Montgomery Springs Manor

On 02/25/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct infection control inspection. LPA met with administrator and explained the purpose of the visit. LPA observed 3 staff wearing face masks and 4 residents watching TV in the living room. The other residents were relaxing inside their bedrooms during visit. LPA toured the facility including but not limited to the front entrance, screening station, hand washing stations, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizer were observed at the screening station. Cough/sneeze etiquette, social distancing signs were posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs maintained at a central location and easily accessible for staff. Comfortable temperature is maintained at 74 deg F. Facility has a mitigation plan in place and maintains records of routine screening for residents and staff. The infection control leader is the administrator. Updated copies of the following documents were requested for facility file and are to be submitted to CCL on or before 02/27/23: · LIC500- Personnel Report · LIC308- Designation of Facility Responsibility · LIC610E- Emergency/Disaster Plan including infection control plans · Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

On 08/24/2021 at 8:50am, Licensing Program Analysts (LPAs) Allison O'Hollaren and Jill Clancy-Czuleger conducted a case management while at the facility for another matter. LPAs met with Administrator Mirriam Paras. PIN 21-38-AS C states " Well-fitting face mask is required in indoor settings (double mask or surgical mask recommended), unless an N95 respirator is required pursuant to Title 8 regulations" for all staff and Licensees. However, LPAs observed Administrator Mirriam Paras, S1, S2, and S3 in facility without a mask in common areas. LPAs observed moldy cantaloupe in cabinet. The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22 and California health and safety code. Failure to correct the deficiencies may result in civil penalties.

Page 2 Review of R1's record showed request to update R1's diet order to reflect R1's preference which the doctor approved. Approved order showed low-fat diet, cut-up texture, thin liquid with special instruction of no milk, apples, nuts and to provide R1 softer food and food preferred by R1 such as tender meat with sauces, soft fruits such as bananas, fruit cups, apple sauce and soft vegetables. LPA observed the meal served for lunch on this day consisted of pasta with ground meat, steamed vegetables and fresh fruit for dessert. LPA observed the dinner prepared by S1 consisted of mash potato, tender chicken with sauce and steamed vegetables. Food supplies were inspected and observed of different varieties which includes apple sauce, fruit cups, canned mixed fruits, fresh bananas and other fresh fruits. Review of other resident's LIC602A showed R2 and R3 with special diet. R2 stated the staff does not give R2 food that is indicated in LIC602A not to be given to R2. R2 stated she can not have food with tomato and tomato sauce and that she is given other meal option when food to be served has tomato and/or tomato sauce. R3 stated she is happy with the food serve. R4 who is not on special diet stated he is given option when the meal is that of R4's preference. R1 stated staff cut the food serve to her to small pieces. All staff interviewed stated R1 is served soft food. S2 and S3 stated R1 is served food cut into pieces. S1 also stated she cuts the food served to R1 except burrito because R1 does like it to be cut. R1 has fruit cups. Based on information obtained, the allegation is unsubstantiated. Allegation: Staff do not provide appropriate care to the resident. RP stated that R1 feels that R1's care needs are neglected by staff. The 2 staff who are providing assistance to R1 denied the allegation and stated that whenever R1 calls for help, they assist. They assist other residents who need assistance. ......continued on 9099C (page 3) 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 Page 3 R1 stated staff assist her with activities of daily living (ADLs) and when she calls for help. Two of the other 3 residents stated the staff assist them whenever they need help while one of these 3 residents stated not needing assistance with ADLs. One of these 3 residents stated not observing staff not providing assistance whenever R1 calls for help. Therefore, the allegation is unsubstantiated. Based on interviews, inspection, observation and records review, the 2 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

While at the facility investigating a complaint (Control # 15-AS-20250808113155) and upon review of residents' files and interviews, Licensing Program Analyst (LPA) Delmundo learned that resident (R1 and R2) LIC602A Physician's Reports are outdated. R1's LIC602A was dated 1/09/17 and showed R1 able to bathe, dress/groom and feed self and care for own toileting needs; however, R1's condition has changed and is now dependent on the staff on all activities of daily living. R2's LIC602 dated 4/14/24 indicated ambulatory but R2 uses walker to ambulate. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

