Cottages at Riverside.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility for a case management visit to retrieve resident records related to case number 56-AS-20251117110643. LPA Prieto met with Executive Director Dion and obtained required documentation. This report was signed by LPA Prieto and Executive Director Dion and a copy was left with the facility.

Based on interviews and records review, the investigation did not produce sufficient evidence to substantiate the allegation of physical abuse. Therefore, the allegation is Unsubstantiated. An exit interview was conducted, during which this report was reviewed and a copy was provided to the facility.

Licensing Program Analysts (LPA) Javier Prieto made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Eva Tawfik and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is 110 with a current census of 85. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following: LPAs inspected all six (6) resident cottages inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient indoor and outdoor activity space for residents in care. Activities are posted in a common area of each cottage. All cottages are enclosed with self-latching gates with combination locks. Facility has no bodies of water. LPAs inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of residents in care. Menus are posted in various areas of the facility. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked and inaccessible to residents. LPAs inspected resident bedrooms. Bedrooms are equipped with beds, bed linen, chairs, night stands, storage space and sufficient lighting. LPAs inspected resident bathrooms. Bathrooms were equipped with grab rails and operating bathroom equipment. The hot water in the bathrooms tested between 109-110 degrees Fahrenheit. 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 LPAs observed the facility is equipped with operating carbon monoxide alarms and telephone service. Facility has a complete first aid kit. Posters such as personal rights, Ombudsman Poster, the disaster plan and emergency numbers were posted in a common area. LPAs reviewed eight (08) resident medications and centrally stored medication logs. All medications are labeled and administered as prescribed. LPAs reviewed five (5) staff files for criminal record clearances, training, and health screenings. All staff records were up-to-date. LPAs reviewed ten (08) resident records for admissions agreements, physician's report, pre-admission appraisals and emergency contacts. All records had the required documentation. No deficiencies were cited during today's visit and copy of the reports LIC809 and LIC809-C were provided to the Executive Director at the conclusion of the visit.

During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 and LIC9099C were discussed and provided to Executive Director Eva Tawfik.

Based on the information obtained there is not enough evidence that staff did not follow resident's hospice care plan . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Memory Care Director Annette Buenrostro and a copy was left with the facility.

Allegation #3 The MAR log for R1, provided by S1, showed that medications were administered as prescribed by a physician. Orders related to changes or discontinuation of R1’s medication were also documented in the MAR log. Narrative Charting concerning R1’s medication, care, and notifications to responsible parties confirmed communication regarding changes in medications as prescribed by the physician. Based on the information obtained, there is insufficient evidence to substantiate the allegations that staff are not assisting residents with self administered medications, not reporting incidents to resident representatives, or administering medications without primary physician authorization. T herefore, these allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Tawfik, and a copy was left with the facility.

#2 Facility did not prevent resident from becoming malnourished while in care - Based on interview, observation, and record review , investigation found that (R8) had a daily assignment that showed meals and snacks are being provided by the facility. Information received during investigation did not corroborate that R8 was malnourished because of facility staff neglect. #3 Facility did not meet resident’s hygiene needs. - Based on interview and file review, the facility has the Daily Assignment for (R8) that showed shower and laundry schedule. Also, information received indicated that R8 was receiving additional services from an outside source from at least 1/20/2023 through 6/6/2023. These services included showers. Information received during investigation did not corroborate that R8s hygiene needs were not being met. #4 Facility did not prevent resident from developing a pressure injury while in care. - Based on record review (R8) was receiving care from outside services from at least 1/20/2023 through 6/6/2023. Services included care for pressure injury. Information received during investigation did not corroborate facility staff neglect resulting in R8 sustaining a pressure injury. #5 Resident's health declined while in the care of the facility. - Based on record review, investigation revealed that (R8) was receiving hospice services from at least 1/20/2023 through 6/6/2023. A review of information received during the course of investigation could not corroborate that R8 health condition declined as a result of facility staff neglect. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation s are unsubstantiated at this time. An exit interview was conducted where this report, LIC9099, LIC909C were discussed and provided to Executive Director Eva Tawfik.

