Loma Clara Senior Living.

Regarding the allegation, facility does not have enough staff to meet the residents needs, according to the reporting party, it was observed that it was 11am and Resident 1 (R1) was still in bed, the blinds were closed, room was dark, and he/she still had not been fed breakfast. During the investigation, LPA interviewed staff. Staff interviewed indicated that there is enough staff in memory care and they are also using agencies. In addition, staff interviewed indicated that staff work really closely together and are experienced. During the visit today, LPA observed 2 caregivers and 1 med-tech in the assisted living unit and 5 caregivers and 1 med-tech in the memory care unit. Regarding the allegation, staff are leaving residents soiled, according to the reporting party, the facility staff are supposed to change and toilet the residents every couple hour, however while helping Resident 1 (R1), he/she was observed to be completely soaked. During the investigation, LPA interviewed staff members. Based on staff interviews, residents are being checked on and changed every two hours or as needed if they soil themselves sooner. Based on interviews conducted, observations and record review, the Department has determined that the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Report is reviewed with the Business Office Manager and a copy is provided.

It was alleged that staff mishandled a resident (R1)’s medication the morning of 02/07/2025. It was stated that on 02/07/2025 around 7:00am, R1’s private caregiver requested a PRN medication for R1 due to increased coughing, but the medication was not administered until around 10:00am. Based on staff interview, it was stated that the NOC shift MedTech administered the PRN cough medicine around 6:00am, which was why the staff waited until 10:00am to give the next dose. Staff stated that they needed to wait until 4 hours had passed (per the physician’s order) before administering the next dose of the PRN cough medication. Based on record review of R1’s PRN log, on 02/07/2025 the 6:00am dose of PRN cough medicine was not recorded in R1’s PRN log. It was only recorded that R1 was administered the cough medicine at 10:12am the morning of 02/07/2025. The prior dose recorded was from 02/06/2025 at 8:27pm. The facility provided a written communication note on 02/07/2025 between MedTechs, which noted that R1 was administered a PRN medicine for cough at 6:00am, however, this note did not include the dosage and effectiveness of the medication. The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Executive Director, Eugenia Smith and Generations Program Director Erin Wiley and a copy of the report and appeal rights was provided. Page 2 of 2. 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 It was alleged that on 01/25/2025, resident (R1) sustained an unexplained spinal fracture injury while in care. During R1’s hospital visit, R1 was diagnosed with a viral infection and spine fracture. It was unclear whether the spinal fracture was caused by an unwitnessed fall that was not reported by the facility or due to symptoms of the viral infection. 6 staff members were interviewed. Based on staff interview, 6 out of 6 staff stated that R1 was a fall risk. 5 out of 6 staff did not observe R1 sustain a fall and was not informed of a fall that R1 had sustained during their shift and prior to their shift. 1 out of 6 staff stated they believe R1 had a fall, which is how R1 sustained a spine fracture, however, this staff could not provide more details to include when and where the fall occurred. This staff stated that if there was a fall, it should have been documented in R1’s chart. Based on record review, there was no indication in R1's notes that R1 had sustained a fall prior to R1’s hospital visit on 01/23/2025. It was only noted that R1 wasn’t feeling well and complained of chest pain and coughing, in where R1 was taken to the emergency room. The review of R1’s medical records did not indicate how R1 sustained the spinal fracture. R1 is diagnosed with a health condition related to weak bones. A witness was interviewed, who was unsure how R1 sustained the spinal fracture. It was alleged that staff did not provide adequate care and supervision due to an incident that occurred on 02/26/2025. On 02/26/2025, a witness (W1) observed R1 bent over, pulling a heavy chair in the common area and there was no staff member in sight. It was stated that the facility was instructed by R1’s family member to ensure R1 is in sight of the caregivers 24/7. Based on record review, the facility was not providing 1:1 care for R1 during the day time. R1’s service plan indicated status checks for 4-6x a day. Page 2 of 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 It was noted that staff are to make frequent