While at the facility investigating a complaint (Control # 15-AS-20250430080657) and upon reviewing residents' records, Licensing Program Analyst (LPA) Delmundo observed the two residents' (R1 and R2) LIC602A Physician's Reports were over a year old. LIC602As showed they have major neuro cognitive disorder. The above were discussed with MIrriam Paras, administrator. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency, plan and proof of correction were discussed. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Page 2 Allegation: Staff does not ensure food is of good quality for residents in care. All 4 staff interviewed stated residents are never serve hard bread and/or stale food. LPA inspected the food supplies and didn't observed stale and/or expired food. Resident (R1) stated the staff serve bread that is hard and stale. Three out of the 5 other residents stated food serve is good and that staff never serve stale food. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Allegation: Staff allow residents to be left in soiled clothing for extended periods of time. R1 stated staff do not change residents out of their urine filled diapers and will leave them in soiled diapers all day. LPA conducted inspection and did not observed any resident smelling urine or soaking wet. The 3 staff stated they change residents who need assistance in changing diapers at least 3x during their shift. ADM stated residents are changed 9x in 24 hours and as needed. Two out of the 5 other residents can toilet on their own. One of these 5 residents stated wearing diaper but does not need assistance in changing. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Allegation: Staff does not ensure residents receive adequate hydration. R1 stated that the staff do not provide water or other fluids to residents to drink throughout the day except during meal time. All four staff interviewed stated residents are provided water, juice, coffee and/or tea during meals. Water is also provided during snacks time and when medications are administered. Three out of 5 residents stated they are provided water and juice during meals. They also stated they have water containers in their rooms which the staff filled regularly. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Allegation: Staff do not ensure resident has personal privacy. R1 stated that R1's room mate has dementia and wakes up R1 constantly when R1 tries to sleep. .....continued on 9099C (page 3) 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 Page 3 Two of the 4 staff stated when R1 has a visitor, the visitor comes inside R1's room shared with R5. R1 would not want R5 to be inside the room so they keep R5 in the living room. One of these staff stated R1 stays outside the room, however, when R5 is already sleepy, she asks R1 and tell that R5 wants to sleep. Three out the other 5 residents stated staff accord them privacy. Due to medical diagnosis, LPA was not able to obtain information from R5. Therefore, the allegation is unsubstantiated. Allegation: Staff do not ensure residents are provided supervision. R1 stated that another resident grabbed R1's arm hard a month ago and that R1 called the staff but the staff did not come to help. All four staff and 3 out the other 5 residents stated not observing the incident. Due to medical diagnosis, LPA was not able to obtain information from the other 2 residents. Therefore, the allegation is unsubstantiated. Based on interviews, inspection, observation and records review, the 5 allegations are unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided. 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 Page 2 Allegation: Staff do not provide meal substitutions for residents in care. R1 stated that R1 has a hard time eating and cannot eat the meat but the staff do not offer substitute. LPA reviewed R1's file which didn't indicate R1 cannot eat meat. Progress Notes from medical provider dated 9/30/24 showed approved diet order which includes food minced and soft. LPA observed during lunch other residents were served fried chicken, mixed vegetables, potato salad and fresh fruit while R1's was served fish fillet cut into small pieces served with tartar sauce, mixed vegetables, potato salad and fresh fruits. R1 told LPA that the fish fillet were hard; however, when LPA tested in front of R1, the fish fillets were soft. The 4 staff interviewed stated they provide substitute. One of these 4 stated stated that R1 began complaining of not wanting to eat meat about 4, 5 days ago, but R1 ate hamburger 2 days ago. R1 wants R1's food cut into pieces in front of R1, which the staff do. Therefore, the allegation is unfounded. Allegation: Staff does not ensure facility has adequate food supply for residents in care. The 3 staff stated that ADM does food shopping 2x a month which LPA confirmed with ADM. All these 4 staff stated they never run out of food supplies. LPA inspected the food supplies and observed more than adequate. Therefore, the allegation is unfounded. Allegation: Licensee does not ensure staff receive training in CPR. R1 stated the staff are not CPR certified and don't do anything when a resident is choking on food and will only give the residents water. All staff interviewed stated there was no incident of resident choking. LPA has not received incident report from the facility indicating resident(s) choked. The staff interviewed stated that R1 thinks that when R5 coughs, R5 is choking. R5 observed R5 wearing mask and R5 stated she's coughing. During investigation, LPA heard R5 coughing. LPA checked the 5 staff records which showed all of them have current First Aid certificate. There fore, the allegation is unfounded. Based on interviews, records review, inspection and observation, the 3 allegations are closed as unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiency cited. Exit interview conducted and copy of this report provided.

