Glen Park at Glendale - Mariposa St.

Regarding the allegation: Staff threatens resident. It is being alleged that Resident #1 (R1) was threatened by staff #1 (S1) to be slapped. During LPA’s interview with R1, R1 admitted that S1 never threatened to slap them and has never hit them. R1 also admitted to LPA, that they wrote a letter apologizing to S1. During LPA’s interview with S1 and staff #2 (S2), they both confirmed that R1 wrote S1 a letter apologizing. LPA received a copy of the letter. During LPA’s interview with S1, S1 confirmed that they have never threatened R1 and/or any other resident. During LPA’s interview with S2, S2 confirmed that S1 has never had any issues with any residents. In addition, S2 conducted their own investigation and R1 admitted that they lied about S1. Furthermore, S2 confirmed that the police dismissed the incident because R1 kept changing their story about what happened. LPA interviewed eight (8) other residents that confirmed S1 has never threatened to hit them and/or has ever slapped them. Therefore, based on the staff and resident interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff is not providing medical care for resident. It is being alleged that Resident #1 (R1) has rashes on their arm and staff #1 (S1) is not providing medical care. During LPA’s interview with R1, R1 admitted that the rashes they had on their arm was from a hygiene bottle they had bought and S1 had been providing a cream on their arms and told them to stop using the hygiene because of the allergic reaction it was causing. During LPA’s interview with S1, S1 confirmed that a prescribed cream was being provided to R1’s arm daily for a rash they had obtained from a hygiene bottle they had and had gotten an allergic reaction. S1 also confirmed that they have never denied any medical care to any of the residents. During LPA’s interview with Staff #2 (S2), S2 confirmed that no residents have complained about S1 not providing care to them and that R1 was currently being provided cream for their rashes. Furthermore, S2 also confirmed when they asked R1 where they received the hygiene bottle R1 confirmed their brother gave it to them. LPA interviewed eight (8) other residents that confirmed S1 has never denied them any medical care. Therefore, based on the staff and resident interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced Annual/Required visit to this facility today. LPA met with Administrator Susan Park and explain the reason for the visit. The facility has a fire clearance for 120 non-ambulatory residents 29 of which may be bedridden. Hospice Waiver for ten (10) and there is three (3) residents receiving Hospice Care at this time. The facility had submitted and approved Mitigation and Infection plan. The facility is a single storey building located in a residential neighborhood consisting of 98 rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. At 9:12 AM, LPA conducted physical plant tour of the facility with the Administrator. Facility currently has 62 residents on the Assisted Living Waiver (ALW) program. Common areas, including the living room, activity room and dining room appeared to be clean and properly furnished. The kitchen appeared clean and the appliances and fixtures are functional. Refrigerated and frozen foods were stored at proper temperatures and properly packed and stored. There was a sufficient amount of perishable and non-perishable food at the facility. Residents do not have access to the kitchen; dangerous items are stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas. Entry/exits passages were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. (continued on LIC 809-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 (continued from LIC 809) The medications were locked in the medication room, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked at a range of 106.7°F to 118.2°F and within the required range. First aid kits are located in the medication carts. Fire alarms are hardwired throughout the facility. Fire extinguishers located in the hallways throughout the facility were checked, extinguishers were observed to be fully charged and last inspected on 03/06/26. Smoke detectors are hardwired and are observed to be operational. The facility is equipped sprinkler system. An annual inspection of the automatic sprinkler system was last completed on 03/06/26. LPA checked alarms on all direct exit doors to ensure they are operational as required, alarms were functional. LPA observed video cameras throughout the facility in the common areas with a non-audio monitoring system in place. Facility emergency disaster plan was reviewed. Facility disaster drills are conducted monthly and was last conducted on 05/21/26. In addition to the physical plant inspection, resident and staff records were reviewed. The facility handles cash for the residents. Therefore, current surety bond was checked and observed to be current. LPA reviewed five (5) of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appeared to be given as prescribed. Staff present records were also reviewed and observed to be complete and updated. Exit interview conducted and copy of report issued.