checks for resident’s safety and to assist the resident during transitions from activities, meals, and back to the apartment. The service plan did not indicate a time frame of how often staff should be checking on the resident. A witness (W1) was interviewed. Based on interview, around 5:30pm W1 did not observe staff supervising the residents in the common area when R1 was bent over with a back brace pulling a heavy chair. W1 denied calling a staff for assistance or looking for a staff after the observation of the incident. W1 states there are usually around 2-3 staff working in memory care. 5 staff members were interviewed regarding this allegation. Based on staff interview, the caregivers check in on R1 very frequently if R1 is in his/her bedroom alone. It’s stated that R1 is normally in the common area during the day to allow for staff to observe R1 closely. Staff stated the facility has at least 3-4 caregivers, 1 medtech, and 1 activities staff working the morning shift; 3-4 caregivers and 1 medtech for the afternoon/evening shift; and 3 caregivers and 1 medtech during the NOC shift. Based on review of the facility’s staffing schedule in memory care, the facility has at least 3 – 4 caregivers and 1 MedTech scheduled in the morning and afternoon shift, and at least 2 caregivers and 1 MedTech during the NOC shift. The Department has investigated the above allegations. Based on interview, record review and observation the above allegations are unsubstantiated. An unsubstantiated finding indicated that although the allegation may have happened and/or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Eugenia Smith and Generations Program Director Erin Wiley and a copy of the report was provided. Page 3 of 3.

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Executive Director, Eugenia Smith. LPA toured Generations (aka Memory Care) with ED to include 4 apartments (RM 113, 109, 105, and 101), bathrooms, activity room, kitchen, and dining room. All fire exit routes were free and clear of obstruction. Temperature maintained between 70 - 72 degrees F. Kitchen refrigerator temperature maintained at 40 degrees F. The beverage refrigerator maintained at 38 degrees F. Freezer temperature maintained below 0 degrees F. Hot water temperature measured between 119.6 - 120 degrees F in RM 113 and 109. Chemicals and disinfectants observed locked. 2 residents in 1 out of 4 rooms is able to store their own hygiene products per their medical assessment. LPA advised ED to take appropriate measure to ensure all resident's safety for those who may wander and is at risk if given direct access to hygiene items. During visit, the facility added a magnetic log on the cabinets in the resident bedroom. Daily program / activities calendar observed posted for the month. During visit, resident's observed participating in activities. 2 resident files in Generations was reviewed. 1 out of 2 resident's who uses a postural support has a physician's order on file. 2 out of 2 resident's physician's report observed outdated from 2022 and 2023. Resident #1 had a medical assessment from a doctor's visit in January 2025. LPA observed the medical assessment did not contain all required information as stated in Title 22 Section 87458. During visit, ED faxed the resident #1 and #2's doctor the facility's physician form. The remainder of the resident files observed complete. LPA inspected 2 resident's centrally stored medication and records. 2 out of 2 resident medications were complete and no issues noted. See LIC809-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 LPA entered in the kitchen with the ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Walk-in refrigerator temperature maintained at 34 degrees F. Walk-in freezer temperature maintained at -33 degrees F. Items inside the refrigerator and freezer observed covered. LPA toured Assisted Living with ED to include 4 resident apartments (RM 226, 223, 236, and 211). Hot water temperature was measured between 115.3 - 118.9 in RM 226 and 236. 1 out of 4 resident apartments observed with hygiene items and based on review of the resident's physician's report the resident may not have direct access to hygiene items. ED implemented the magnetic lock on resident's cabinet. 2 residents file in Assisted Living was reviewed. 2 out of 2 resident's files were complete. LPA inspected 2 resident's centrally stored medication and records. 2 out of 2 resident medications were complete and no issues noted. Fire extinguishers observed throughout the facility, last service date was 01/09/2025. Facility has carbon monoxide and smoke detectors present. Fire drills are being completed quarterly and the last drill was completed on 01/30/2025. Elevator observed in working condition. Activities calendar posted throughout assisted living. LPA observed first aid kits in the medication room in Generations and Assisted Living. Facility has a back-up generator and flash lights available, if needed. 