LIC809D pages. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(4) · Plan of correction due date: Dec 19, 2025

87615 Prohibited Health Conditions (a)Persons who require health services for{...}including, but not limited to{...} shall not be admitted or retained in a residential care facility for the elderly: (4)Staphylococcus aureus ("staph") infection or other serious infection. This This requirement was not met as evidenced by" Based on records reviewed and interview held with Administrator which revealed that R1 was re-admitted to the facility with prohibited health condition, which posed an immediate health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: The Administrator will submit written statement explaining the actions will take before admitting residents to facility to avoid similar situations in future. An immediate $500.00 Civil Penalty will be issued for retention and readmission of the residents with prohibited health condition.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tihesha Smith and Perchui Milena Khurshudyan conducted an unannounced case management to this facility. LPAs were greeted by staff. The administrator arrived later, and LPAs disclosed the reason for the visit. LPA Smith requested former resident file at approximately 10:48 am under prior case: 31-AS-20230323112447. Due to former resident files being in electronic format, LPA Smith requested specific home health documents at approximately 10:55 am. Administrator will contact nurse providing care between 09/20/22-10/24/22 for notes and or records. No deficiencies noted at time of visit Exit interview conducted/Copy of report giventhe state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Incident

On 12/8/25, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Tihesha Smith, conducted an unannounced Case Management visit to this facility. Upon arrival LPAs met with Shakila Ardakani Administrator and explained the reason for the visit. The purpose of today’s visit is to evaluate R1’s health condition, care plan, and the facility’s improper assessment practices related to R1’s return from the hospital. At approximately 10:50am, LPAs conducted a brief physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit. On 10/17/25, LPA Khurshudyan received an Incident Report (IR) regarding R1, who developed wound on the right toe and per home health nurse evaluation R1 required antibiotic. On 10/23/25, LPA received another Incident Report regarding R1 being transferred to hospital due to wound infection on the toe. LPA contacted the Administrator for additional information regarding R1’s health condition. During phone conversation with the Administrator, LPA requested R1’s home health nurse visit notes, medical evaluation reports, hospital records, and informed the Administrator that to continue providing care under home health agency in the facility, the department will need an Exception Letter with care plan details before discharging R1 back to the facility with higher than stage 2 pressure ulcer. On 11/25/25, LPA received R1’s hospital discharge records and Home Health agency visit reports via email and revealed that R1 was discharged from the hospital back to the board and care on 10/28/25, with assigned home health care. According to discharge records, Resident 1 (R1) was diagnosed with a unspecified pressure wound (no stage noted) on the right fifth toe and sepsis in the body. The records note the presence of an infection, but do not indicate whether the infection had spread or become persistent." Continue on LIC809-C At the time of this visit LPAs spoke with the Administrator and the Administrator acknowledged that R1 was readmitted back to the facility while was getting antibiotics for unspecified infection through the IV Pick line. The Administrator verified that prior to readmission, she failed to contact Licensing Office to request an exception to readmit and/or retain the resident with the health conditions requiring higher level of care. LPAs spoke with the Administrator and informed them the time if resident’s readmission on 10/28/25 the facility was operating in major noncompliance with Title 22 Regulations that posed an immediate risk to R1’s health and safety. Based on today’s inspection, observation and record review, the following deficiencies were cited and recorded on LIC809D. During exit interview, the Administrator was informed that immediate Civil Penalty will be issued for readmission and retention of the resident with prohibited health condition. Deficiencies issued during today’s visit, check LIC809D pages. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87455(c)(2) · Plan of correction due date: Dec 9, 2025

Acceptance and Retention Limitations (c)No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care […] This requirement was not met as evidenced by: Based on observations, records review and interview, the administrator revealed that R1 was re-admitted to the facility with IV PICC line that required 24h nursing assistance posed an immediate Health [..] risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: The resident is no longer receiving IV PICC line therapy. Verification of scheduled training need to be submitted to LPA by POC due date 12/09/25. Training materials will need to be submitted later after comlition.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87616(a) · Plan of correction due date: Dec 19, 2025

(a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by Based on records reviewed and interview held with Administrator which revealed that R1 was re-admitted to the facility prior to submitting and received an exception request approval, which posed a potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 8, 2025

Plan of correction: The resident is no longer receiving IV PICC line therapy.Licensee/administrators and all staff will need to attend 2 hours vendorized traiing related to acceptance retention limitation, prohibited health condition and exception requests. Verification os scheduled training will need to be submitted 12/9/25 and proof of completion will need to be at a later time.