their rooms and in the dining room; in addition Med Techs provide medications timely. During interviews with residents, six (06) out of nine (09) residents stated they have not called for assistance but three (3) residents stated that when pulling the cord, staff respond with five (05) to ten (10) minutes or sooner. LPA Shahbazian pulled the cord for the signal system in two rooms and one bathroom and in each incident, caregivers attended to residents within 2 minutes. LPA Shahbazian interviewed nine (9) care staff members, working in various shifts. All care staff members stated that they are assigned to assist 16-20 residents during their daily shift but approximately 5-8 residents needs total care and others require assistance every 2-3 hours. Care staff stated they shower residents two times or more weekly, assist with ADLs, cleaning the rooms, taking out the trash and assisting residents in the dining room. All staff interviewed stated they feel they are short staffed, they all help each other to ensure residents are care for. Several staff members informed LPA that due to shortness of staff, facility is using caregivers from agencies, also Med Techs and LVN do assist caregiver when needed. Interview with Executive Director revealed that usually there are five (5) caregivers in the morning shift, four (4) assigned to pm shift and three (3) to graveyard shift and each caregiver is assigned to approximately sixteen (16) residents daily. Executive Director stated that currently one (1) caregiver is out on medical leave and residents for the caregiver are divided amongst the other caregivers, but there is enough coverage per shift. In addition Executive Director mentioned that caregivers, housekeepers and med techs all assist each other and communicate with each, to ensure residents are assisted as soon as possible or within seven (7) minutes. Executive Director stated that facility uses services from two (2) separate staffing agencies to complete any caregiver staff shortages. Records obtained by LPA from September 2025 through current, revealed that facility has been using caregivers from the staffing agencies, on regular basis, to cover staff during various shifts. During the initial complaint visit on 10/28/2025 LPA had observed a banner hanging outside regarding hiring but during today's visit LPA did not see the banner. Executive Director stated that they have hired a Human Resources Manager at the facility, in order to concentrate on interviewing and hiring staff, including caregivers and housekeepers. Facility has hired five (5) caregivers and one (1) housekeeper in January 2026 and are still recruiting for more caregivers. During facility visits, residents were observed to be appropriately supervised, and staff were present and engaged in resident care activities. Based on staff interviews and records review, if was reveled that facility is using staffing agencies and has hired multiple caregivers to address staff shortages. Therefore, the allegation is UNSUBSTANTIATED at this time. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Licensee does not ensure that staff are adequately trained. It was alleged that the caregivers do not have proper training to provide care to residents. To investigate the allegation, LPA Shahbazian interviewed nine (9) caregivers. All caregivers stated that they feel the training was sufficient in the beginning and there is always trainings and meetings to cover various topics. Caregivers stated that initial training is learning facility policies and online training specific for their duties. In addition, they stated for 2-3 weeks caregivers shadow other senior caregivers and med techs to learn their tasks. Based on interviews with staff, it was revealed that staff are satisfied with their training and facility provides continued training to all staff. Therefore, the allegation is UNSUBSTANTIATED at this time. Licensee does not ensure that the facility has sufficient hygiene supplies. It was alleged that facility does not have enough gloves or hygiene supplies such as shampoo or personal care items. To investigate the allegation, LPA Shahbazian interviewed staff who revealed that there is no shortage of personal or hygiene supplies. Staff informed LPA that they are always provided a supply of masks, gloves and any required items at the front desk but several caregivers stated the quality of the gloves are not good. Interview with Office Manager revealed that it is their responsibility to purchase supplies, including office and personal care items. Supplies are ordered every 2 weeks and there is available funds for any immediate purchases. LPA toured the facility with Office Manager and observed three storage areas filled with boxes of masks, alcohol pads, shampoos, gloves, incontinence supplies, office supplies and medical supplies. LPA also observed supplies in med room and front reception area. Based on interviews and observations, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and copy of the report was signed and given to the Administrator.

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual required inspection. LPA was greeted by the front receptionist, who was informed the reason of the visit. Administrator Susan Park was contacted and arrived shortly after, she was explained the purpose of today's visit. Today's census was (89. Facility is licensed to care for (120) non ambulatory elderly residents with a hospice waiver for ten (10). A complete physical plant inspection of the inside and outside was conducted with Administrator. The following areas were observed during the visit. Physical Plant: The facility is a single story building, which consist of 98 rooms; rooms are either private or shared. The front lobby, is a common area for residents to lounge. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk with a receptionist. There are empty rooms used for storage, and there are administration offices. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. The interior and exterior physical plant was inspected. Exit doors have delayed egress alarms. Smoke and carbon monoxide detectors are operational and located in resident's room. There are fully charged fire extinguishers throughout the hallways,current inspection dates. The facility has a fire suppression system. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature were measured from various resident's rooms, and were in within the required Licensing requirements. There is sufficient space to accommodate both indoor and outdoor activities........ Continue on 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 An activity calendar was observed posted in the hallway. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Personnel Records-Training: Staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. They have the required training. Resident Records: Resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights. Medication: Medication is stored in the medication room which is locked and is inaccessible to residents in care. No health and safety issues noted at the time of this visit, exit interview conducted and copy of report provided to Administrator.

Allegation: Staff did not ensure the Wi-Fi internet was fixed in a timely manner. Regarding this allegation it is reported that staff did not ensure that Wi-Fi internet was fixed in a timely manner. Interview with the Assistant Administrator (AA) revealed that the Wi-Fi has been intermittently working in some areas of the facility for approximately two (2) weeks. The AA stated that Spectrum, the internet provider, has been contacted twice, on 8/11/25 and 8/22/25 to resolve the matter, however the internet is still intermittent. Facility has hired a third-party vendor to resolve the concern and interview with this vendor indicates that internet will be at full capacity within the next 72 hours. The facility currently has six (6) access points and will be upgraded to ten (10) access points to provide better coverage for residents and staff. LPA inquired if an alternative was offered and AA stated that residents are free to use the areas of the facility such as the activities room for their internet needs since these areas seem to have Wi-Fi access. Furthermore, the AA made arrangements for staff to help residents make appointments and calls to providers when needed, as well as the use of their hot spots for Wi-Fi access. AA stated that ethernet or hard wire internet is functioning and only Wi-Fi is down, further providing internet to residents in the administration area. Interview with office staff confirmed that the Wi-Fi has been intermittently down, but that staff has been assisting residents with making appointments and any needs that require internet use. Interview with ten (10) out of ten (10) residents revealed that although the Wi-Fi is down, they have no concerns since if/when they ask for assistance to make appointments or need to access the internet, it is always granted. Therefore, based on interviews, observations and record reviews this allegation is deemed unsubstantiated. No citation issued. Exit interview conducted. A copy of the report provided to the Administrator.