#2 Staff handled resident in a rough manner - Based on interviews. Resident #9 (R9) was unable to recall the incident, therefore LPA cannot corroborate if the alleged incident happened. Additional interview with witnesses and the alleged perpetrator were unable to be conducted at this time due to unavailability. #3 Staff are not properly mitigating the scabies outbreak at the facility - Based on interview and file review, the facility provided the paperwork of the necessary steps that they did to mitigate the scabies outbreak. They provided all the communication/paperwork to the dermatologist, nurses, and other responsible parties. They provided the sanitation procedure/schedule that they did to control the spread and prevention of the outbreak from coming back. #4 Facility's laundry machine is in disrepair - Based on interview and observation, the facility has laundry machine on each cottage and if one laundry machine is out and not working, they can use the other washing machine from other cottages or the main one in the maintenance room. According to information received, there has not been interference with laundry service for residents. #5 Staff did not inform resident's authorized representative of resident's incident - Based on staff interview, 6 out of 6 staff stated that every time there is an incident in the facility, they immediately let the nurse know (if there is an injury), the Resident Care Coordinator and Executive Director and they in turn inform the responsible parties. They also send the Special Incident Report (SIR) to Community Care Licensing. Information received during investigation did not corroborate that reports have not been provided to resident’s representative as required . During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted where this report, LIC9099, LIC909C were discussed and provided to Executive Director Eva Tawfik