4 staff files were reviewed and observed complete. 4 out of 4 staff members had over 20 hours of annual training. LPA advised to ensure appropriate staff receive at least 20 hours of training, in which 8 hours shall be dementia care and 4 hours of which shall be specific to postural supports, restricted health care conditions and hospice care. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Executive Director, Eugenia Smith and a copy of the report was provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Executive Director (ED), Eugenia Smith. LPA toured Generations (aka Memory Care) with ED to include 6 apartments (RM 119, 201, 204, 111, 114, and 115), bathrooms, activity room, dining room and kitchen. 6 apartments equipped with beds, linens, chairs, dressers, night stands and adequate lighting. LPA observed 2 residents who uses oxygen. Oxygen in use sign posted outside of resident apartments. Temperature in Generations observed between 72 - 76 degrees Fahrenheit. All fire exit routes were free and clear of obstruction. No observations of chemicals, sharp objects, or items which could pose a danger that are accessible to residents in care. LPA reviewed 4 resident files in Generations. 4 out of 4 resident files contained an updated medical assessment, TB result, service plan, emergency/contact information, admission agreement, safeguard of personal property and valuables, and personal rights form. LPA observed the residents who are using oxygen and half rails contained physician's orders on file. LPA reviewed 4 residents centrally stored medications and centrally stored medication records. Resident (R1)'s medications were counted and observed with extra dosages of medications for 4 bubble pack medications. Facility was unable to track where the discrepancy had stemmed from as the electronic MAR shows that staff had signed off on the administration of the medications daily. LPA entered the kitchen with ED. The facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 36 degrees Fahrenheit. Items inside the refrigerator observed covered and labeled. Freezer temperature maintained at 0 degrees Fahrenheit. SEE LIC809-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 LPA toured Assisted Living with ED to include 5 resident apartments (RM 226, 241, 239, 219, and 214), bathrooms, activity room, fitness center, salon, kitchen, and dining room. 5 resident apartments equipped with beds, linens, chairs, dressers, night stands and adequate lighting. Hot water temperature in RM 226 and 219 maintained at 110 degrees Fahrenheit. Temperature in assisted living measured at 72 degrees Fahrenheit. All fire exit routes are free and clear of obstruction. Fire extinguisher last serviced on 01/09/2024. LPA observed the presence of fire detectors / carbon monoxide detectors throughout the facility. Elevator observed in working condition. LPA reviewed 4 resident records in Assisted Living. 4 out of 4 resident files contained an updated medical assessment, TB result, service plan, emergency/contact information, admission agreement, safeguard of personal property and valuables, and personal rights form. Medication room observed locked. The medication room is equipped with supplies for hand hygiene, a lidded trash bin, and separate container for sharps. LPA observed the facility's electronic medication administration record which logs PRN medication. LPA reviewed 5 staff files to include a health screening, TB result, fingerprint clearance, job application, and employee rights. Facility has at least one staff present per shift who obtains a 1st Aid Certification to include Med-Techs and Directors. LPA reviewed 5 out of 5 staff training records. 3 out of 5 staff are provided at least 20 hours of annual training on topics to include but not limited to Alzheimer's, ADL care, Infection control, Dementia care, proper positioning, and hospice. Facility has an emergency disaster plan and is currently in the process of updating the plan. ED advised to provide the Department a copy of the updated plan once completed. Emergency drills are conducted quarterly, the last drills were completed on 08/02/2023, and 09/04/2023, 11/13/2023, and 01/29/2024. LPA observed flash lights located in the medication room. Facility has an updated and complete infection control plan. LPA observed the facility has sufficient PPE supplies. LPA observed residents participating in activities throughout my visit. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Executive Director (ED), Eugenia Smith, Julie Mayder, Maria Martinez, Cassandra Pace, Rubin Aguila, Anissa Padilla, Rebecca DiRubio and a copy of the report and appeal rights were provided.