Regarding the allegation: Staff inappropriately isolated resident. It was alleged that R1 was placed in isolation after being discharged from the hospital, although they were not deemed contagious. To investigate the allegation, LPA interviewed one (1) staff member and one (1) resident. Interview with S1 revealed that when R1 was discharged from the hospital, they were given instructions to place R1 in isolation until their symptoms had subsided. Interview with R1 revealed that they were made aware of their diagnosis while hospitalized and when they returned to the facility, they “…understood and did not object to being isolated…”. LPA’s record review confirmed the instructions given by R1’s Physician stated R1 needed to be placed in, “Isolation”. Further record review of the facility’s Infectious Control Plan (2022) showcased the facility’s policy outlining their procedures to help minimize and/or eliminate exposures related to airborne communicable diseases. Such procedures include precautionary steps involving the avoidance of small, enclosed areas where continual contact with others can or may occur. During LPA’s physical plant tour, LPA observed R1’s bedroom to be a shared room with another resident. LPA observed the temporary room R1 was placed in to be a single room separate from other residents. Based on interviews, record review and observations, the facility followed R1’s physicians order including their Infectious Control Plan regarding R1’s isolation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident was provided with a comfortable environment. It was alleged that R1 was placed in a temporary room where they could hear staff giggling, talking and the radio playing. LPA’s record review of R1’s Admission Agreement revealed that they are to be provided with such amenities as: a comfortable and suitable bed and bedroom furniture. During LPA’s physical plant tour, LPA observed the bedroom R1 was temporarily placed in. LPA observed the room to be neat, clean and organized. LPA observed the bedroom to be equipped with the following: a bed, a closet, a drawer, a chair, a small refrigerator and a bathroom. Additionally, LPA observed the immediate surroundings outside of the bedroom. LPA observed there to be a workstation assigned to the Medication Technicians (Med-Techs). However, LPA observed the station to be empty and observed the Med-techs conducting their rounds throughout the facility. LPA did not observe any radio or music being played. LPA did not observe there to be any staff near the bedroom conversating loudly. Based on record review and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation: Staff did not ensure resident was provided with activities. It was alleged that R1 was not provided with a television and/or any activities for them to do. To investigate the allegation, LPA interviewed four (4) staff members and one (1) resident. Interview with all four (4) staff members confirmed that R1 was provided with their laptop and cell phone. LPA’s interview with R1 confirmed that staff did provide them with their electronic equipment, however they were not provided with a television. LPA’s interview with S1 stated that a television was not included in their services but instead considered a resident’s own personal inventory. S1 stated that they offered to bring R1’s television from their room but R1 declined. Interview with R1 confirmed that they, “…didn’t want them touching my TV because I didn’t want them breaking anything”. Further interview with S1 revealed that S5 attempted to call R1 multiple times to inquire if they needed any other activities. LPA’s interview with R1 confirmed that S5 did attempt to call them but they refused to answer. R1 did state that if they would have spoken to S5, they could have asked for anything and S5, “…would have helped me”. LPA attempted to interview S5 but they were not present during LPA’s visit nor could be reached. LPA’s record review of R1’s Personal Property Inventory confirmed a television was listed. Additionally, LPA’s record review of R1’s Admission Agreement under the Facility’s Basic Services plan confirmed that such equipment is not provided. During LPA’s physical plant tour, LPA observed R1’s television mounted onto the wall of their bedroom. Based on interviews, record review and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff restricted resident’s access to their personal belongings. It was alleged that R1 was not given access to their personal belongings. To investigate the allegation, LPA interviewed four (4) staff members and one (1) resident. All four (4) staff members confirmed that R1 was given access to their personal belongings such as clothing and electronic equipment. Interview with S2 stated that when R1 would ask for, “…clothes…I would take them…”. Interview with R1 confirmed they were provided with their clothing and electronic equipment. Based on interview with R1 that staff did allow them access to their personal belongings, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Regarding the allegation: Staff spoke to resident in an inappropriate manner. It was alleged that R1 was yelled at by a staff member. To investigate the allegation, LPA interviewed four (4) staff members and four (4) residents. Interview with R1 revealed that S1 had yelled at them during a phone conversation. Interview with S1 revealed that when they spoke with R1, R1 was upset and raised their voice. S1 stated they told R1, “…my pitch is a little high because I am trying to explain to you, but I am not yelling at you”. Additional interviews with three (3) staff members stated that they have never yelled or witnessed a staff member yell at a resident. LPA’s interview with two (2) out of the four (4) residents stated that they have never witnessed staff yell at any residents nor have they been yelled at. Based on interviews, 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 conducted and a copy of this report was provided to the Administrator.