Furthermore, Department staff noted that R1 was seen by the Orthopedic doctor on 05/18/2021 and was placed in a short-arm cast. In addition, Department staff reviewed the facility's Narrative Charting and it indicated that on 05/23/2021, R1 removed the cast and notification was made to R1's doctor and R1 was sent to the Emergency Room to have R1's wrist splinted. Also, Department staff noted that a new appointment with the Orthopedic was scheduled and completed on 06/01/2021. Lastly, Department staff obtained additional verification and documentation through R1's Healthcare provider, R1's primary physician and the Orthopedic doctor. This agency has investigated the complaint alleging staffs do not seek timely medical care. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director Eva Tawfik and a copy of this report (LIC9099) was discussed and 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 The second allegation indicates that responsible parties of residents are not contacted regarding incidents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs are contacting their family or responsible party regarding the incidents at the facility. Three (3) of three (3) residents interviewed stated that staffs at the facility are communicating regularly with their family and responsible party and they could not remember an incident at the facility that staffs are not reporting incidents to their family or responsible party. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that they are reporting all incidents at the facility to a resident family or responsible party the same day it happened. Five (5) of five (5) staffs interviewed stated that all staff at the facility were provided training to report all incidents at the facility to residents family or responsible party and it's the management that report incidents to Community Care Licensing Division (CCLD) and other government agencies if applicable. Interviews with five (5) of five staffs revealed that there's no incident that happened at the facility that a staff did not contact a resident family or responsible party regarding incidents at the facility. The third allegation indicates that staffs are told not to share information about the resident with the families. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with three (3) of three (3) residents indicated that staffs at the facility are sharing all information about them to their family or responsible party. Three (3) of three (3) residents interviewed stated that they do not know of an incident at the facility that staffs were told not to share information about them to their family or responsible party. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that they were not told by the management not to share information about their residents to their family or responsible party. Interviews with five (5) of five (5) staffs revealed that all staffs are sharing information about a resident to their family or responsible party to keep them updated. The fourth allegation indicates that staff is not giving medications per the doctors order. Interviews with three (3) of three (3) residents indicated that staffs at the facility are giving their medications daily per their doctor's order. Three (3) of three (3) residents interviewed reported that staffs at the facility never missed giving their medications per their doctor's order. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that they are giving their residents medications per their residents' doctors order. ***Cont. in LIC9099*** 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 Interviews with five (5) of five (5) staffs revealed that they are using electronic medication administration record (MAR) to ensure that they are giving their residents medications per their doctors order. During the facility visit on 01/24/2025 and 01/29/2025, LPA Brown audited five (5) residents medications and LPA Brown observed that residents medications were given per their doctors order. The fifth allegation indicates that food service inadequate. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that they like the food at the facility and staffs are always serving them good portion of food and they can get second serving if they prefer. Three (3) of three (3) residents interviewed reported that the facility staffs are always serving them breakfast, morning snacks, lunch, afternoon snacks, and dinner, and no incident happened at the facility that food service was inadequate. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they are serving all their residents healthy and enough amount of food and there's no incident that happened at the facility that their food service is inadequate. During the facility visit on 01/24/2025, ED Tawfic provided LPA Brown the facility Menu. Moreover, LPA Brown conducted a quick tour of the facility and observed that the facility has more than the required two (2) days' supply of perishable food and more than seven (7) days supply of non-perishable food. The sixth allegation indicates that staff is crushing medications without a doctor's order. Interviews with three (3) of three (3) residents indicated that there's no incident at the facility that staffs are crushing their medications without their doctor's order. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed reported that they are not crushing their residents medication without a doctor's order. Interview with five (5) of five (5) staffs indicated that there's no incident that happened at the facility that a staff is crushing residents' medications without a doctor's order. Five (5) of five (5) staffs interviewed revealed that medication training was provided to medical technician (MedTech) staffs, and they never crushed residents medications without a doctor's order. During the facility visit on 01/24/2025 and 01/29/2025, LPA Brown observed that MedTech staffs are not crushing a resident medication without a doctor's order. The seventh allegation indicates that PPE is not provided. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs at the facility are wearing gloves and mask when they are assisting them. **Cont. in LIC9099C* 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 Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Interviews with five (5) of five (5) staffs indicated that they are always provided personal protective equipment (PPE) at the facility. Five (5) of five (5) staffs interviewed stated that they have plenty of PPE supplies on all six (6) cottages at the facility and they never ran out of PPE supplies. Interview with five (5) of five (5) staffs revealed that the PPE supplies are always available to them on each cottage. During the facility visit on 01/24/2025, LPA Brown noted that the facility has sufficient PPE supplies maintained per cottages. Based on the evidence, the allegation that facility residents and staff have scabies (Allegation #1), responsible parties of residents are not contacted regarding incidents (Allegation #2), staffs are told not to share information about the resident with the families (Allegation #3), staff is not giving medications per the doctors order (Allegation #4), food service inadequate (Allegation #5), staff is crushing medications without a doctor's order (Allegation #6), PPE is not provided (Allegation #7) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to ED Eva Tawfik