Type of visit: Required - 1 Year

On 1/15/25 at approximately 9:05am an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver Bella Belkees Bassam, who granted access to the facility. LPA introduced herself and explained the reason for the visit. Shortly after the Administrator, Shakila Ardakani arrived and helped with physical plant tour and staff/residents’ files. During today's visit, LPA conducted a physical plant walk through, at approximately 9:45am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and of which fire clearance for one (1) Bedridden. Facility also has a hospice waiver for two (2) residents. There are four (4) bedrooms and all four are designated for residents’ use. All bedrooms observed to be appropriately furnished and have appropriate lighting. There are three (3) bathrooms in the facility of which two (2) are designated for residents’ use and one (1) for staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:15am to be 115°F. Extra towels and linens were readily available in the linen closet next to bedroom #2. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. LPA observed facility alarms were present on all exit doors and all of the signals were functional. SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:00pm they were tested and observed to be operational. The facility has one (1) fire extinguisher that was last purchased on 10/14/2024. Continue on LIC809-C KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored in a locked drawer inaccessible to residents in care. Extra emergency food was properly stored inside the storage cabinet. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 15:35am to be 75°F. No obstructions and or tripping hazards throughout the facility found. MEDICATION: LPA observed centrally stored medication and First Aid kit locked in the kitchen cabinet and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. PRN medications have written orders from a physician. The facility serves residents with dementia and facility has trained staff to meet the needs of residents who are diagnosed with dementia. Facility has two (2) staff for AM shift and one (1) awake caregiver for PM shift. COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has land line, LPA checked its operational. LAUNDRY ROOM: Laundry machines are located in the separate locked area located outside next to the main entrance. LPA observed chemicals and detergents were stored and locked inside the laundry room.. LPA discussed the importance of keeping potentially dangerous items locked at all times. SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area available for residents to rest and enjoy outside weather. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is a garage in the property, which is currently being used for storage. FILE REVIEW: Between 10:45am to 11:50am, LPA reviewed records and files of six (6) residents and six (6) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians. Continue on LIC809-C A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility. Facility also provides activities to the residents. An emergency exit plan/sketch along with other posting requirements are posted on the wall in the living room. Medications Review: At approximately 11:55am. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts. LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate, and Facility Disaster Plan. No citation issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 15, 2025

Allegation investigated: Resident sustained multiple severe pressure injuries due to staff neglect

Licensing Program Analyst (LPA) Tihesha Smith made an unannounced complaint visit to this facility at 10:35 am to deliver findings. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was contacted and arrived later. The initial visit was conducted by LPA Tihesha Smith on 03/24/2023, at which time LPA Smith conducted a physical plant tour at around 11:07 am and conducted an interviews with staff and requested documents relevant to the investigation at 11:18 am. Resident sustained multiple severe pressure injuries due to staff neglect Staff interviews conducted on 03/24/2023 at 11:18 am, revealed that upon admission to the facility, Resident #1 (R1) required help with all ADLs (Activity of Daily Living). A review of skilled nursing records and Physicians’ report skilled nursing records revealed that R1 was admitted to the facility with a pressure ulcer of sacral region stage 2. Wound progress notes revealed the following wound progression: Substantiated (Cont from 9099) Wound #2 Sacral is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Wound #3 Left, Lateral Lower Leg is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed with presence of slough. Wound #5 Right Buttock is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Wound #7 Left Back is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Wound #8 Right Hip is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed Wound #9 Right Upper Back is a chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Wound #10 Left Back lower is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Interviews with administrator revealed that although they had wound care nurse, they did receive information that R1’s wounds were not healing. Overall, the investigation revealed that although facility staff including the Administrator had knowledge that R1’s pressure injuries were not healing, they failed to take appropriate measures to ensure that there is no immediate threat to the health and safety of the resident. Based on the information revealed from interviews and records review, there is sufficient information to support the above stated allegation. Therefore, the allegation is determined to be Substantiated at this time. Exit interview conducted. Appeal rights given. Copy of report given.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 31-AS-20230323112447

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Feb 27, 2024

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on record reviews & interviews, R1 wounds were not healing, and developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: Licensee shall submit a written plan describing how the facility shall prevent injuries to residents in care as a result of this deficiencies. Licensee shall submit to CCL no later than 03/1/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Feb 27, 2024

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Feb 27, 2024

Plan of correction: he Administrator agreed to do the following: Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening and to ensure compliance to the cited regulation Licensee shall submit to CCL no later than 03/1/24

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan, met with Administrator Shakila Ardakani for a One (1) year required visit for this facility. A tour of the physical plant was conducted at 3:23 PM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory resident, one of which maybe bedridden. Hospice waiver for two (2) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. The smoke detectors were tested and observed to be operational. There is a fire extinguisher located in the kitchen and was observed to be full and last bought on 10/05/23. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 9099-C) (continued from LIC 809) The garage is detached to the house. It is also being used as storage for frozen foods, PPE and other toxins. Laundry room is located outside in the front yard. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in a cabinet in the laundry room. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the kitchen cabinet. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. Sink in the bathrooms were removed and under construction. The hot water temperature measured at 118.9°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet. Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet. Client records: Client records are reviewed. Residents records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appear to be complete and updated. Disaster drill was last conducted on 10/01/23 . Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued.the state’s words, verbatim · CDSS document, Jan 11, 2024