Review of records showed facility has copy of ePrescription dated 2/01/25 with antibiotics prescribed 3 times a day for 3 days with out-of-state pharmacy listed and with comments 'deliver by CPN tomorrow'. This document showed received 2/06/25. PCP1 stated that PCP1 prescribed the antibiotics on 1/31/25 and that if the medications need to be delivered immediately, it should be delivered by the local pharmacy. PCP1 stated that it could be pharmacy issue that the medication was not delivered the following day the prescription was written. S1 stated she only came to know about the prescription and was only informed by R1 once. S1 and ADM stated they called the Center for Elder's Independence to follow-up. S1 stated the medication was received on 2/06/25 and started the administration dinner time on 2/06/25. Based on information gathered, the allegation is unsubstantiated. Allegation: Facility is in disrepair. R1 stated that residents have to put their used (soiled) toilet paper in the garbage because they are not allowed to flush the toilet paper in the toilets. R1 also stated that staff tell residents to use the garbage because if they flush the toilet paper the toilets get clogged up. LPA conducted inspection and flushed all the toilets. LPA observed all the toilets draining properly. The 3 staff, ADM and R2 stated the toilet in the big bathroom was not draining properly but did not overflow, and was replaced with a new one recently. Therefore, the allegation is unsubstantiated. Allegation: Staff not treating resident with respect and dignity. R1 stated that when R1 was asking S1 about R1's antibiotics medication, S1 told R1 to shut up. S2 and S3 stated not hearing S1 and denied telling R1 such. R2 stated not hearing S1 or other staff respond to any residents inappropriately. Therefore, the allegation is unsubstantiated. Based on review of records, interviews and inspection, the 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Page 2 R1 stated S1 yelled at R1 when R1 asked for help. R1 also stated when she asked S2 for lighter because her lighter is broken, S2 did not provide and instead laughed at her. Both S1 and S2 denied the allegation. W1 stated he was at the facility when the incident happened and it was R1 who yelled at the staff. Five out of 8 residents interviewed stated not observing staff yelled nor dis-respected R1. One out of the 8 residents stated hearing S1 screamed back when R1 screamed at S1 but does not know what transpired and where it happened. The other resident stated he maybe in his room when the incident about the lighter happened. Due to the medical diagnosis of the other resident, LPA was not able to obtain information. Based on information obtained, there's not enough preponderance of evidence to prove that a violation occurred, therefore the allegation is closed as unsubstantiated. Allegation: Staff does not respond to resident's request in a timely manner. R1 stated when R1 called S1 to help care for her room mate, S1 will not come. R1 also stated when she had something red on her ear and thought it was blood, S1 provided R1 a napkin to blot her ear. S1 did not call 9-1-1 and R1 called 9-1-1 herself. R1 stated it was not blood but a piece of red plastic of unknown origin. S1 stated she attended to R1 when R1 called her about the blood in R1's ear. S1 stated she checked R1's ear and observed a red dot on the middle outside part of R1's left ear and it's not blood so she gave R1 a napkin but R1 scolded her and called 9-1-1 herself. ADM stated the incident was reported to her by S1. All staff interviewed stated R1 does not provide care to R1. One of the resident (R6) stated he does not think R1 takes care of R1 and that what R1 thinks of care is down playing others. Due to medical diagnosis, LPA was not able to obtain information from R1's room mate. Based on information obtained, there's not enough preponderance of evidence to prove that a violation occurred, therefore the allegation is closed as unsubstantiated. ....continued on 9099C (page 3) 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 Page 3 Allegation: Staff does not provide resident a safe environment. R1 stated R2 makes R1 feel threatened, R3 does not allow R1 eat with the rest of the residents and staff are not doing anything about it. R1 also stated that she is not allowed to eat in her room. All staff interviewed stated not observing R2 and R3 threaten and prevent R1 from eating with the rest of the residents. All the staff also stated residents are allowed to eat in their room. LPA observed R1 eating in the dining room with other residents. LPA also observed during investigation 2 residents eating in their rooms. LPA was not able to get information from R2 and R3 regarding the allegation. Therefore, the allegation is unsubstantiated. Allegation: Staff does not provide adequate food service to resident. R1 stated S1 would not provide alternative food options and serves certain foods S1 cannot eat. R1 also stated that on 11/19/24, she asked S3 for sandwich because she can not eat meat and S3 did not give her sandwich. S1 stated residents are given substitute if they do not want the food served. S3 stated when R1 asked for sandwich on 11/19/24, she gave R1 peanut butter sandwich and R1 ate the sandwich, pork stroganoff and half of the pasta that was served to R1 that day. Six out of 8 residents interviewed stated there's no issue on the food serve. R4 stated if she does not like the food serve, she is offered substitute. One of the 8 residents stated being serve small servings of salad but didn't ask for seconds. Due to medical diagnosis of one of the resident, LPA was not able to obtain information. LPAs inspected the food supplies which were observed sufficient and different varieties. LPA Delmundo observed staff served dinner which consisted of pasta with ground pork, salad and fita bread which LPA observed R1 ate. Based on information obtained, the preponderance of evidence is not met, therefore, the allegation is unsubstantiated. Allegation: Facility failed to maintain a comfortable room temperature. R1 stated it's cold in her room. LPAs conducted inspection and observed a portable heater in R1's room. LPA Delmundo tested the temperature at R1's room which was measured at 69.8 degrees Fahrenheit. ....continued on 9099C (page 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 Page 4 All staff interviewed stated the facility has centralized heater which LPA Gharachorloo checked with ADM and observed the temperature at 72 degrees Fahrenheit. However, one of the residents stated it's cold. The other 5 residents stated temperature is comfortable. Due to medical diagnosis, LPA was not able to obtain information from 1 of the resident. Therefore, the allegation is unsubstantiated. Based on interviews, inspection and observation, all 5 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