but the home health nurse was unsuccessful to re-insert the catheter and they called for medical emergency. S3 and S5 added that R1 was transported to the hospital. Department staff reviewed R1's medical records and it indicated that R1 was admitted to the hospital with multiple medical issues. Moreover, R1's medical records revealed that R1 passed away on 07/14/2021 at the hospital with the primary cause of death listed. The second allegation indicates resident developed multiple pressure injuries due to neglect. During the Department investigation, six (6) of six (6) staffs interviewed indicated that R1 was placed in Pacifica Senior Living of Riverside on 05/21/2021 and R1 had documented multiple medical issues and non-ambulatory. Interviews with six (6) of six (6) staffs revealed that R1 was receiving home health with nurse visits three (3) times per week. Six (6) of six staffs interviewed reported that R1 was a two person assist and they are using Hoyer lift to transfer R1 from R1's bed to R1's wheelchair. Interviews with six (6) of six (6) staffs indicated that caregiver staffs at the facility are turning or repositioning R1 every two (2) hours. Medical records indicated that a meeting was conducted on 06/25/2021 and meeting notes documented that R1 was doing well, and wounds are healing slowly and R1 would be transferred to home health. In addition, Department staff noted that the pictures taken by the hospital of R1's wounds on or about 07/08/2021 showed that some wounds are improving while others were not. Department staff added that R1's medical records indicated that the wounds on R1's legs were diabetic ulcers. Due to insufficient evidence, the Department was not able to corroborate the allegation that resident developed multiple pressure injuries due to neglect. The third allegation indicates facility failed to seek timely medical care for resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs at the facility are always seeking timely medical care for them if they are sick and not feeling well. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they are always seeking timely medical care for their residents. Five (5) of five staffs interviewed reported that there's no incident that happened at the facility that they failed to seek timely medical care for a resident. Five (5) of five (5) staffs interviewed revealed that there's no incident that they did not seek timely medical care for R1 as any changes they observed on R1 or change of condition were all reported to R1's home health nurse and home health nurse was immediately dispatch to the facility after they notified them. ***Continuation in LIC9099C*** 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 The fourth allegation indicates facility did not meet resident's needs. Interviews with three (3) of three (3) residents indicated that staffs at the facility are meeting their needs. Three (3) of three (3) residents interviewed reported that staffs at the facility are checking on them four (4) to five (5) times in a day, providing them a shower two (2) or three (3) times in a week, brushing their teeth and staffs are making sure that they are wearing clean clothes. Three (3) of three (3) residents interviewed indicated that staffs at the facility are always ready to assist them if they need help. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they are providing care and supervision to all their residents to ensure that they are meeting their needs. Five (5) of five (5) staffs interviewed reported that there's no incident that happened at the facility that they did not meet R1's needs. Five (5) of five (5) staffs interviewed revealed that they are always checking on all their residents every two (2) hours, more often if needed to ensure that they are providing appropriate care and supervision to their residents and to meet their needs. During the facility visit on 01/24/2025, LPA Brown observed staffs at the facility providing care and supervision to their residents. The fifth allegation indicates facility staff did not follow sanitary precautions during care of resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs at the facility are always following the sanitary precautions when they are assisting them and providing care. Three (3) of three (3) residents interviewed reported that staffs at the facility are always wearing gloves when they are assisting them and will take off the gloves when they are leaving their room. Three (3) of three (3) residents interviewed stated that staffs at the facility are following sanitary precautions when they are providing care. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they always follow the sanitary precautions when they are providing care to their residents. Five (5) of five (5) staffs interviewed reported that when they are providing care to their residents, they are using new sets of gloves and they make sure that when they are leaving the residents room, they are taking off the gloves, throw it in the trash bin and sanitized their hands. In addition, five (5) of five (5) staffs interviewed revealed that they were provided training at the facility on sanitary precautions and infection control when they are providing care to their residents. Five (5) of five (5) staffs interviewed stated that there's no incident that happened at the facility that they did not follow the sanitary precautions when they are providing care to R1. During the facility visit on 01/24/2025, LPA Brown observed staffs at the facility are following sanitary precautions when they are providing care to the residents. ***Continuation in LIC9099C*** 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 Therefore, based on the evidence obtained during the Department staff and LPA Brown's investigation, there is insufficient evidence to prove that resident died due to staff neglect (Allegation #1), resident developed multiple pressure injuries due to neglect (Allegation #2), facility failed to seek timely medical care for resident (Allegation #3), facility did not meet resident's needs (Allegation #4), and facility staff did not follow sanitary precautions during care of resident (Allegation #5) are unsubstantiated at this time. Although the allegations of resident died due to staff neglect, resident developed multiple pressure injuries due to neglect, facility failed to seek timely medical care for resident, facility did not meet resident's needs, and facility staff did not follow sanitary precautions during care of resident may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted where this report (LIC9099) was discussed and provided to Executive Director Eva Tawfik.