(Continued from LIC9099) Delayed egress exit doors were inspected by LPA Rios. LPA observed, each door required several seconds of pressing before they opened, and the alarm sounded on all attempts. Subsequently, the ED and LPA proceeded to the reception area to observe the camera video stream. The ED explained that when the door is activated, the camera feed switches to focus solely on that door. LPA did not observe any operational concerns with the doors. LPA attempted to review video footage from the day in question. Footage was not saved. LPA's review of fire clearance confirmed, the facility is approved for a secured perimeter. On 02/14/2025 LPA Rios did the following: From 11:18 a.m. to 11:50 a.m., LPA interviewed three (03) staff that were present during the afternoon shift on 02/04/25. LPA also interviewed the ED who was not present when the incident took place. At 11:51 a.m., LPA interviewed resident #1's (R1's) Responsible Party via telephone and at 12:22 p.m., LPA interviewed, staff #1 (S1) via telephone. At 12:45 p.m. LPA reviewed and obtained copies of R1's file, such as their Physician’s Report, Functional Capabilities Resident Appraisal, Preplacement Appraisal and medication list. From 1:29 p.m. to 2:02 p.m., LPA interviewed, R1 and two (02) more staff. LPA’s review of R1’s record corroborates R1 is unable to leave the facility unassisted due to R1’s diagnosis which may cause R1 to become confused and disoriented. LPA’s interview with four (04) staff present on the day in question corroborate R1 did exit the facility but deny that R1 was unsupervised. LPA's interview with S1 revealed they rushed to R1 outside and followed R1 trying to redirect them to return to the facility, then a bystander contacted 911 for assistance. According to S1, police retuned the resident to the facility. R1's, responsible party confirmed staff contacted them when the incident occurred. Resident interviews corroborate they are supervised and those that may leave the building may sign out at reception and those that need assistance go out as groups. Three (03) out of the ten (10) residents reported they had witnessed different residents attempt to leave the building or making it out of the building but according to them staff always responded and assisted the residents back into the facility. LPA Rios submitted a call of service request to the local police department but has not received a response. R1 did not recall the events that took place on 02/04/2025. Based on interviews and observations this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report provided.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda delivered, in person, an amended LIC 9099 and LIC 9099-C complaint investigation report in association with complaint report# 31-AS-20250218151741, and the initial complaint investigation visit conducted on 2.25.2025 The Amended LIC-9099 and LIC 9099-C Complaint Investigation Report was hand delivered to executive director, Susan Park.

Interviews with nine (09) out of 88 residents, which was at least 10% of the current census, revealed they had no knowledge of the licensee, other staff, or anyone else selling drugs in the facility. Residents interviewed had not seen the licensee in the facility. LPA observed no indications of drug sales in the facility during the physical plant tour today. Based on observations and interviews, the licensee is not selling drugs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff is abusing the residents" it was alleged that the licensee is abusing residents. LPA Valenzuela’s interview with the administrator at approximately 1:10 p.m. on 07/22/24 revealed the licensee is rarely at the facility and does not abuse residents. Interviews with three (03) staff today revealed they have not witnessed or heard any reports of the licensee or any staff abusing residents. Interview with Staff #1 (S1) at 12:20 p.m. today who was watching the camera footage in common areas confirmed they had not observed any abuse on surveillance footage. Interviews with nine (09) out of 88 residents, which was at least 10% of the current census, revealed they had never been abused by the licensee or any staff. LPA observed no indications of abuse in the facility during the physical plant tour today. Based on observations and interviews, the licensee is not abusing residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. During today’s inspection, no immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.

During interviews with residents, one (01) out of nine (09) residents stated staff are not cleaning filter regularly. All other interviewed residents stated they do not have issue with their oxygen filters. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Due to lack of supervision, resident was left on floor for an extended period of time. It was alleged that the resident fell and was found on the floor for unknown duration of time before staff found the resident. To investigate the allegation, LPA interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. On 03/22/2025, LPA reviewed the Department’s records which shows resident had a fall on 10/25/2024 and 11/15/2024, however, there was nothing that indicate resident was left for an extended time. During interviews with staff, all staff stated they check on residents every two (02) hours, respond to the call button within five (05) to ten (10) minutes and do not leave residents on the floor for an extended time. During interviews with residents, one (01) out of nine (09) residents stated staff doesn’t check on them frequently and left them on the floor for an extended time. Resident was unable to provide dates or identify alleged negligent staff. All other interviewed residents stated staff check on them about every two (02) hours and have not experienced being left on the floor for an extended time. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

Staff interviews revealed that R1 was admitted at this facility on 8.31.2020. R1 purchases vitamins and supplements through Amazon without a prescription/ approval from Primary Care Physician (PCP)/ specialists. Packages delivered to the facility would be opened by R1 in-front of staff. In order to protect R1, facility takes away R1 belongings (vitamins and supplements) until obtaining a prescription/ approval from PCP/ specialists. LPA interviewed R1 at 10:28AM and they verified the information provided by staff. LPA interviewed eight (8) out of eighty-eight (88) residents who are at the facility, and it was revealed unanimously that residents have all their belongings with them and that they are happy and safe living at the facility. A review of R1’s records records between 12 PM to 1:30 PM, revealed that R1 required staff assistance to manage their medication. Based on inspection, observation, interviews and record reviews, it was concluded that there is no sufficient information to determine validity of the complaint. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #2: Staff are retaliating against resident for making a report against the facility. It was alleged that resident #1 (R1) fears that facility staff is retaliating against them for filing reports. To investigate this allegation, LPA spoke with the administrator and interviewed five (5) staff and they denied retaliating against residents for any reason. They treat all their residents with respect and dignity. LPA interviewed eight (8) out of eighty-eight (88) residents and they revealed unanimously that they were never were retaliated by staff and all of them are treated well. They are happy and have no concerns about staff. Based on overall information obtained during investigation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citations were issued for the above allegation(s), and a copy of this report was given to the executive director.