While at the facility investigating a complaint (Control # 15-AS-20250206094236) and upon review of resident's (R1) file, Licensing Program Analyst (LPA) Delmundo observed R1 has prescribed antibiotics medication to be administered 3 times a day for 3 days. The medication was received by the facility on 2/06/25 and administration was started same day; however, the medication was not recorded on LIC622 Centrally Stored Medication and Destruction Record nor administration of this medication recorded on Medication Administration Record (MAR). Staff (S1) stated the medication was received and administered but she didn't record. These were discussed with Mirriam Paras, administrator (ADM). Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

Page 2 One of the staff stated not working on the day the incident happened while the other one indicated not working on the same shift S1 worked. One of the four staff stated R1 told her about S1 telling R1 she's heavy. ADM stated S1 told her that she (S1) told R1 to help out in getting up from the bathing chair because she's heavy. Based in interviews conducted, the preponderance of evidence has been met, therefore the allegation is found to be substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. A $250.00 civil penalty is assessed for repeat violation within 12 month of section 1569.269(a)(1). Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction, and civil penalty were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided. 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 Page 2 Allegation: Staff do not answer resident's (R1) request. R1 indicated she requested the staff to move the wheelchair away from the door and staff did not answer the request. All the staff interviewed indicated not observing wheelchair blocking the door nor R1 requesting to remove the wheelchair. R2 and R3 stated not observing a wheelchair blocking the door. Allegation: Staff does not ensure resident (R1) is accorded privacy. R1 indicated she needed to use the bathroom and was not accorded privacy. One of the staff interviewed stated she was to give R1 eye drops and looked for R1 by calling her who was at the time was in the bathroom. The other staff indicated there are times when R2 will knock when R1 is in the bathroom to check first if someone is inside and that there's another toilet but these 2 residents prefer to use the big bathroom. The other residents interviewed stated being accorded privacy and staff are respectful. Allegation: Staff does not provide adequate food service. It was alleged that R1 had diarrhea for several days and was told by a nurse that it's due to the food. R1 was interviewed who stated she's having diarrhea for days and her doctor told her it's because of the abscess tooth and that she was referred to the dentist. Copy of documents obtained by LPA showed R1 is prescribed anti-biotics. The other 2 residents interviewed stated food serve is always good. All the staff interviewed indicated not serving stale food. LPA conducted inspection and didn't observe any expired food. Based on information gathered, the above allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