R1 was interviewed by LPA and stated that she was not treated in a rough manner during transfers by staff. Allegation #3, the allegation was made relating to instructions made to R1 during a transfer by staff. Staff spoke to R1 in a loud tone of voice because R1 is hard of hearing. S1 heard these instructions and assisted caregiver during this transfer. S1 confirmed that R1 is hard of hearing. LPA interviewed R1 who confirmed she is hard of hearing. R1 also stated that she only wears her hearing aids when she is visited by her responsible party. Allegation #4, stems from the allegation that R1's air mattress is not properly inflated. This bed was prescribed by the Hospice Agency and has an electronic monitor. S1 interview states the monitor appears to by faulty and called the Hospice Agency to either replace monitor or observe mattress for leaks. This device is provided by the Hospice agency who is responsible for the device to work properly. Based on the information obtained there is not enough evidence that resident sustained unexplained injuries in care , facility staff handled resident in a rough manner , facility spoke inappropriately to resident and facility staff did not follow hospice care plan . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Tawfik and a copy was left with the facility.

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have Eva Tawfik, Executive Director, sign an amended licensing complaint investigation report (LIC 9099) (56-AS-20240430155237). Report was signed by LPA Prieto and Executive Director Tawfik and a copy was left at the facility.

staff (Staff 3) indicated that resident #1 (R1) hands were lightly bruised in the morning because of the staff trying to restrain R1 and prevent R1 from hitting the staff. However, the lightly bruising was not because of abuse but by R1 skin being sensitive. This happened about a year ago and Staff 3 did not notice any bruising lately. #2 Resident sustained multiple falls due to lack of care or supervision from staff - Based on residents and staff interview, 6 out of 6 residents and 5 out of 6 staff stated that they did not witness or observe any resident sustained multiple falls due to lack of care and supervision from staff. 1 staff (Staff 2) stated that they were some fall incidents, however it was not due to lack of supervision or care but by the resident’s medical condition like Parkinson’s disease. During the investigation, LPA did not find evidence to corroborate the allegations. Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Eva Tawfik.

Licensing Program Analysts (LPAs) Becky Mann and Javier Prieto made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Eva Tawfik, Executive Director and Annette Buenrostro, Memory Care Director and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is 110 with a current census of 76. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following: LPAs inspected all six (6) resident cottages inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient indoor and outdoor activity space for residents in care. Activities are posted in a common area of each cottage. All cottages are enclosed with self-latching gates. Facility has no bodies of water. LPAs inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of residents in care. Menus are posted in various areas of the facility. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked and inaccessible to residents. LPAs inspected resident bedrooms. Bedrooms are equipped with beds, bed linen, chairs, nightstands, storage space and sufficient lighting. LPAs inspected resident bathrooms. Bathrooms were equipped with grab rails and operating bathroom equipment. The hot water in the bathrooms tested between 109-110 degrees Fahrenheit. LPAs observed the facility is equipped with operating carbon monoxide alarms and telephone service. Facility has a complete first aid kit. Posters such as personal rights, Ombudsman Poster, the disaster plan and emergency numbers were posted in a common area. 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 LPAs reviewed ten (10) resident medications and centrally stored medication logs. All medications are labeled and administered as prescribed. LPAs reviewed five (5) staff files for criminal record clearances, trainings, and health screenings. All staff records were up-to-date. LPAs reviewed ten (10) resident records for admissions agreements, physician's report, pre-admission appraisals and emergency contacts. All records had the required documentation. No deficiencies were cited during today's visit and copy of the reports LIC809 and LIC809-C were provided to the Executive Director at the conclusion of the visit.

LPA Prieto interviewed S2, who was present at the time of the altercation. S2 stated that there was proper supervision in accordance with regulations and that the appropriate follow-up steps were taken after the incident. LPA Prieto also interviewed S3, who works with R1, and confirmed that staffing was adequate per regulations and that there had been no previous instances of aggression from R1 or R2. Regarding the allegation that staff did not provide adequate supervision, resulting in a fall, LPA Prieto interviewed S1, S2, and S3, all of whom were present at the time of the altercation. Administrator Tawfik provided the names of S4 and S5, who were working in the cottages where the altercation occurred and met the required supervision standards according to regulations. Based on the information obtained, there is insufficient evidence to support the allegations that staff failed to prevent a resident from harming another resident and that staff did not provide adequate supervision resulting in a fall. Therefore, these allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Tawfik, and a copy was left with the facility.