R1 added when they asked why, staff replied it is because they asked specifically for sourdough and they only had a few slices. All other residents stated they are not served expired foods or moldy bread. During interviews with staff, all staff stated they do not recall the incident and do not serve expired foods or moldy breads to residents. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not administer medications as prescribed. It was alleged that staff do not administer medications on time. To investigate the allegation, LPA requested documents at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. to 1:00p.m. A review of Resident #2’s (R2) Medication Administration Records lists all medications, however, there are many empty spaces. When staff were questioned about the blank spaces, they stated it is a system error they have not been able to fix it, and the meds were given on those dates. The records also have several “refused” and “away” indications for medications. During interviews with residents, R1 and R2 stated facility does not give two (02) of the medications to R2 during food as prescribed. R1 and R2 added that one (01) of the MedTechs refused to give R2 medications while they were in R1’s room. During interviews with staff, Staff #2 (S2) stated they give R2 their medications as prescribed but at times R2 either does not wait for the medications to be given or refuses medications entirely. S2 added, R2 is sometimes away without prior notice. All other staff stated, to their knowledge, residents are being given their medications as prescribed. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

At approximately 10:30 a.m. on 01/14/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the assistant administrator and disclosed the reason for the visit. Today’s case management visit was conducted to ensure the safety and welfare of evacuees from the Eaton Fire who were relocated temporarily to the facility. LPA toured the facility at 10:45 a.m. and interviewed the assistant administrator at 11:00 a.m. Interview with the assistant administrator revealed the facility admitted twenty-two (22) residents on 01/08/25, and all residents left as of 01/12/25. As of today, no residents from other facilities still reside at this facility. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.

During interviews with residents, one (01) out of nine (09) residents stated room had a bad smell and smelled of insect spray but that now everything is okay as they move to another room. All other residents stated they do not experience malodor in the facility. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ------Staff do not answer residents calls for assistance timely. It was alleged that staff does not answer the call for the resident’s pull cord. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During the physical plant tour, LPA selected five (05) rooms at random and observed an average response time of six (06) minutes. During interviews with staff, all staff stated they respond to the call button within five (05) to ten (10) minutes. During interviews with residents, three (03) out of nine (09) residents stated staff respond within ten (10) to fifteen (15) minutes. All other residents stated staff respond with five (05) to ten (10). Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff are not ensuring resident's room is cleaned properly. It was alleged that resident had an accident on the floor and the staff did not ensure that they cleaned it up properly. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During the physical plant tour, LPA did not observe any stains on the carpet of Resident #1’s (R1) old room or any other room. During interviews with staff, all staff stated R1’s carpet was shampooed and vacuumed and that it was cleaned right away. Staff #1 (S1) added that they tried removing the carpet to install vinyl but that the store was out of stock. S1 also stated R1 was moved to a room without carpeting as soon as one became available. (CONT. on LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During interviews with residents, one (01) out of nine (09) residents stated staff does not clean the room properly. All other residents stated they feel staff does a good job of keeping their rooms clean. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

During interviews with residents two (02) out of nine (09) residents stated they feel facility does not provide a variety of diverse foods, all remaining residents stated meals are diverse and well-balanced. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not treat resident(s) with dignity and respect. It was alleged that staff lack proper "bedside manners" and yell at other residents. To investigate the allegation, LPAs interviewed three (03) staff and nine (09) residents from around 11:00a.m. to 1:15p.m. During interviews with staff, all staff stated they treat residents with dignity and respect. During interviews with residents one (01) out of nine (09) residents stated they feel staff do not treat them with dignity and respect. All other residents stated they feel staff treat them with respect and dignity. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