On this day, September 4, 2024, while at the facility investigating a complaint (Complaint Control # 15-AS-20240830112641), Licensing Program Analyst (LPA) Delmundo observed the following: 1. Staff (S1) is not fingerprinted and cleared. 2. Flies flying around the residents' rooms, kitchen area, bathroom and living room. 3. Lavatory in the common bathroom not properly draining and cabinet in this bathroom in disrepair. 4. Inside of the refrigerator untidy. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Civil penalties were assessed on this same day for the following: 1. Deficiency section 87355(e)(1) - $100.00 and will continue for $100.00/day until corrected. 2. Deficiency section 87303(a) - $250.00 for repeat violation within 12-month period. Failure to submit proof of corrections may result in additional civil penalties. Deficiencies, plan and proof of corrections, and civil penalties were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM and LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Jonalyn Legarto , staff, and informed the reason for visit. LPA called and spoke over the phone with Mi rriam Paras, administrator, who authorized to sign and receive this report. On 4/26/24, LPA continued the annual inspection and issued citation section 87705(c)(1) for having residents (R3 and R4) in bedrooms not fire cleared for non-ambulatory. For plan of correction, the administrator stated she'll have the residents move-out. The administrator submitted the POC;however, the POC didn't indicate when the residents moved-out. On this day, 5/01/24, LPA toured the facility with staff (S1). and didn't observed R3 and R4. LPA interviewed S1 who confirmed R3 and R4 were moved-out. Deficiency is cleared. Exit interview conducted, and copy of this report provided.

On this day, 8/06/24, while at the facility investigating a complaint (Complaint Control # 15-AS-20240731080957), Licensing Program Analyst (LPA) Delmundo observed the following: 1. Staff (S1) is not fingerprinted and cleared. 2. Portable bed in resident's room and foldable bed in the closet in this resident's room. LPA verified, and according to the administrator, the beds are that of the staff. LPA also observed staff's personal stuff in the same room. Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. Civil penalties were assessed on this same day for the following: 1. Deficiency section 87355(e)(1) - $200.00 and will continue for $100.00/day until corrected. 2. Deficiency section 87307(a) - $250.00 for repeat violation within 12-month period. Failure to submit proof of corrections may result in additional civil penalties. Deficiencies, plan and proof of corrections, and civil penalties were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC421IM and LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.