Licensing Program Analyst (LPA) Javina George made an unannounced case management visit to the facility. The purpose of the visit was to review and obtain copies of documentation pertaining to an open complaint for the facility. LPA met with Eva Tawfik and explained the purpose of the visit. In addition LPA conducted interviews with staff. No health and safety concerns were observed at the time LPAs visit. An exit interview was conducted and a copy of this report was provided to Eva Tawfik, Executive Director.

During document review of R1’s records, LPA did not find information to collaborate that R1 was not provided food while in care. For allegation, Resident suffered from dehydration while in care: Interviews with the residents and the staff revealed that the residents are provided with water and other liquid options throughout the day. The staff denied not providing water and or other liquids to ensure the residents stay hydrated. The residents stated that the staff provided the residents with plenty of water and other liquids to stay hydrated throughout the day. The facility provides a pitcher of water outside each cottage where the residents can access water on their own. If a resident needs assistance getting water from the pitchers, the residents can ask a staff member to bring water to their room or their current location. The facility also provides juice, coffee, milk, and tea as liquid options. During document review of R1’s records, LPA did not find information to collaborate that R1 was dehydrated while in care. For allegation, Facility failed to observe resident's change in condition: Interviews with the residents and the staff revealed that the staff checks on the residents frequently throughout the day. The residents are checked on average every thirty (30) minutes to two (2) hours depending on the residents’ needs. The staff denied that they do not observe the changing conditions of the residents’ needs. If a staff notices a change of condition, the change is escalated to the nurse for review. The nurse will analyze the resident and escalate the situation to their doctor, family, and call for emergency medical help if necessary. During document review of R1’s records, LPA did not find information to collaborate that R1 had a change in condition that was not observed. For allegation, Staff failed to meet the resident's needs: Interviews with the residents and the staff revealed that the staff are meeting the needs of the residents. The staff denied not meeting the needs of the residents. The residents stated that the staff is very caring, and the staff helps them with their daily needs. During document review of R1’s records, LPA did not find information to collaborate that R1’s needs were not being met. Overall, there was not enough evidence to collaborate the allegations listed above. 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 Based on evidence obtained during the investigation, the four (4) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Executive Director Eva Tawfik, along with a copy of the appeal rights.

For allegation, Staff is not allowing resident to have visitors : LPA interviewed R1's responsible party, who has instructed facility staff to only limit visitations to the responsible party, who is also R1's Power of Attorney (POA). Interviews with staff and POA state the visitations from other parties, aggravate R1 who has shown aggression towards staff after visitations or facetime calls from other parties. Overall, there was not enough evidence to collaborate the allegations listed above. Based on evidence obtained during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. This report was signed by LPA Prieto and Executive Director Tawfik and a copy was left with the facility.

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility for the purpose of collecting a signature on licensing report LIC412BG issued on 10/04/2023 during an annual inspection. LPA met with Eva Tawfik, Executive Director and discussed the purpose of the visit. An exit interview was conducted where reports LIC421BG/LIC809 were discussed and copies provided to the Executive Director at the conclusion of the visit.

Regarding the allegation the facility staff not meeting resident’s needs, interview with staff #1 (S1) and Executive Director Tawfik and documentation obtained reveal the R1 was receiving proper care to meet R1's needs. Regarding the allegation that staff did not safeguard client's personal belongings, LPA obtained documentation listing the client's personal property and medication, given to the responsible party at time of R1's departure from the facility without further incident. Based on the information obtained there is not enough evidence that facility did not inform authorized representative(s) about residents change of medical condition , facility staff not meeting resident’s needs and staff did not safeguard client's personal belongings Therefore, the allegations are deemed UNSUBSTANTIATED at this time. A copy of this report was signed by LPA Prieto and Executive Director Tawfik and facility obtained a copy.