Allegation: Facility staff are not allowing residents to leave the building. Allegation: Facility staff are tying the doors at night trapping residents in the facility. Based on the information gathered, LPA addressed the above allegations collectively, which claim that residents are prevented from leaving the building by staff obstructing the facility doors. Interviews conducted by LPA Rios on 10/15/24 and 11/12/24 revealed that eight (8) residents and five (5) staff members who were present during the initial visit denied witnessing any instances of the doors being tied up or obstructed by furniture or other means, day or night. According to resident interviews, those who do not require assistance when leaving the facility can do so by signing out. According to residents that are not able to leave the facility unassisted based on their Physician’s Report (LIC602), theydid not express concerns about being able to leave the facility. Staff interviews indicated that residents who need assistance, as per their LIC602, typically leave with the Activities Coordinator for planned outings, with family members, or are redirected to stay while waiting for a planned outing. The Executive Director denies that residents are trapped in the building. Furthermore, according to the ED cameras placed in common areas that have been reviewed have not alerted to such instances. LPAs' tours of the facility on 05/30/23, 10/15/24, and 11/12/24 did not observe any health or safety concerns. Based on interviews, record reviews, and observations, the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff steal residents' money and belongings. In regards to the allegation, it was alleged resident’s money, medication, and belongings are being stolen. On 10/15/24, LPA's interview with six (6) out of eight (8) residents that were interviewed denied having money or items stolen or witnessing staff stealing from residents. Two (2) out of eight (8) residents interviewed reported items being stolen or going missing, eight (8) to thirteen (13) years ago. Both stated that the issue was addressed and has not reoccurred. LPA's interviews with five (5) staff and the ED between 10/15/24 and 11/12/24, deny the allegation. On 10/15/24 the ED informed LPA, residents that receive P&I sign a log when a check is provided to them and the facility keeps petty cash and receipts when purchases are made. ED also informed LPA residents' personal belongings are recorded and updated annually on a Personal Property Inventory form by residents and family members. Staff and the ED noted, resident diagnosed with Dementia occasionally claim money or items are missing, but these are typically found to be misplaced or already spent by the resident. On 11/12/24, LPA with the assistance of the LVN conducted a medication and medication record review for nine (9) residents of which four (4) are taking a PRN narcotic medication. (Continue to LIC9099-C) Page 2 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Centrally Stored Medication and Destruction records matched medication in locked cart. LPA observed narcotic pills popped out of bubble wrap packs were documented on the electronic medication administration record (MAR). LPA observed narcotic PRN medication from 2023 that had not yet expired, was still intact in bubble wrap. Based on interviews, observation and record review the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff allow residents with prohibited health conditions. Regarding the allegation, it was alleged the facility retains residents with prohibited health condition such as severe pressure injuries. Interview with the ED on 10/15/24 and 11/12/24 revealed residents who have prohibited health conditions are receiving Hospice services for such conditions and have care plans on file. ED also noted training is conducted by a certified professional and the facility documents such training when they are done for residents with prohibited and restricted health conditions. There is currently one (1) resident, Resident #1 (R1) with a pressure injury. LPA's review of R1's file on 10/15/24, revealed R1 is receiving Hospice services and wound care by Hospice for a stage 3 pressure wound. The prohibited health condition is allowable as R1 has been diagnosed as terminally ill and is currently receiving hospice care. Record review confirmed a wound care specialist is seeing R1 and providing proper and adequate care for the wound. Review of eight (8) other resident records revealed resident #2 (R2) has a restricted but allowable health condition and is also receiving services from a Hospice agency. Interviews with eight (8) residents revealed no issues with pressure injuries. Based on record review and interviews, the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff deny residents food. Regarding the allegation, it was alleged residents are being denied food. Interviews conducted on 10/15/24 with eight (8) residents revealed that the facility provides meals and snacks regularly, and none of the residents reported being denied food by the staff. One of the eight residents mentioned that the facility had stopped serving oranges and apples, but LPA and resident noted that other fruit options were available. Resident interviews also indicated that they had not observed any staff members denying food to other residents. Additional interviews with five (5) staff members and the Executive Director (ED) on 10/15/24 and 11/12/24 further confirmed that staff have never denied food to the residents. According to two staff members, residents who refuse a meal are offered a substitute. One staff member mentioned that the facility provides special meal and snack requests made by residents. Based on interviews, there is insufficient evidence to support the claim, facility staff deny residents food. Therefore, this allegation is deemed Unsubstantiated at this time. (Continue to LIC9099-C) Page 3 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Allegation: Facility staff are emotionally abusing residents. Allegation: Facility staff threaten residents. Based on the information gathered, LPA addressed the above allegations collectively, which claimed that residents are being bullied and threatened, causing emotional damage. LPA Rios interviewed eight (8) residents living in the facility during the initial visit. They revealed having no knowledge of bullying or emotional damage caused by staff. One of the eight residents stated they had observed preferential treatment given to certain residents during lunch and expressed that Staff #3 (S3) lacked professionalism. Resident interviews also revealed that there are staff members whom residents are very happy with and that they are satisfied with the assistance provided. Interviews with five staff members on 10/15/24 and 11/12/24 denied the allegations. Two staff members stated they had witnessed residents being confrontational with other residents but never witnessed staff being confrontational with residents. LPAs' tours of the facility on 05/30/23, 10/15/24, and 11/12/24 did not reveal any health or safety concerns. Based on interviews and observations, there is insufficient evidence to support the claims that facility staff are emotionally abusing or threatening residents. Therefore, these allegations are deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued. Page 4 of 4

(Continued from LIC9099) Allegation #1: Staff are sexually abusing residents and staff. Regarding the allegation, it was reported that Staff#1 (S1) has been sexually abusing residents. Interviews conducted by LPA Rios on 10/15/24, and 11/12/24 revealed eight (8) residents and five (5) staff that lived and worked in the facility since the initial visit all denied either being sexually abused or witnessing any staff sexually abuse residents. Interview obtained from Complaint Control 29-AS-20230406155619 with S1 revealed they deny ever abusing any residents in any form. Staff interviews revealed S1 has minimal to no contact with residents at this facility and they have never witnessed S1 alone with a resident. Furthermore seven (7) out of the ten (10) residents interviewed revealed all staff in general treat residents well, and residents did not voice any concerns of sexual abuse. Interview with one (1) resident had concerns regarding staff, but it did not involve sexual abuse and two (2) residents were asleep during visit. LPAs tours of the facility on 05/30/23, 10/15/24 and 11/12/24 did not observe and health or safety concerns or issues. Based on interviews, there is insufficient evidence to support the claim that, staff are sexually abusing residents and staff, therefore the allegation is deemed Unsubstantiated at this time. Allegation #2: Facility staff are not qualified. Regarding the allegation, it was reported that Staff#1 (S1) is not qualified to run and manage the facility. To investigate the allegation LPA conducted interviews with the ED and staff. According to the ED, S1 is part of the cooperation and has no contact with residents directly. When S1 visits the facility they meet with the administration to discuss and conduct building safety checks. S1 reports any concerns to the Administrator. According to the ED, S1 does not work in the capacity to "run and manage" the facility. The ED is responsible for the day to day operations of the facility. Furthermore, the there is also an administrator assistant at this facility. Review of the Administrator Certification for Susan Park is active and she has been the administrator since the initial visit. According to staff, S1 conducts quality assurance visits, for example issues with the physical building in regards to issues like workers compensation. Based on interviews and record review the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued to Assistant Administrator, Bryanna Luke .

Interviews with ten (10) out of ten (10) residents revealed no staff abuse or treat them or other residents poorly. Interviews with staff revealed they and residents have good relationships. No staff revealed information regarding mistreatment of residents. The administrator stated that all staff and owners treat residents with dignity and respect. During facility tours on 10/22/24 and today, LPA observed staff addressing residents’ needs and providing activities. Based on observations and interviews, staff treat residents with dignity. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steals residents P&I monies" it was alleged staff members steal residents’ monthly income. Interviews with ten (10) out of ten (10) residents revealed no occurrences of stolen or missing money. Residents interviewed who receive P&I money had no problems with accessing all their money. Interviews with staff revealed no reports of staff stealing resident money. Interview with the administrator revealed all resident money is recorded on the internal P&I ledger. Review of P&I ledgers today at 2:00 p.m. revealed all resident money was accounted for and none was missing or stolen. Based on record review and interviews, staff do not steal residents’ money. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff are using illegal substance during working hours" it was alleged staff use and sell drugs at the facility. Interviews with ten (10) out of ten (10) residents revealed no occurrences of drug use or sales in the facility. Interviews with staff revealed no reports of staff using or selling drugs. The administrator also confirmed no staff use or sell drugs in the facility. During facility tours on 10/22/24 and today, LPA did not observe any indications of drug use or transactions. Based on observations and interviews, staff do not steal residents’ money. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents’ medications" it was alleged staff steal bottles of resident medication. Interviews with ten (10) out of ten (10) residents revealed no occurrences of missing or stolen medications. Residents confirmed they receive all medications in the right doses. Interviews with staff and the administrator revealed no staff steal medications and no residents are missing any medications. Medication review on 10/22/24 revealed three (03) out of three (03) residents’ medications were accounted for. None were missing or stolen. Based on medication review and interviews, staff do not steal residents’ medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during today's visit. Exit interview conducted. Copy of report provided.

During interviews with residents, Resident #1 (R1) stated that R2 inappropriately exposes themselves. All other residents stated that they have never witnessed R2 exposing themselves from the waist down. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are not preventing resident from harassing other residents in care. It was alleged that R2 calls people socialist, Marxist, communist and makes trouble for everyone. To investigate the allegations, LPAs interviewed four (04) staff and nine (09) residents from around 11:00a.m. to 1:30p.m. During interviews with staff, all staff stated that R2 calls staff socialist and Marxist but does not make trouble for resident. During interviews with residents, R1 stated that R2 calls them socialist and Marxist and makes trouble. All other residents stated residents do not make trouble or call them socialist and Marxist. Based on the interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.

It was alleged that Licensee did not ensure to return resident's SSI checks upon relocation. To investigate this allegation on 07/22/2024, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that the facility did contact Social Security and had notified them that R1 had moved out of the community and that their money needed to be paid to the other facility. Between 1:00pm and 1:30pm, LPA reviewed facility records. Records revealed that facility returned $7,171,.79 back to Social Security. Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.

It was alleged that Staff is abusing the residents. To investigate the allegation, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that Staff #1 (S1) is not a staff member at the facility, but rather is the Licensee. The Licensee is not present at the facility and does not abuse residents since they do not interact, have contact with, or see any residents. Between 2:00pm and 2:30pm, LPA reviewed the Personnel Report and confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support this allegation. Hence, the allegation will be UNSUBSTANTIATED at this time.

Interviews with (10) residents out of eighty-nine (89) residents and five (5) out of forty-five (45) staff that the above statement is untrue, and all residents expressed no concern regarding this allegation. Allegation: Staff do not provide adequate food service. More specifically the complainants concern was that the facility does not provide adequate food service, which result in an illness of a resident in care. On May 27, 2024, one resident in care suffered an upset stomach after having breakfast and believes it came from old, spoiled food. On June 3, 2024, LPA Ngo-Casteneda conducted a facility tour which included a food service tour and inspection. LPA observed sufficient supply of 2-day perishable foods and one week of non-perishable foods. LPA inspected food service area which include food storage and prep areas, refrigerator, and freezer. LPA observed areas to be clean. Foods were observed to be properly stored at temperatures within regulations. Foods were observed to be property wrapped and stored to protect foods from spoilage and cross-contamination. Interviews with facility staff revealed that when food supplies arrived from Sysco food is immediately stored in the freezer and walk-in refrigerator. Based on the information received this allegation is Unsubstantiated at this time. LPA could not determine that the resident in care became ill from the food. Proper food handling appears to be followed. No other residents reported illness related to food on or about June 3, 2024. Allegation: Staff do not ensure the residents have hygiene products while in care. It was alleged that R1 was not supplied enough hygiene products from the facility. During the interview, it was revealed that R1 would not ask staff for more supplies when they run out of products. R1 is expecting to be given and handed the number of supplies as requested without using the supplies they have first. ED advised LPA that the following number of products are given to residences: two (2) daily towels, toilet paper one (1) per week, One (1) paper towel monthly, one (1) shampoo per month, one (1) bodywash (or soap) per month, and one (1) toothpaste per month. Interview with residents six (6) residents out of ten (10) revealed that there is no issues with receiving extra supplies when asked. If the facility runs out of supplies, the facility has a driver who can run errands for them to purchase and supply the residents with what the facility needs. During the facility tour, LPA also observed a supply of hygiene products. Based on the information received this allegation is Unsubstantiated at this time.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an annual required inspection. LPA met with Susan Park Administrator and explained the purpose of today's visit. There are currently 89 residents at the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant/Environment Safety: The facility is a single story building located in a residential neighborhood consisting of 98 rooms, some of which are being used as model rooms, administration offices and storage rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. It is licensed to care for 120 non ambulatory elderly residents with a hospice waiver for ten (10). Current census is (89) elderly residents. The facility has some Dementia residents. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has twenty six (26) fully charged fire extinguishers which were last inspected on Jan of 2024. Administrator stated that the local fire department conducted an annual inspection of the facility in January 2024. The facility has a fire suppression system. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit. The hot water temperature measured at 114 degrees F. Continue on 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Personnel Records-Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Staff employed are over the age 18 and are fingerprint cleared. They have the required training. Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. Resident Rights-Information: Resident personal rights were posted near the lobby area. The Incident report binder was also reviewed. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation. An activity calendar was observed posted in the hallway. The facility has a Resident Council. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Medication: Medication is stored in the medication room which is locked and is inaccessible to residents in care. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.

Licensing Program Analyst (LPA) Bennette Pena conducted the required annual inspec tion. LPA was met by Rachel De Chavez, Assistant Administrator and explained the purpose of today's visit. T here are currently 81 elderly residents 60 years and older residing in the facility. Only one (1) resident is receiving hospice care and currently, no bedridden residents. At 2:10pm, the Administrator, Susan Park arrived and assisted LPA with the inspection. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility and LPA was screened upon entry. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements : A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. The facility has a Dementia waiver in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 12/05/2023. Surety Bond is valid and in place. The last fire Drill was conducted on 07/23/2023. C are and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single storey building located in a residential neighborhood consisting of 98 rooms, some of which are being used as model rooms, administration offices and storage rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. It is licensed to care for 120 non ambulatory elderly residents with a hospice waiver for ten (10). Current census is (81) elderly residents. The facility has Dementia residents. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk and Covid-19 symptom screening is initiated at entry, where LPA was screened. COVID-19 Infection Control screening protocols and supplies included a thermometer, PPE supplies, screening logs, and sign-in sheet were observed in the main lobby. COVID-19 signage was posted around the building. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has twenty six (26) fully charged fire extinguishers which were last inspected on 02/24/2023. Assistant Administrator stated that the local fire department conducted an annual inspection of the facility in February 2023. The facility has a fire suppression system which did not run properly during that time, which required a 2nd inspection on 8/14/2023. During the last fire marshal's visit, the fire suppression system worked and ran smoothly. Facility is currently awaiting for their fire clearance. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit. The following random resident rooms were inspected and the water readings are as follows: Room #1 (113.9 deg F), Room #7 (112.4 deg F), Room #18 (112.7 deg F), Room #33 (108.5 deg F), Room #47 (107.4 deg F), Room #52 (116.2 deg F), Room #67 (105.6 deg F), Room #69 (105.9 deg F), ***CONTINUED ON LIC 809-C*** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staffing: A total of thirty seven (37) staff including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate expired on 8/11/2023, however, Administrator was able to provide proof that renewal was submitted to CDSS on 5/23/2023. Administrator also completed the required courses. Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medica tion Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. The Incident report binder was also reviewed. Resident Rights-Information: Resident personal rights were posted near the lobby area. The Incident report binder was also reviewed. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation. An activity calendar was observed posted in the hallway. The facility has a Resident Council. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel serviced the residents in the facility. Residents medication are centrally stored in the medication room which is inaccessible to residents. Five (5) centrally stored resident medications were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents. Residents with Special Health Needs: Twenty eight (28) residents are receiving home health services. One (1) resident receives hospice care. Postural support physician orders are on file. Half bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Exit interview was conducted with Susan Park, Administrator and a copy of the report was provided.

residents. Moreover, in order to avoid problems and to keep the community safe, they usually refer residents to the home health agencies that they have worked with the past. S1 told LPA that the facility does not force any resident to use the home health agencies they provide referrals to. At 1:30pm, LPA spoke to R1's responsible party and they confirmed what staff had told LPA. Neither responsible party or R1 had looked into other home health agencies besides the one suggested by the M.D. Between 1:50pm and 2:23pm, LPA reviewed facility records. Records revealed that per admission agreement attachment concerning personal rights it states that residents have a right to receive or reject medical care or health-related services. R1 can choose any home health agency of their liking and the facility can not force them to use the ones provided by third parties within the facility. Based on interviews and records review, there is not suffificient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time It was alleged that staff denied resident’s home health agency access to the facility. To investigate this allegation, LPA initiated staff interviews between 11:15am and 12:20pm. Interviews revealed that staff would not deny health-related services chosen by R1 or any other resident. S2 stated that no one was notified of a home health agency coming to the facility and not being allowed inside. At 1:30pm, LPA called R1's responsible party and they said they did not know if in fact the home health agency had even gone to the facility. They were told that they were going to go, but no one saw them. Based on interviews, there is not sufficient information to support this allegation. Thus this allegation is deemed to be UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.