R1 confirmed that staff gave R1 chicken broth and juice. The two staff interviewed stated that on 7/31/24, R1 had a procedure and there's instruction that R1 should not be given solid foods day before the procedure which LPA confirmed from the document obtained during investigation. The other staff was not able to provide information as this staff is new and was not working yet at the time of the said incident. Allegation: Staff do not meet resident's dietary needs. It was alleged that staff serve meat a lot and that R1 can not eat meat and staff does not offer substitute. LPA observed during inspection that residents were served barbecued meat during lunch. R1 stated she ate the barbecue and is not on special diet. Review of records showed R1 is not on special diet nor on diet restrictions. Two of the staff stated R1 eats meat and there are times when R1 does not want to eat meat but is not on special diet. These 2 staff stated facility offers substitute. The other four residents stated the food served is good. Three out of these 4 residents stated staff provides substitute if they don't want what is served. Based on information gathered, the above allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Although 3 of the 4 staff interviewed stated they check R1's BP when requested and put cream on R1's forehead, ears and on the back of R1's ears, the fungus cream run out which was confirmed by LPA with the administrator. MAR showed R1 is given eye drops. Review of records showed R1 has doctor's order for other cream for the scalp in August 2023, however, this particular cream was never refilled, and administrator admitted to not following-up with the doctor. Based on records review and interviews, the preponderance of evidence is met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations, and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. 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 Page 2 Allegation: Staff did not ensure the bathroom has hot water. R1 stated the bathroom has no hot water. All 4 staff, administrator and 2 other residents interviewed stated the facility never run out of hot water. LPA tested the water temperature which was measured at 105.2 degrees Fahrenheit. Allegation: Staff are not meeting residents needs. R1 stated when R1 wet self and asked to be changed, staff told her she'll come back and it took more than 1 hour to be changed. R1 futher stated that the bedsheet was not changed. Staff (S3) stated that on the date of incident, she was assisting other resident in the bathroom and told R1 to wait. S3 stated she came back in less than 20 minutes and assisted R1 to the bathroom and changed her. All 4 staff stated they change residents bed covers daily. During today's inspection, LPA observed the residents beds clean and R1's bed with 2 chux on top of the bed cover. None of the beds were observed wet. Allegation: -Staff did not prevent resident from engaging in inappropriate behaviors. R1 stated resident R4 laughs and stares at her , R2 grabbed her water bottle and R3 stares at her. All 4 staff interviewed confirmed the incident happened but the other 2 residents who were laughing were talking to each other. Staff also confirmed R2 grabbed R1's water bottle; however the R4 and R2 have dementia and they separate and redirect residents when incidents happen. Allegation: Staff made inappropriate comments towards resident. R1 stated when R4 made fun of her and reported the incident to the administrator, the administrator told her to be nice and mind her own business. Although the administrator stated saying to R1, "Be nice, because the residents have dementia", she denied saying 'Mind your own business." All 4 staff and other 2 residents stated not hearing the administrator made inappropriate comments to R1. LPA was not able to obtain information from other 3 residents either due to residents' medical condition/diagnosis or resident was not at the facility. .....continued on 9099C (page 3) 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 Page 3 Allegation: Staff did not ensure facility furniture was clean. R1 stated chairs in the living room never get washed. LPA interviewed 4 staff who stated the chairs and couches in the living room have covers and at times get soiled when residents spill food or have accidents but when these happen, they removed the covers, and covers are washed. The administrator stated the couches have covers and when get soiled, one of the staff does the washing. LPA conducted inspection and didn't observed any of chairs and couches soiled or dirty. Allegation: Facility has bed bugs. R1 stated she has bed bugs in her body. LPA interviewed 4 staff and 2 residents who all stated not observing bed bugs. LPA conducted inspection and didn't observed any. Based on information obtained and LPA unable to obtain information from 3 residents, all 7 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Continued from LIC9099. Allegation: Staff do not provide adequate care and supervision to the residents Residents stated during interview if they require any medical assistance or just help in the facility the staff will oblige. Staff stated during interview that if the residents require help that they can not provide they would notify the Administrator or call 9-1-1. LPA observed Residents in care appear to be safe, groomed, and there are no imminent health/safety concerns on today's date. Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of this report provided.