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the complaint findings for complaint control number 26-AS-20220830100730. During visit, a case management – deficiencies visit was conducted due to violations observed during the complaint investigation. LPA met with Interim Executive Director, Becca Black. On 07/10/2022, resident (R1) tested positive for COVID-19. From 07/11/2022 - 07/17/2022, R1 was noted to have symptoms and became progressively became weak. On 07/18/2022, R1 was sent to the hospital for medical treatment after being assessed by an outside agency medical professional. Based on record review, from 07/11/2022 – 07/17/2022, there was no indication that a physician was being notified of R1’s condition. The facility was also unable to produce documents to prove R1’s physician was being notified of R1’s condition during 07/11/2022 – 07/17/2022. Based on complaint investigation interviews, it was stated the facility’s procedures are to inform the resident’s physician and/or responsible party if a resident has a change of condition. A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Interim Executive Director, Becca Black and Generations Program Director Maria Martinez and a copy of the report was appeal rights were provided.

On 07/16/2022, staff observed R1 was weak when attempting to get R1 out of bed for meals. It was noted that R1 was still testing positive, and fluids were being provided. On 07/17/2022, R1 was given PRN medication for symptoms. That night, R1 refused dinner and only drank fluids. There was no indication that a physician was being notified of R1’s condition. On 07/18/2022 at 04:41am, R1 was observed very weak. Staff tried to hydrate R1 but R1 refused to drink fluids. A note on 07/18/2022 at 01:47pm states an outside agency Nurse Practitioner asked to have R1 sent out as R1 was not eating that morning, not responding to anything being told, and was only responding to pain. R1’s POA was at the facility. The nurse practioner assessed R1 and was sent to the hospital for medical treatment. The review of R1’s medical records on 07/18/2022 states R1 was admitted and was diagnosed with altered mental status, dehydration, and other medical conditions. The medical record notes that R1 was in quarantine for x10 days and has been progressive more confused. On 07/27/2023, R1 returned to the facility under hospice care. On 07/12/2023, 5 staff members were interviewed. Based on interview, staff (S3 – S5) stated to observe R1 was weak and tired during the time R1 had COVID-19 at the facility. Staff (S5) stated R1 was sent to the hospital due to a decline in R1’s health. Staff (S1) was unable to provide an explanation to why it took a couple days before R1 was sent out to the hospital despite showing signs of weakness. The Department has investigated the above allegations and the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. A case management – deficiencies visit was conducted due to violations found during the complaint investigation. See LIC809 from 07/14/2023. This report was reviewed with Interim Executive Director, Becca Black and a copy of the report and appeal rights were 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 On 07/10/2022, resident (R1) tested positive for COVID-19. On 07/18/2022, R1 was transported to the hospital due the observation of weakness. R1 was admitted to the hospital and discharged back to the facility on 07/27/2022 under hospice care due a decline in health. On 08/02/2022, R1 passed away under hospice care. Based on review of R1’s hospice records, R1 was admitted under hospice care with a terminal diagnosis of a neurodegenerative disease. The cause of death based on R1’s death certificate states complications of clinically diagnosed neurodegenerative disease. The review of the staff schedule from July 2022 – August 2022 shows the facility was utilizing agency staff, most especially during the PM weekends of July 2022. The staff schedule shows the facility was providing at least 3-4 caregivers and 1 MedTech for AM/PM shifts and at least 2 caregivers and 1 MedTech for NOC shifts. Based on interview, there was no indication that the facility was short-staffed as they were utilizing outside agency staffing, when needed. The Department was investigated the above allegations. Based on record review, interview, and observation the above allegations are unsubstantiated. An unsubstantiated finding indicates that although the allegations may have happened and/or is valid there is not a preponderance of evidence to provide the allege violations did or did/not occur. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Interim Executive Director, Becca Black and a copy of the report was provided.