Allegation: Staff made inappropriate comments towards resident. It was alleged that staff (S1) tells R1 "that's your problem" and call R1 "bitch". Although 4 of the staff stated it was R1 who always say "bitch" to the staff and other residents, S1 admitted to telling R1 "it's your problem if you don't ignore e R1" when R1 called S1 when R2 was bothering R1. Allegation: Staff did not prevent resident from engaging in inappropriate behaviors. It was alleged that R2 keeps on following resident (R1) around and barging into residents rooms and staff is not doing anything. It was further alleged that R1 was upset due to staff sitting R2 next to R1 in the dining table. Four of the staff stated R2 has wandering behavior. One of the two residents interviewed stated staff do nothing to get R2 out of his room while the other one stated the staff yells at R2 to have R2 go out from the residents' room but most of the time, do nothing at all and R1 gets agitated when R2 goes to R1's room. Review of R2's record showed R1 has wandering behavior which LPA observed R2 wandering and going in and out of residents' rooms, kitchen, dining and hallways the whole time LPA was conducting investigation. LPA further observed and upon interview learned that there's only caregiver on duty from 6:00 a.m. to 3:00 p.m., and 1 caregiver from 3:00 p.m. to 11:30 p.m. and most of the time not able to redirect R2 right away when R2 goes to residents' rooms. Based on the information obtained, the preponderance of evidence has been met, therefore the allegations of "Staff made inappropriate comments towards resident" and "Staff did not prevent resident from engaging in inappropriate behaviors." are substantiated. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 9099Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Mirriam Paras over the phone. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. 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 All 3 staff interviewed stated they check R1's blood pressure when requested and record the reading, All 3 staff confirms R1's roommate (R5) screams when being changed; however, they try to calm R5 down. LPA was unable to interview R5. There was record of R1's blood pressure but only for 1 day. Allegation: Staff are not providing a comfortable environment for resident. R1 stated that her room is cold at night. All 3 staff interviewed stated that R1 complained about R1's room being cold. Facility has centralized heater but when R1 complained about the room being cold, R1 was provided a portable heater. LPA observed a portable heater in R1's room and the room's windows with coverings/curtains. LPA also checked the room temperature at around 4:00 pm which was measured at 68.7 degrees Fahrenheit. LPA was not able to obtain information from R1's roommate. Two other residents were interviewed who stated the temperature is at comfortable level. Allegation: Staff did not ensure facility furniture was clean. It was alleged that chairs in the living room are not clean. LPA interviewed 4 staff who stated the chairs and couches in the living room have covers and at times get soiled when residents spill food or have accidents but when these happen, they removed and wash the covers. LPA conducted inspection and didn't observed any being soiled or dirty, Based on information obtained and LPA unable to obtain information from R1's roommate, all 3 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Mirriam Paras, administrator, and informed the reason for visit. On 3/08/24, LPA issued citations for the following deficiencies with POCs to be submitted by 3/09/24. On 3/09/24, the administrator submitted the LIC9098 Proof of Correction form, however, the POCs submitted were either missing or the in-service training do not pertain to the deficiencies cited. LPA informed the administrator about these on 4/17/24 and requested to submit the POCs before the end of the day that day, but the POCs were not submitted up to this date, 4/26/24: 1. Section 87202(a) – picture showing the storage on the 2 nd floor is converted back to it’s original use. 2. Section 87309(d)(6 ) - in-service pertaining to the cited deficiency is missing. The in-service training submitted is not related to the cited deficiency. 3. Section 87309(a) - in-service pertaining to the cited deficiency is missing. The in-service submitted is also not related to the cited deficiency. On this day, 4/26/24, the above deficiencies are re-cited. On this same day, LPA toured the facility with the administrator. LPA observed the storage on the 2nd floor is converted back to it's original use. Deficiencies and proof of corrections were discussed with the administrator. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.

On 06/13/23 at 10:30 AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving an incident report regarding 13 residents evacuated by staff and the fire department as a result of a fire hazard (smoke from stove wall) which occurred at the facility on 06/11/23. All residents and staff were temporarily transferred by staff to 3 different unlicensed facilities (2) in San Leandro CA and one (1) in Hayward CA. LPA explained the purpose of the visit with staff (S1, S2) and administrator (ADM). During the health and safety checks at the three (3) unlicensed facilities, LPA observed a total of two (2) staff (S1, S2) and seven (7) residents (R1, R2, R3, R4, R5, R6, R7) relocated at 429 Linnel Avenue San Leandro, CA 94578 . LPA observed a total of three (3) residents (R8, R9, R10) relocated at 15997 Wellington Way San Leandro CA 95478 with one (1) staff (S3) providing care and supervision. LPA observed three (3) residents (R11, R12, R13) relocated at 2843 Sunnybank Lane Hayward CA 94541 with one (1) staff (S4) providing care and supervision. LPA toured the three (3) unlicensed facilities with ADM including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care were observed safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.

On 2/23/2024 at 1:20pm Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Mirriam Paras, Administrator, and explained the purpose of the visit. While LPA L. Hall was conducting a complaint investigation (15-AS-20240221085509) on 2/23/2024. While touring facility LPA observed residents' beds did not have a mattress cover, top sheet, and some did not have a blanket. Staff stated beds are changed weekly or more often if necessary. LPA also observed two (2) slide latch locks on front entry/exit door. Staff 1 (S1) stated during interview that facility uses lock at night for a resident that wanders. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided